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Colour Atlas of Ophthalmic Plastic Surgery

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Known for its superb, step-by-step photo sequences, Colour Atlas of Ophthalmic Plastic Surgery, 4th Edition, by Drs. A. G. Tyers and J. R. O. Collin, remains your first choice for gaining essential knowledge in oculoplastic surgery. Ideal for both novices and experienced surgeons, this award-winning title offers comprehensive coverage of ophthalmic plastic surgery including eyelids, brows, and mid-face – all highlighted by unsurpassed photographic sequences and explanatory text that depict key stages of each procedure. New photos and new operative series, as well as major updates throughout the book, make this an invaluable resource for your practice.

  • Provides more than 1,000 high-quality photos of every key step of every procedure, with corresponding explanatory legends and detailed descriptive text, making the surgeries easy to understand and follow.
  • Features discussion of indications, preferences and advice on the management of complications with each chapter.
  • Presents the knowledge and expertise of two internationally acclaimed oculoplastic surgeons, both previous Presidents of the British Oculo-Plastic Surgery Society and the European Society of Ophthalmic Plastic and Reconstructive Surgery.
  • Includes an expanded video collection, now with 25 narrated surgical clips with over 2 hours running time, including brand new recordings and improvements to existing video footage.
  • Includes updated coverage of ptosis surgery, lid and periocular reconstruction, and blepharoplasty and forehead rejuvenation.
  • Expert Consult™ eBook version included with purchase. This enhanced eBook experience allows you to search all of the text, figures, and references from the book on a variety of devices.
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Colour Atlas of

Plastic Surgery


This page intentionally left blank

Colour Atlas of

Plastic Surgery





A. G. Tyers
FRCS(Eng), FRCS(Ed), FRCOphth, DO, OStJ
Consultant Ophthalmic Surgeon
Salisbury District Hospital
Salisbury, UK
Formerly Moorfields Eye Hospital,
London, UK

J. R. O. Collin
MA, MB, BChir, FRCS (Eng), FRCOphth, DO
Consultant Ophthalmic Surgeon
Moorfields Eye Hospital
London, UK

For additional online content visit

© 2018, Elsevier, Ltd. All rights reserved.
First edition 1995
Second edition 2001
Third edition 2008
Fourth edition 2018
The right of Anthony G. Tyers and J.R.O. Collin to be identified as author of this work has been asserted by
them in accordance with the Copyright, Designs and Patents Act 1988. All fourth edition new images and videos
are copyright to Dr. Tyers.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without permission
in writing from the publisher. Details on how to seek permission, further information about the Publisher’s
permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the
Copyright Licensing Agency, can be found at our website:
This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using
any information, methods, compounds or experiments described herein. Because of rapid advances in the medical
sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest
extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/
or damage to persons or pr; operty as a matter of products liability, negligence or otherwise, or from any use or
operation of any methods, products, instructions, or ideas contained in the material herein.
ISBN: 978-0-323-47679-9
E-ISBN: 978-0-7020-7180-5
Printed in China
Last digit is the print number: 9




Content Strategist: Russell Gabbedy
Content Development Specialist: Nani Clansey
Content Coordinator: Joshua Mearns
Project Manager: Andrew Riley
Design: Christian J. Bilbow
Illustration Manager: Amy Faith Heyden
Illustrator: Richard Tibbits
Marketing Manager: Melissa Fogarthy






Video Table of Contents x
Preface to the Fourth Edition xi
Preface to the Third Edition xii
Preface to the Second Edition xiii
Preface to the First Edition xiv
Acknowledgements xv
New Images and Videos for this Edition xvi
Dedication xviii

Section B

Chapter 1




The bony orbit 2
Surface anatomy of the eyelids 4
Eyelid skin 6
Eyelid structure 7
Muscles of facial expression, the mimetic
muscles 7
Muscles of mastication 11
Facial fat and fascia 11
Orbital fat and fascia 16
The retro-orbicular fascia and related spaces 17
The septum and tarsal plates 19
The conjunctiva 19
The upper lid retractors 19
The lower lid retractors 20
The lacrimal apparatus 20
Blood supply to the lids 21
Lymphatic drainage of the lids 22
Nerve supply to the lids and face 23
The eyelids of Asians 26
Age changes in the lids and face 28

Chapter 2

Basic techniques in ophthalmic
plastic surgery 29
Section A

Incisions 30

Wound closure 31

Routine wound closure 32
Continuous sutures 33
Intradermal sutures 34
Mattress sutures 35
Three-point suture 35
Full-thickness eyelid margin excision and
repair 36
Horizontal lid tightening 36

Section C

Skin grafts 37
Taking full-thickness skin grafts 38
Upper lid skin 38
Postauricular skin 39
2.10 Preauricular skin 41
2.11 Taking a split skin graft 43
Skin graft fixation 47
2.12 Graft stabilisation with a fixed bolster 47
2.13 Graft fixation with a pressure dressing 48
2.14 Quilting sutures 48
Section D

Grafts for reconstruction of the posterior eyelid
lamella 49

Taking an oral mucous membrane graft 50
Split-thickness mucous membrane grafts 51
Donor sclera 52
Taking auricular cartilage 52
Taking a tarsal graft 54
Harvesting hard palate grafts 55

Section E

Other techniques 56

Taking autogenous fascia lata 57
Lid traction sutures 59
The Z-plasty 60

vi Contents
Chapter 3

Preoperative evaluation


Section A

Obvious pathology 62

Margin–reflex distance 64
Telecanthus 64

Section C

Eyelid movement 65
Levator function 66
Laxity of the lower lid retractors 68
Bell’s phenomenon 68
Jaw wink 69
Fatigue in myasthenia gravis 70

Section D

Eye position 71

Exophthalmometry 72
Eye displacement 72

Section E

Other examinations 76
Brow position 77
Lateral canthus and cheek 77
Upper lid skin crease 78
Horizontal lower lid laxity 78
Medial and lateral canthal tendons 79
Eye and orbit 80


Section A

Local infiltration 84
Subcutaneous approach 85
Subconjunctival approach 85
Tumescent local anaesthesia 85

Section B

Regional blocks 86

The basic instruments 92
Detail of forceps 92
Putterman clamp 92
Pen, scalpel, blades 93
Commonly used sutures 93
Nasal speculum and bone punches 93
Fascia lata set 93
Malleable retractors 94
Transnasal wire set 94
Air-powered drill and oscillating saw with
blades 94
5.11 Watson split skin knife with blade and
boards 94
5.12 Dermatome 95
5.13 Orbital sizers and orbital implant
introducer 95
5.14 Evisceration spoon and enucleation scissors 95


Section A

Involutional entropion 98

Suture repair 99
Wies 101
Quickert 101
Jones 105

Section B

Cicatricial entropion 108

Chapter 4





Section F


Adverse reactions to local anaesthetics 90

Chapter 6

Eye movement 73


Section C


Eyelid position 63


Retrobulbar nerve block 88
Facial nerve block 89

Chapter 5

Section B


Frontal nerve block 87
Infratrochlear nerve block 88
Infraorbital nerve block 88


Tarsal fracture 109
Posterior graft (lower lid) 111
Anterior lamellar reposition with or without lid
split (upper lid) 112
Tarsal wedge resection 116
Lamellar division 116
Posterior graft (upper lid) 116
Lid margin rotation (trabut) 117

Alternative procedures 117
6.12 Excision of the tarsal plate 117
Section C

Congenital entropion 118

Tarsal fixation (Hotz) 119

Contents vii
Chapter 7


Chapter 9




Section A

Section A

Involutional ectropion 124

Levator aponeurosis repair 178

Horizontal lid shortening 125
7.1 Full-thickness excision 125
7.2 Lateral tarsal strip (canthal sling) 126
7.3 Bick lid tightening 132
7.4 Excision of a medial conjunctival
diamond 135
7.5 Horizontal shortening medially with
excision of a medial conjunctival diamond
(‘Lazy-T’) 138
7.6 Horizontal shortening and blepharoplasty
(Kuhnt-Szymanowski) 140
7.7 Stabilisation of the medial canthal tendon –
conjunctival approach 141
7.8 Medial wedge excision 142


Section B


Section B

Levator resection 189

Anterior levator resection 190

Alternative procedure 199
Posterior levator resection 200
Alternative procedures 202
Section C

Müller’s muscle shortening 204

Cicatricial ectropion 145

Anterior levator aponeurosis repair
(advancement) 179
Posterior levator aponeurosis repair
(advancement) 184


Müller’s muscle–conjunctiva resection
(Putterman) 206
Tarso-Müllerectomy (Fasanella-Servat) 211

7.9 Z-plasty 146
7.10 Skin graft 148
7.11 Upper lid to lower lid flap based
medially 152
7.12 Upper lid to lower lid flap based
laterally 154

Section D

Section C


Paralytic ectropion 158

Alternative procedures 224
Brow suspension – closed Fox approach 225
9.10 Brow suspension – open Fox approach 229

7.13 Medial canthoplasty 159
7.14 Autogenous fascia lata sling 161
Alternative procedures 165
7.15 Medial canthal tendon plication 165

Chapter 8

Eyelash abnormalities


Section A

Trichiasis 168

Cryotherapy 169

Alternative procedures 213

Brow suspension 214

Fascia lata brow suspension – Crawford
method 215
Levator weakening 218

Alternative procedures 229
9.11 Prop contact lenses 229
9.12 Whitnall’s sling 230

Chapter 10

Section A

Upper lid blepharoplasty 235

Distichiasis 170



Section B

Section B
Lamellar division and cryotherapy to the
posterior lamella 171

Alternative procedure 173
8.3 Eyelid split and direct excision of distichiasis
lash roots 173


Skin and muscle excision 236
Ptosis correction 244
Lacrimal gland prolapse 248

Lower lid blepharoplasty 250
10.4 Transconjunctival lower lid blepharoplasty 251
10.5 Transcutaneous lower lid blepharoplasty 255
10.6 Festoons and malar bags 265

viii Contents
Section C

Brow ptosis 266

Direct brow lift 268
Mid-forehead brow lift 271
Pretrichial brow and forehead lift 273
Transblepharoplasty brow lift 275
Lateral brow elevation 276
Coronal brow and forehead lift 278
Endoscopic brow and forehead lift 278

Alternative procedures 329
12.4 Split skin lining to socket 329
12.5 Preservation of eyelid skin 330
12.6 Skin flaps to socket 331
12.7 Osseointegrated fixation for prosthesis 332

Chapter 13

The anophthalmic socket
Section A

Section D

Primary implants 336

Cheek ptosis 279


Chapter 11

Eyelid retraction


Section A

Muller’s muscle 282

Muller’s muscle excision 283

Section B

Recession of Muller’s muscle and levator 286

Upper lid retractor recession without spacer –
posterior approach 287
Upper lid retractor recession without spacer –
anterior approach 290



Primary spherical implant with Vicryl mesh
wrap 337
Primary porous implant with a scleral wrap 342
Primary dermofat graft 344

Section B

Secondary implants 347

Secondary wrapped implants 348
Secondary unwrapped implants 352
Secondary dermofat graft 354
Subperiosteal orbital floor implant – single
sheet 354
Subperiosteal orbital floor implant – multiple
strips 356
Dermofat graft to the superior sulcus 357

Alternative procedures 360

Alternative procedure 293
11.4 Full-thickness upper lid recession 293
11.5 Upper lid retractor recession with spacer –
anterior approach 295

Section C

Alternative procedure 297
11.6 Upper lid retractor recession with spacer –
posterior approach 297
11.7 Gold weight implant 298

Section D

Exposed and extruding orbital implants 361
13.10 Patch repair 362

Contracted socket 364

Section C

13.11 Fornix deepening sutures 365
13.12 Fornix reconstruction – lower fornix 367
13.13 Fornix reconstruction – upper fornix 369

Lower lid 302

Alternative procedures 369


Section E

Recession of lower lid retractors 303
Cheek lift 307

Section D

Other procedures 311
11.10 Temporary central tarsorrhaphy sutures 312
11.11 Temporary lateral tarsorrhaphy 313
11.12 Permanent lateral tarsorrhaphy 314

Chapter 12

Evisceration, enucleation,
exenteration 317

Evisceration with removal of the cornea 318
Enucleation 323
Exenteration 326

Other problems with the anophthalmic socket 370
13.14 Ptosis 371
13.15 Lower lid ectropion 371
13.16 Entropion 371

Chapter 14

Eyelid reconstruction – eyelid margin
closure 373
Section A

Direct closure of the lid margin 374

Full-thickness eyelid margin excision – repair
with silk 375
Eyelid margin repair with a buried knot 377

Contents ix
Alternative procedure 380
14.3 Lid margin closure with a transverse
incision 380

Chapter 16

Section B

Eyelid reconstruction – posterior
lamella 427

Direct closure with extra tissue laterally 382

Section A


Grafts to reconstruct the posterior lamella 428

Lateral cantholysis 383
Lateral advancement flap 385
Semicircular flap (Tenzel) 385
McGregor cheek flap 387

Chapter 15

Eyelid reconstruction – anterior
lamella 389
Section A

Use of skin grafts to fill the defect 390
15.1 Full-thickness graft to partial-thickness defect –
lower lid 391
15.2 Full-thickness graft to partial-thickness defect –
upper lid 392
15.3 Full-thickness graft to inner canthus 393
15.4 Split-thickness graft to partial-thickness
defect 394
Section B

Use of flaps to cover the defect 396


Using grafts for the posterior lamella 429

Alternative procedures 430
16.2 Nasal septal cartilage with
mucoperichondrium 430
16.3 Tarsomarginal graft 431
Section B

Flaps to reconstruct the posterior lamella 432

Hughes’ tarsoconjunctival flap 433
Lateral periosteal flap 439
Hewes tarsal transposition flap 442

Chapter 17

Eyelid reconstruction – anterior and
posterior lamellae combined 445

Cutler-Beard flap 446

Alternative procedure 449
17.2 ‘Switch’ flap to the upper lid 449

Advancement flaps 397
15.5 Advancement flap in the cheek 397
15.6 Advancement flaps in the lower lid 398

Chapter 18

Rotation flaps 400
15.7 O to Z rotation flaps 400
15.8 Mustardé cheek rotation flap 401

Section A

Transposition flaps 401
15.9 Upper lid to lower lid transposition flap – based
laterally 402
15.10 Upper lid to lower lid transposition flap – based
medially 404
15.11 Nasojugal transposition flap 406
15.12 Lateral cheek to lower lid transposition flap 409
15.13 Rhombic transposition flap 413
15.14 Bilobed transposition flap 417
Glabellar flaps 418
15.15 Glabellar V-Y sliding flap 418
15.16 Glabellar transposition flap 421
15.17 Glabellar flap and Cutler-Beard bridge flap
combined 421
15.18 Glabellar flap and Hughes’ tarsoconjunctival
flap combined 423
Alternative procedures 424
15.19 Midline forehead flap 424
15.20 Lateral forehead flap 426

Miscellaneous conditions


Epicanthus and/or telecanthus 454

Mustardé double Z-plasty 455
Y-V plasty 460
Transnasal wire to fix the canthi 463

Section B

Vertical displacement of the canthi 464

Vertical displacement of the lateral canthus 465
Vertical displacement of the medial canthus 465

Section C

Miscellaneous 466
18.6 Autogenous fat harvesting (Coleman) 468
18.7 Orbicularis muscle strip 472

Index 479

Video Table of Contents
Chapter 2

Chapter 10

Basic techniques in ophthalmic
plastic surgery


Video 1
Video 2
Video 3

Hughes flap lower lid reconstruction
Quilting sutures
Graft of oral mucosa to a socket
Harvesting fascia lata

Chapter 6



Suture repair of entropion
Quickert entropion repair
Jones correction of entropion
Anterior lamellar reposition
Hotz procedure

Video 18
Video 19
Video 20
Video 21

Upper lid blepharoplasty
Upper lid blepharoplasty and ptosis
Direct brow lift
Pretrichial brow and forehead lift

Chapter 11

Eyelid retraction
Video 22

Gold weight to upper lid

Chapter 13

The anophthalmic socket
Video 23

Graft of oral mucosa to a socket

Chapter 7

Chapter 14


Eyelid reconstruction – eyelid
margin closure

Video 9

Lateral tarsal strip

Chapter 9

Video 10
Video 11
Video 12
Video 13
Video 14
Video 15
Video 16
Video 17

Anterior aponeurotic advancement
Posterior levator aponeurosis
Anterior levator resection
Putterman Müllers muscle-conjunctiva
Fasanella Servat Müller’s muscle
Fascia lata frontalis suspension
Levator muscle weakening
Silicone frontalis suspension ptosis

Video 24

Lid margin closure and cantholysis

Chapter 15

Eyelid reconstruction – anterior
Video 25
Video 26

Advancement cheek flap
Rhombic flap

Chapter 16

Eyelid reconstruction –
posterior lamella
Video 27

Hughes flap lower lid reconstruction
Quilting sutures

Preface to the
Fourth Edition
Ophthalmic plastic surgery continues to progress and
develop in an exciting and challenging way. The request
by many colleagues, trainees and the publishers, to
prepare a Fourth Edition of this Colour Atlas prompted
a complete revision of the text, the colour images and
the videos.
The book has been expanded by the addition of new
text, surgical procedures and illustrations in several
chapters. To maintain a manageable size, some of the
less common surgical series have been placed online,
but referenced from within the printed text. The variety
of surgical operations on videos has been significantly
expanded and several videos from previous editions have
been replaced. A very small number of operative series
have been omitted from the Fourth Edition. Orbital
surgery is increasingly specialised and rapidly changing
orbital operations, such as orbital decompression, have

been omitted; there are several excellent texts covering
these procedures. As in previous editions, lacrimal surgery
has been omitted because this field is comprehensively
covered in other texts. Cosmetic surgery has continued
to expand and develop; while there has been a small
increase in cosmetic surgery procedures in the Atlas,
non-surgical procedures have been omitted, as in the
Third Edition; many recent texts fully cover this rapidly
changing field.
The aims of the Fourth Edition are unchanged from
previous editions: to stimulate the quest for excellence
in ophthalmic plastic surgery and to foster, at all levels,
the best teaching of the extensive variety in this fascinating

Preface to the
Third Edition
Ophthalmic plastic surgery continues to evolve in many
areas but especially in the dramatic increase in demand
for cosmetic surgery. These developments have prompted
a third edition.

Some surgical manoeuvres are more easily understood
from a video than a still image. Video clips of selected
procedures are to be found on a DVD included with this

The text and illustrations have been extensively revised.
The anatomy chapter has been significantly enlarged to
include the detailed anatomy of the forehead and face:
the superficial musculo-aponeurotic system (SMAS), the
sub-orbicularis oculi fat (SOOF), the retro-orbicularis oculi
fat (ROOF) and the other deep fat pads of the face, as
well as the facial muscles. Aging changes are discussed
in detail and the surgical approach to facial rejuvenation
has been expanded to include the wider assessment of
the aging face, transblepharoplasty brow lift and mid
face lift. Other chapters have also been expanded. Additional procedures include rhombic and bilobed flaps and
the Hewes procedure, full-thickness upper lid recession
for lid retraction and the harvesting of autogenous fat.

We have not included non-surgical treatments such as
the use of botulinum toxin, fillers and facial resurfacing.
There are many excellent alternative sources for these.
Nor have we included lacrimal or orbital surgery which
also merit separate texts.
The aims of this edition are unchanged from the first
edition. We hope that these photographic series will
stimulate the quest for better understanding of the
procedures and safer practice in this exciting discipline
of ophthalmic plastic surgery.

Preface to the
Second Edition
Recent advances in ophthalmic plastic surgery have
stimulated a revision of both the text and the surgical
content of this edition. There has been a trend away
from preserved, homologous materials, in the wake of
the perceived risk of transmitted infection, and towards
autogenous and alloplastic materials. These materials
are the subjects of continuing assessment and new
ones are regularly introduced. A few surgical procedures omitted from the First Edition, for example the
conjunctival-approach lower lid blepharoplasty, gold
weight implantation into the upper lid and the autogenous
fascia lata lower lid sling, have been included. Newer
techniques have also been included, for example in the

approach to upper lid retraction, and the use of hard palate
The aims of this edition of the Atlas are unchanged.
Judging by the response to the First Edition these aims
have been realized and we have been encouraged to
make as few changes as possible! We hope that it will
continue to raise surgical standards and to stimulate
interest in ophthalmic plastic surgery.

Preface to the
First Edition
Surgeons commencing ophthalmic plastic surgery
commonly find difficulty identifying the anatomy of the
eyelids even though they may know the theory well.
Cadaver dissection is only part of the answer because
of the distortion of colour, morphology and ‘feel’ of the
tissues. The ideal is to spend time with an experienced
ophthalmic plastic surgeon and no substitute can compete
with this, but it is not always possible.
Our aim in this atlas is to provide surgical photographs
sufficiently realistic in colour and detail – and supported
by key diagrams where necessary – so that the anatomy
can be recognized at operation and each step of the
procedure understood. Ideally the reader who is competent in general ophthalmic or plastic surgery should
be able in this way to perform many of the operations
without the help of an experienced ophthalmic plastic
We have endeavoured to include a wide range of ophthalmic plastic procedures which cover almost every
aspect of the specialty. The choice inevitably reflects our
own practices but we hope that enough information is
given through the illustrations to allow alternative
procedures to be performed from a detailed description
only. We have not attempted to write a comprehensive

textbook of ophthalmic plastic surgery – there are many
excellent ones on the market. Our intention has been to
facilitate the surgery where there is difficulty due mainly
to poor recognition of the anatomy. However, in each
chapter we have given guidance on the choice of operations and some suggestions for further reading. In
addition, insets of related disorders appear at the end of
some chapters to summarize in outline the management
of certain conditions, for example facial palsy, which do
not fit easily into any single chapter.
We hope that this atlas will allow more direct access to
the field of ophthalmic plastic surgery for those with
relatively limited experience and provide a sound basis
on which to build as experience grows. We also hope
that teachers in the specialty will find it a useful resource
when describing and illustrating the details of surgical
techniques to their trainees. Finally, we hope to stimulate
interest and improve standards in this fascinating branch
of both ophthalmic and plastic surgery.

This Atlas would not have been possible without the
Surgical Theatre Staff and Ophthalmology Residents and
Fellows at Salisbury District Hospital, who have given
constant input to the planning and hands-on surgical
assistance of the procedures recorded. Russell Gabbedy

and Nani Clansey of Elsevier have given constant support,
encouragement and advice at every step in preparation.
Many friends and colleagues, as always too numerous
to mention, have guided and supported the preparation
of the new edition of this Colour Atlas.

New Images and Videos
for this Edition
Dr A.G. Tyers retains the copyright of any new photos
(see list below) and video material in this edition:
Chapter 2: Fig. 2.8c; Fig. 2.8d; Fig. 2.15c; Fig. 2.15d;
Fig. 2.19c.
Chapter 3: Fig. 3.3e; Fig. 3.3f; Fig. 3.3g; Fig. 3.3h;
Fig. 3.3i; Fig. 3.3j; Fig. 3.7a; Fig. 3.7b; Fig. 3.7c; Fig. 3.7d;
Fig. 3.10a; Fig. 3.10b; Fig. 3.11a; Fig. 3.11b; Fig. 3.11c;
Fig. 3.12a; Fig. 3.12b; Fig. 3.12c; Fig. 3.12d; Fig. 3.13c.
Chapter 5: Fig. 5.3.
Chapter 6: Fig. 6.1c; Fig. 6.1d; Fig. 6.1e; Fig. 6.3a;
Fig. 6.3b; Fig. 6.3c; Fig. 6.3d; Fig. 6.3e; Fig. 6.3f; Fig. 6.3g;
Fig. 6.3h; Fig. 6.3i; Fig. 6.3j; Fig. 6.3 post A; Fig. 6.3 post
B; Fig. 6.4 pre; Fig. 6.4 post; Fig. 6.7b pre; Fig. 6.7b post;
Fig. 6.7c pre; Fig. 6.7c post.
Chapter 7: Fig. 7.2a; Fig. 7.2b; Fig. 7.2c; Fig. 7.2d;
Fig. 7.2e; Fig. 7.2f; Fig. 7.2g; Fig. 7.2h; Fig. 7.2i; Fig. 7.2j;
Fig. 7.2k; Fig. 7.2l; Fig. 7.2m; Fig. 7.2n; Fig. 7.2o; Fig. 7.2p;
Fig. 7.2q; Fig. 7.3a; Fig. 7.3b; Fig. 7.3c; Fig. 7.3d; Fig. 7.3e;
Fig. 7.3f; Fig. 7.3g; Fig. 7.3h; Fig. 7.10B pre A; Fig. 7.10B
post A; Fig. 7.10B pre B; Fig. 7.10B post B; Fig. 7.11a;
Fig. 7.11b; Fig. 7.11c; Fig. 7.11d; Fig. 7.11e; Fig. 7.11f;
Fig. 7.11g; Fig. 7.11h; Fig. 7.11 pre; Fig. 7.11 post;
Fig. 7.12a; Fig. 7.12b; Fig. 7.12c: Fig. 7.12d; Fig. 7.12e;
Fig. 7.12f; Fig. 7.12g; Fig. 7.12h; Fig. 7.12i; Fig. 7.12j;
Fig. 7.12 pre; Fig. 7.12 post; Fig. 7.13a; Fig. 7.13b;
Fig. 7.13c; Fig. 7.13d; Fig. 7.13e; Fig. 7.13f; Fig. 7.14 pre
B; Fig. 7.14 post B.
Chapter 9: Fig. 9.3a; Fig. 9.3b; Fig. 9.3c; Fig. 9.3d;
Fig. 9.3e; Fig. 9.3f; Fig. 9.3g; Fig. 9.3h; Fig. 9.3i; Fig. 9.3j;
Fig. 9.3k; Fig. 9.3l; Fig. 9.3m; Fig. 9.3n; Fig. 9.3o; Fig. 9.3p;
Fig. 9.3q; Fig. 9.3r; Fig. 9.3s; Fig. 9.3t; Fig. 9.3u; Fig. 9.3v;
Fig. 9.3w; Fig. 9.3x; Fig. 9.3 pre; Fig. 9.3 post A; Fig. 9.3
post B; Fig. 9.3 post C; Fig. 9.5a; Fig. 9.5b; Fig. 9.5c;
Fig. 9.5d; Fig. 9.5e; Fig. 9.5f; Fig. 9.5g; Fig. 9.5h; Fig. 9.5i;
Fig. 9.5j; Fig. 9.5k; Fig. 9.5l; Fig. 9.5m; Fig. 9k.5n;
Fig. 9.5o; Fig. 9k.5p; Fig. 9.5q; Fig. 9.5 pre A; Fig. 9.5 post
A; Fig. 9.5 pre B; Fig. 9.5 post B; Fig. 9.8a; Fig. 9.8b;

Fig. 9.8c; Fig. 9.8d; Fig. 9.8e; Fig. 9.8f; Fig. 9.8g; Fig. 9.8h;
Fig. 9.8i; Fig. 9.8j; Fig. 9.8k; Fig. 9.8l; Fig. 9.8m; Fig. 9.8n;
Fig. 9.8o; Fig. 9.8p; Fig. 9.8 pre B; Fig. 9.8 post B; Fig. 9.8
pre C; Fig. 9.8 post C; Fig. 9.10a; Fig. 9.10b; Fig. 9.10c;
Fig. 9.10d; Fig. 9.10e; Fig. 9.10f; Fig. 9.10g; Fig. 9.10 pre:
Fig. 9.10 post A; Fig. 9.10 post B.
Chapter 10: Fig. 10.1a; Fig. 10.1b; Fig. 10.1c; Fig. 10.1d;
Fig. 10.1e; Fig. 10.1f; Fig. 10.1g; Fig. 10.1h; Fig. 10.1i;
Fig. 10.1j; Fig. 10.1k; Fig. 10.1r; Fig. 10.1s; Fig. 10.1t;
Fig. 10.1u; Fig. 10.1v; Fig. 10.1w; Fig. 10.1x; Fig. 10.1y;
Fig. 10.1 pre A; Fig. 10.1 post A; Fig. 10.1 pre B; Fig. 10.1
post B; Fig. 10.1 pre C; Fig. 10.1 post C; Fig. 10.1 pre D;
Fig. 10.1 post D; Fig. 10.4 preA; Fig.i 10.4 postA; Fig. 10.4
preB; Fig. 10.4 postB; Fig. 10.4 preD and Fig. 10.4 postD;
Fig. 10.5a; Fig. 10.5b; Fig. 10.5c; Fig. 10.5d; Fig. 10.5e;
Fig. 10.5f; Fig. 10.5i; Fig. 10.5j; Fig. 10.5k; Fig. 10.5l;
Fig. 10.5m; Fig. 10.5n; Fig. 10.5o; Fig. 10.5p; Fig. 10.5q;
Fig. 10.5x; Fig. 10.5y; Fig. 10.5 preB; Fig. 10.5 postB;
Fig. 10.5 preD; Fig. 10.5 postD; Fig. 10.6 postB; Fig. 10.6
preB; Fig. 10.7 preB; Fig. 10.7 postB; Fig. 10.8 preB;
Fig. 10.8 postB; Fig. 10.9a; Fig. 10.9b; Fig. 10.9c; Fig. 10.9d;
Fig. 10.9e; Fig. 10.9 preA; Fig. 10.9 postAa; Fig. 10.9 post
Ab: Fig. 10.9 preB; Fig. 10.9 post Ba; Fig. 10.9 PosBb;
Fig. 10.11 preA; Fig. 10.11 postA; Fig. 10.11 preC;
Fig. 10.11 postCa; Fig. 10.11 post Cb; Fig. 10.14 pre; Fig.
10.14 post.
Chapter 11: Fig. 11.3 preB; Fig. 11.3 post B; Fig. 11.12
Chapter 12: Fig. 12.3g; Fig. 12.3h; Fig. 12.3i; Fig. 12.4a;
Fig. 12.4b; Fig. 12.4c; Fig. 12.4d; Fig. 12.4e; Fig. 12.4f; Fig.
12.5 preA; Fig. 12.5 postA.
Chapter 13: Fig. 13.4 pre; Fig. 13.4 post; Fig. 13.7 pre;
Fig. 13.7 post; Fig. 13.10 post.
Chapter 14: Fig. 14.3a; Fig. 14.3b; Fig. 14.3c; Fig. 14.3d;
Fig. 14.3 post.
Chapter 15: Fig. 15.3a; Fig. 15.3b; Fig. 15.3c; Fig. 15.3
post; Fig. 15.6a; Fig. 15.6b; Fig. 15.6c; Fig. 15.6d; Fig. 15.6

New Images and Videos for this Edition xvii
post A; Fig. 15.6 post B; Fig. 15.9a, Fig. 15.9b; Fig. 15.9c;
Fig. 15.9A pre: Fig. 15.9A post; Fig. 15.9B pre; Fig. 15.9B
post; Fig. 15.10a; Fig. 15.10b; Fig. 15.10c; Fig. 15.10d;
Fig. 15.10e; Fig. 15.10 pre; Fig. 15.10 post; Fig. 15.11B pre
a: Fig. 15.11B pre b; Fig. 15.11 B post; Fig. 15.12d;
Fig. 15.12e; Fig. 15.12f; Fig. 15.12g; Fig. 15.12A pre;
Fig. 15.12A post; Fig. 15.12B pre; Fig. 15.12B post a;
Fig. 15.12B post b; Fig. 15.12C pre a; Fig. 15.12C pre b;
Fig. 15.12C post a; Fig. 15.12C post b; Fig. 15.13B pre;
Fig. 15.13B post; Fig. 15.19a; Fig. 15.19b; Fig. 15.19 post.

Chapter 16: Fig. 16.4a; Fig. 16.4b; Fig. 16.4c; Fig. 16.4d;
Fig. 16.4e; Fig. 16.4f; Fig. 16.4g; Fig. 16.4h; Fig. 16.4i; Fig.
Fig. 16.4a pre: Fig. 16.4a post; Fig. 16.4b pre; Fig. 16.4b
post; Fig. 16.4c pre; Fig. 16.4c post A; Fig. 16.4c post B.
Chapter 18: Fig. 18.2a; Fig. 18.2b; Fig. 18.2c; Fig. 18.2d;
Fig. 18.2e; Fig. 18.2f; Fig. 18.2g; Fig. 18.2 pre; Fig. 18.2

Renee, Jonathan, Richard, Johanna and Rebecca
The Staff and Patients at The St John Eye Hospital, Jerusalem


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 complex anatomy.
Muscles arising from the bones of the facial skeleton
insert either into the soft tissues of the face, the muscles
of facial expression (1.5), or into the mandible, the muscles
of mastication (1.6). The forehead and scalp muscles – the
frontalis and occipitalis – function separately.
The spaces between the muscles are filled by fat pads
which are discrete and individually named (1.7). Vessels

and nerves weave around the muscles and at certain
points they are at risk from the surgeon’s knife
(1.15, 1.17).
The actions of the muscles of the temple, forehead and
face are supported and disseminated smoothly across
the face by a multilayered sheet of fascia of varying
thickness: the superficial musculo-aponeurotic system,
or SMAS (1.7).
Supporting these facial structures are several short, strong,
fibrous retaining ligaments (1.7) which arise from specific
sites in the facial skeleton and insert into the overlying
tissues and the skin. Progressive laxity in the retaining
ligaments and loss of elasticity in the skin are responsible
for many of the aging changes which prompt referral
for cosmetic or functional advice.



Colour Atlas of Ophthalmic Plastic Surgery

1.1 The bony orbit
(Diags 1.1–1.3)
The bony orbit is a roughly pyramidal space with its
base anteriorly; in cross-section it is rectangular anteriorly
and triangular posteriorly. Each orbit is about 4 cm deep
and has a volume of about 30 mL. The apex is the optic
foramen, enclosed between the two roots of the lesser
wing of the sphenoid. The inferior root, a thin bar of
bone, separates the optic canal from the superior orbital
fissure laterally. The inferior orbital fissure extends
inferiorly and laterally from just below the optic foramen.

About midway along its length the infraorbital groove
branches anteriorly.
The medial walls of the orbits are parallel to each other.
The lateral orbital walls are at 45 degrees to the medial
walls and 90 degrees to each other. The floor, narrow at
the apex, broadens as it slopes down and laterally. It is
separated from the lateral wall by the inferior orbital
fissure and it is continuous with the medial wall. The

Coronal suture
Greater wing
of sphenoid

Superciliary arch
Supraorbital notch


Zygomatic process


Frontal process
Infraorbital foramen


Mental foramen

Diag. 1.1
Anterior view of the skull.

Anatomy 3
Supraorbital notch
Frontal bone
Anterior and posterior
ethmoidal foramina

Optic foramen

Nasal bone
Anterior lacrimal crest
Posterior lacrimal crest

Lesser wing of sphenoid
Greater wing of sphenoid
Superior orbital fissure

Lacrimal sac fossa

Zygomatic bone

Lacrimal bone

Inferior orbital fissure

Infraorbital groove

Infraorbital foramen

Diag. 1.2
Oblique view of the bony orbit.

Superior and inferior
temporal lines

Greater wing
of sphenoid
Corrugator m.
Lacrimal part of
orbicularis oculi m.
Orbicularis oculi m.
Levator labii superioris
aleque nasi m.
Infraorbital foramen
Levator labii superioris m.
Zygomaticus minor m.
Zygomatic arch
Coronoid process
Masseter m.
Zygomaticus major m.

Diag. 1.3
Lateral view of the skull.

Buccinator m.


Colour Atlas of Ophthalmic Plastic Surgery

junction of the medial wall and the roof is marked by
the anterior and posterior ethmoidal foramina.
The lacrimal gland fossa is just posterior to the superolateral orbital rim. The lacrimal sac fossa is just posterior
to the inferomedial orbital rim, bounded anteriorly by
the anterior lacrimal crest, a continuation of the inferior
orbital rim, and posteriorly by the posterior lacrimal crest,
a continuation of the superior orbital rim.
Each orbital margin measures approximately 40 mm,
although the horizontal margins are usually greater than
the vertical. The lateral and inferior rims are posterior
to the medial and superior rims (Diags 1.3, 1.5) and this
is more marked in children. The lateral rim is approximately 20 mm posterior to the medial and the plane
between them has almost one-third of the eye in front
of it. The superior orbital rim protrudes about 10 to 15 mm
beyond the inferior rim. The adult corneal apex is 8 to
10 mm posterior to the superior rim and 2 to 3 mm
anterior to the inferior rim and just reaches the plane
between the two. Measured from the lateral orbital rim
the corneal apex is about 13 mm in a child and up to
22 mm in an adult.
Just within the midpoint of the lateral rim, Whitnall’s
(lateral orbital) tubercle may be palpated. The trochlea
is palpable just within the superomedial rim. The supraorbital notch is at the junction of the medial third and the
lateral two-thirds of the superior rim and the infraorbital
foramen is about 5 mm below the midpoint of the inferior
rim or just medial to this.
The orbits are lined by periosteum (periorbita) which
can be lifted easily (see Figs 12.3c, 13.7c) except at the
orbital margins, at the sutures, fissures and foramina
and at the margins of the lacrimal sac fossa. At the
posterior lacrimal crest the periosteum splits to enclose
the lacrimal sac and reunites at the anterior lacrimal crest.
The orbits offer protection and support for the eyes and
they transmit nerves and vessels to the face.

1.2 Surface anatomy of

the eyelids (Figs 1.1–1.5)

The upper and lower lids enclose the palpebral aperture
and they join at the medial and lateral canthi. The lateral
canthus is acute; the medial canthus is rounded and
separated from the eye by a small bay, the tear lake (lacus
lacrimalis), in which are a rounded elevation, the caruncle,
and a vertical fold, the plica semilunaris.
The average size of the palpebral aperture in an adult is
30 mm horizontally and 10 mm vertically between the
centres of the lids. The point of maximum concavity is
different in the two lids. In the upper lid it is just medial
to the pupil. In the lower lid it is just lateral. With the
eye in the primary position the upper lid covers 1 to
3 mm of the upper cornea and the lower lid is at or close
to the lower limbus. Scleral show of up to 2 mm between
the lower lid and the limbus can be considered a normal
variation but excessive scleral show may indicate lower
lid retraction, proptosis or anomalies of the midfacial
The lateral canthus is higher than the medial canthus
– a line drawn between the canthi is elevated about 0 to
7 degrees laterally, a mean of about 3.5 degrees. The
distance between the medial canthi is approximately half
the interpupillary distance (Table 1.1).
Variations in children may reflect anomalies of facial
development. The final dimensions of the palpebral
apertures are achieved toward the late teens.
In the upper lid the delicate preseptal skin (inferior to
the brow) and the pretarsal skin (superior to the lashes)
meet at the level of the skin crease, a transverse crease
6 to 10 mm from the lash line in an adult, lower in a
child. The skin crease is formed by the insertion of the
levator aponeurosis into the orbicularis muscle at this
level (see Diag. 1.16). It is occasionally twice this size.

Table 1.1

Periocular measurements 0–16 years; mean and 2 standard deviations
Inner intercanthal distance
Outer intercanthal distance
Interpupillary distance
Palpebral fissure length
Angle IC to OC
Globe protrusion


8 years

16 years

20 (15–25)
67 (62–72)
39 (33–45)
19 (17–21)

30 (24–34)
96 (86–106)
53 (46–60)
28 (25–31)
3.5 deg (0–7)

32 (26–36)
105 (95–115)
59 (52–66)
31 (28–33)
3.5 deg (0–7)

13–22 children and adults

Source: Hall JG, Froster-Iskenius UG, Allanson JE 1989 Handbook of normal physical measurements. Oxford University Press.

Anatomy 5

Fig. 1.1
Surface anatomy of the open eyelids.

Fig. 1.2
Surface anatomy of the closed eyelids.

upper lid sulcus

Preseptal skin

Fullness due to
preaponeurotic fat

Upper lid fold

Upper lid skin crease
Pretarsal skin
Lower lid
skin creases

Key diag. 1.1

Key diag. 1.2

There is often redundant skin superior to the skin crease
in the upper lid so that a fold of skin, the upper lid skin
fold, is created which covers the skin crease (Fig. 1.1).
Superior to the skin crease the ‘fullness’ in the upper lid
(Fig. 1.2) is due to orbital fat. The lacrimal gland lies
laterally. Immediately below the brow there may be some
hollowing of the upper lid – the upper lid sulcus (see
Fig. 1.1). This is often marked in the elderly, especially
if there is a ptosis (see Fig. 9.1 Pre B). If a skin crease is
present in the lower lid, it is usually less obvious than
the upper lid crease. It is formed approximately at the
level of the lower border of the inferior tarsal plate, 4 to
5 mm from the lash line (see Diag. 1.15).

The brow position and profile are different in males and
females. The brow lies just above the superior orbital
rim in females and it tends to be slightly arched. In males
the brow is flatter and deeper and it lies at a lower level,
along the anterior aspect of the superior orbital rim. As
the orbital rim descends laterally the downward curve
of the brow is gentler. In contrast to the thin skin of the
upper lid, brow skin is thick (see Fig. 10.7d). It bears
numerous hairs whose follicles are directed laterally at
about 30 degrees, except at the medial end of the brow
where they are directed upwards. Deep to the brow is a
fat pad – the retro-orbicularis oculi fat or ROOF – which
is variable in volume. It is more prominent in males but
in both males and females the brow fat may spread
inferiorly, especially laterally, causing a fullness in the
upper lid which some find unaesthetic.

In the lower lid the junction of the lid and the root of
the nose, the naso-jugal fold, may develop a shallow
linear depression, the ‘tear trough’, which extends down
and laterally from below the inner canthus (Figs. 10.1g,l).
It deepens with age.

In profile view (Fig. 1.3), the anterior surface of the adult
cornea is approximately in line with the malar eminence


Colour Atlas of Ophthalmic Plastic Surgery
In downgaze (Fig. 1.5) the lower lid level is depressed
by the pull of the lower lid retractors and the lower lid
skin crease is accentuated. The lateral canthus moves
down slightly. The upper lid fold is reduced, revealing
the previously covered skin crease.

Fig. 1.3
Profile of face.

Fig. 1.5
Eyelid features in downgaze.

or slightly posterior to it. If the cornea is anterior to the
malar eminence the intrinsic support for the lower lid
is weaker; this is known as a ‘negative vector’.
In upgaze (Fig. 1.4) the action of the levator and Müller’s
muscles lifts the upper eyelid. The action of the frontalis
lifts the brow. The elevation of the brow contributes about
2 mm to the elevation of the upper lid. The lateral canthus
rises slightly. The upper lid fold is accentuated.

1.3 Eyelid skin
The skin of the eyelids is the thinnest in the body, less
than 1 mm thick and almost transparent in places. It is
attached quite loosely to the orbicularis muscle and more
firmly to the region of the canthal tendons – especially
the medial.
Apart from the lashes, the skin hairs are very fine. The
sweat glands of Moll secrete between the lashes or into
the ducts of the glands of Zeis. The sebaceous glands of
Zeis secrete into the lash follicles.
Fig. 1.4
Eyelid features in upgaze.

Deep to the skin is a thin layer of loose connective tissue
which contains no fat and which lies on the orbicularis

Anatomy 7

1.4 Eyelid structure
The eyelids are conveniently divided into two anatomical
lamellae (see Diags 1.15, 1.16). The anterior lid lamella
includes the skin and the orbicularis muscle. The posterior
lamella is formed by the tarsal plate and the conjunctiva.
A grey line, visible transversely along the middle of each
lid margin, marks the junction of the anterior and posterior
lamellae (see Fig. 3.16). These lamellae are very important
in eyelid surgery. Between the lamellae there is a layer
of connective tissue.

1.5 Muscles of facial

expression, the mimetic
muscles (Diags 1.4, 1.5)
These muscles are derived from the second branchial
arch and they are innervated by the seventh cranial nerve.

The margins of the eyelids are 2 mm wide. The posterior
lid margin is sharp and applied to the globe. The anterior
lid margin is rounded and holds the eyelashes. The
mucocutaneous junction is at the Meibomian gland
openings, just posterior to the grey line at the margin of
the lid.

Galea aponurotica

Superficial branches,
supraorbital nerve
Frontalis muscle
Deep branch,
supraorbital nerve
Temporal crest
Frontal branch,
facial nerve

supercilii muscle
Procerus muscle

Zygomatic major
Zygomatic branches,
facial nerve

Diag. 1.4
Anterior view of muscles of facial expression and their relationship with local nerves.

Superficial and deep
branches, supratrochlear


Colour Atlas of Ophthalmic Plastic Surgery
Epicranial aponeurosis
(Galea aponeurotica)

Superior &
temporal lines


Orbicularis oculi

Zygomatic arch

Levator labii


Orbicularis oris

Depressor anguli oris

Diag. 1.5
Lateral view of muscles of facial expression and muscles of mastication.

1.5.1 Muscles and tendons of the eyelids
(a) The muscles – orbicularis oculi
(Diags 1.6, 1.7)

Palpebral part
of orbicularis


Orbital part of
orbicularis muscle

The orbicularis oculi muscle closes the eyelids. The muscle
is a flat sheet of fibres which encircles the palpebral
aperture spreading out beyond the orbital rim. It is
divided into two concentric zones – orbital (overlying
the orbital rims) and palpebral (overlying the lids). The
palpebral part is further divided into a preseptal part
(anterior to the orbital septum) and a pretarsal part
(anterior to the tarsal plate).
The orbital part arises from the medial orbital rim and
its fibres sweep laterally in concentric bands to join at
the lateral orbital rim. The palpebral part arises from the
lateral canthal tendon and inserts medially. At the lid
margins the pretarsal muscle extends posteriorly as far
as the Meibomian gland openings and the muscle of
Riolan (see Diags 1.15, 1.16).

Terminal branches
of the zygomatic division
of the facial nerve

Diag. 1.6
Orbicularis oculi muscle and the terminal branches of the facial

Anatomy 9
Superficial insertion
of preseptal
orbicularis muscle

Deep insertion
of pretarsal
orbicularis muscle

Fibromuscular part of
medial canthal tendon
Superficial insertion of
pretarsal orbicularis muscle
Lacrimal sac

Deep insertion of
preseptal orbicularis muscle

Diag. 1.7
The medial canthus.

The medial attachments of the palpebral part of the
orbicularis oculi muscle are complex (Diag. 1.7).
The pretarsal muscles, firmly attached to the tarsal plates,
insert medially by a superficial head and a deep head.
The superficial head from each lid blends with a fibrous
component to form the anterior part of the medial canthal
tendon. The deep head from each lid is also known as
the pars lacrimalis, or Horner’s muscle. Its fibres begin
at the medial ends of the tarsal plates and insert into the
posterior lacrimal crest a few millimetres behind the
lacrimal sac. Contraction of the deep head pulls the lid
medially and posteriorly.
The preseptal muscles, less firmly attached to the orbital
septum, also insert medially by a superficial head and
by a deep head. The superficial head from each lid inserts
into the superficial part of the medial canthal tendon.
The deep heads insert into the fascia overlying the lacrimal
sac and on the medial orbital wall above and below
Horner’s muscle. Contraction of the deep heads pulls
the lacrimal fascia laterally.
There is some discussion about the detailed anatomy of
the medial canthus. In practice the individual muscle
insertions described previously are not usually identified
at operation.
At the lateral canthus the pretarsal muscles join and insert
by a common tendon into Whitnall’s tubercle. The preseptal muscles join laterally to form a lateral raphe which
is connected to the underlying tendon.

(b) The canthal tendons (also known as
palpebral ligaments)
(i) The lateral canthal tendon (Diag. 1.8)
Deep to the muscle insertions described above a Y-shaped
fibrous thickening in the orbital septum joins the lateral
ends of the tarsal plates to Whitnall’s tubercle. These
muscular and fibrous structures together form the lateral
canthal tendon.

(ii) The medial canthal tendon (Diag. 1.7)
The medial canthal tendon also has a fibrous and a
muscular component. The muscular component was
described in detail previously.
The fibrous component is attached laterally to the medial
ends of the tarsal plates as two limbs of a Y. It has a
superficial and a deep component. The superficial component inserts medially on the frontal process of the
maxilla just anterior to the anterior lacrimal crest, level
with the upper part of the lacrimal sac. It has a definite
inferior border but the superior border blends with the
periosteum. The deep component leaves the deep surface
just lateral to the anterior lacrimal crest and inserts into
the posterior lacrimal crest behind the lacrimal sac. This
deep component of the tendon is the main medial anchor
of the lids.

(c) The lacrimal pump
During blinking the deep heads of the pretarsal muscles
(Horner’s muscle) pull the medial ends of the eyelids


Colour Atlas of Ophthalmic Plastic Surgery

Lateral raphe

Diag. 1.8
The lateral canthus.

medially, shortening the canaliculi, while the lacrimal
fascia and sac wall are pulled laterally by contraction of
the deep heads of the preseptal muscle. The puncta close
and the tears in the ampullae of the canaliculi are forced
medially and are sucked into the sac. As the deep insertions of the orbicularis muscle relax at the end of the
blink the lacrimal fascia and sac wall move medially
again, the medial ends of the lids move laterally, the
puncta reopen and the ampullae refill with tears. Drainage
of tears from the lacrimal sac into the nasolacrimal duct
is not influenced directly by the lacrimal pump mechanism
and is mainly due to gravity.

1.5.2 Muscles of the forehead and scalp
(Diags 1.4, 1.5)

The occipitalis muscle posteriorly and the frontalis muscle
anteriorly are joined by an aponeurosis, the galea aponeurotica or epicranial aponeurosis. Laterally, it blends with
the temporoparietal (superficial temporal) fascia which

together form part of the superficial musculo-aponeurotic
system (SMAS, see 1.7.1 and Diag. 1.9). The frontalis
muscle fibres insert into the orbicularis muscle and
the skin of the brows. The occipitalis arises from the
occipital bone.
The corrugator supercilii muscle (Diag. 1.4) arises from
the medial end of the superciliary ridge, lateral to the
origin of the procerus muscle, and passes upwards and
laterally through both frontalis and orbicularis muscles
to insert into the skin of the middle of the brow. It draws
the brow in and down. The superficial and deep branches
of the supraorbital nerve pass either side of the muscle,
approximately at its midpoint, as they ascend into the
The procerus muscle arises on the nasal bones and inserts
into the skin of the lower forehead and bridge of the
nose. It wrinkles the nose.
These muscles are all innervated by the frontal branch
of the facial nerve.

Anatomy 11
1.5.3 Muscles of the mouth (Diags 1.5, 1.11)
Several small muscles deep within the cheek arise from
the facial skeleton below and lateral to the eye and
converge on the angle of the mouth. They and their
anatomical relationships are important in any surgery
in the mid face. The zygomaticus major and minor muscles
arise from the zygomatic bone. The levator labii superioris
and the levator anguli oris respectively arise from above
and below the infraorbital foramen. A number of other
smaller muscles in the mid face are less relevant surgically.
They include the levator labii superioris alequae nasi
which arises from the frontal process of the maxilla just
anterior to the orbicularis oculi.

1.6 Muscles of

mastication (Diag. 1.5)
These muscles are derived from the first branchial arch
and they are innervated by the motor fibres in the
mandibular division of the fifth cranial nerve.

1.6.1 Temporalis muscle
This fan-shaped muscle arises from a wide origin on the
side of the skull – the inferior temporal line. It also has
attachments to the strong overlying temporal fascia which
inserts into the superior temporal line. The temporalis
muscle fibres descend and converge to insert on the
coronoid process and anterior part of the ramus of the

1.6.2 Masseter muscle
The masseter muscle, which can be easily palpated in
the cheek when the teeth are clenched, arises from the
lower border of the zygomatic arch and inserts on the
angle and ramus of the mandible. The anterior border
of the parotid gland wraps around the posterior border
of the masseter. The parotid duct passes forward across
the middle of the muscle and winds around its anterior
border to pierce the buccinator muscle and enter the
mouth at the level of the second upper molar tooth.

1.7 Facial fat and fascia
Subcutaneous fat throughout the body is separated into
a superficial, continuous layer of fat, just deep to the
dermis and of variable thickness, and a deeper, discontinuous layer which is formed of collections of fat between
the muscles.
The superficial fat layer is thickened in the cheek where
it is known as the malar fat pad. It also has a deep
component between the facial muscles.
Of the deep fat pads in the face, a number are important
during surgery in the periocular region.
These superficial and deep fat layers are separated by a
layer of thin superficial fascia.
Fascia is also found at a deeper level where it is of variable
thickness. It invests the muscles of facial expression (the
mimetic muscles), binds the deeper structures together,
forms intermuscular septa between muscles or groups
of muscles and binds muscles or tendons to deeper
This system of superficial and deep layers of fascia is
the superficial musculo-aponeurotic system, or SMAS.
The facial nerve pierces the deep layer of the SMAS in
the mid cheek to innervate the enclosed muscles of facial

1.7.1 The superficial musculo-aponeurotic
system (SMAS) (Diags 1.9, 1.10)
The multilayered sheet of fascial tissue which forms the
SMAS extends from the galea aponeurotica (epicranial
aponeurosis) in the scalp to the platysma muscle in the
neck. It splits, en route, to enclose the muscles of facial
expression, binding them together so that their action is
disseminated and their effect is smoothly coordinated.
There has been some discussion about the extent and
continuity of the SMAS. The following is a summary of
the main features.
In the scalp the SMAS is represented by the galea
aponeurotica. Here it splits to enclose the frontalis muscle
(Diag. 1.10). The superficial part covers the anterior surface
of the frontalis and orbicularis muscles. The deep part,
lying on the periosteum, splits again into anterior and
posterior layers to enclose the fat pad of the brow – the
retro-orbicularis oculi fat pad or ROOF (see 1.7.4). The
anterior layer of the deep galea covers the posterior
surface of the orbicularis muscle. It is thickened laterally
as part of the orbital retaining ligament (1.7.5). The
posterior layer of the deep galea becomes the orbital


Colour Atlas of Ophthalmic Plastic Surgery

The superficial and deep layers of the deep galea continue
their descent into the upper lid and ultimately reunite
on the surface of the levator aponeurosis (Diag. 1.10).
The superficial and deep galea, lying superficial and deep
to the orbicularis muscle respectively, become attenuated
within the lid and unite close to the lid margin. Laterally,
within the lid, the layers of the galea pass around the
canthi into the mid face to unite with the facial SMAS
to lie superficial and deep to the other facial muscles.
Laterally from the scalp the SMAS descends into the
temple as the temporoparietal (superficial temporal) fascia,
a sheet lying on the surface of the (deep) temporal fascia
(see 1.7.2). It continues down superficial to the zygomatic
arch and masseter muscle (Diag. 1.9). Within the temporoparietal fascia the frontal branch of the facial nerve
passes superiorly across the midpoint of the zygomatic
arch where it is particularly vulnerable to injury during
face and brow lift surgery. Inferior to the zygomatic arch
the temporoparietal fascia splits into a superficial layer
and a deep layer to enclose the muscles of facial expression
in the mid face and neck – the zygomatic, orbicularis
oculi and platysma muscles and other small muscles in
the mid face.

The SMAS is a well-formed layer in the scalp (the galea
aponeurotica) and the temporal region (the temporoparietal fascia) but it becomes thin and variable elsewhere,
including most of the mid face. In the parotid-masseteric
region, it is also thin but it is adherent to the parotid
fascia which results in a uniform sheet overlying the
parotid gland and extending some way into the mid face.
Attenuated anterior and posterior layers envelop the
orbicularis muscle of the lower lid.

1.7.2 Temporal fascia and fat pads
(Diag. 1.9)

The terminology of the temporal fascial layers can be
The temporoparietal fascia, the SMAS in the temporal
region, is sometimes known as the superficial temporal
fascia. It is described above (1.7.1).

Anatomy 13
The temporal fascia, also known as the deep temporal
fascia, is a strong membrane stretching over the temporal
fossa and covering the temporalis muscle. It has superficial
and deep layers (Diag. 1.9). It arises above, along the
superior temporal line (also known as the temporal fusion
line or temporal line of fusion) (Diag. 1.3), just superior
to the origin of the temporalis muscle which arises from
the inferior temporal line. Along the superior temporal
line the temporal fascia fuses with the periosteum and
the bone. As it descends toward the zygomatic arch the
temporal fascia splits. The superficial layer inserts along
the superior border of the zygomatic arch. The deep layer
descends on the surface of the temporalis muscle, deep

to the zygomatic arch, then on the surface of the masseter
muscle down to its insertion on the mandible.
Between the superficial and deep layers of the (deep)
temporal fascia lies the superficial temporal fat pad – often
termed simply the temporal fat pad. It is situated just
above the posterior half of the zygomatic arch. Between
the deep layer of the (deep) temporal fascia and the
temporalis muscle lies the deep temporal fat pad; this is
the temporal extension of a pad of fat extending up from
the cheek – the fat pad of Bichat. It is situated more
anteriorly, between the zygomatic arch and the lateral
orbital rim.

Scalp skin

plane (loose-areolar)

Superior & inferior
temporal lines

Temporoparietal fascia
(superficial temporal fascia)
layer DTF
Anterior branch superficial
temporal artery
Frontal (temporal)
branch facial nerve
Zygomatic arch
Deep temporal
fat pad

Superficial temporal
fat pad
Deep layer DTF
Temporalis muscle

Hard palate

Parotid gland
Parotid duct
Buccal branch
facial nerve

Buccinator muscle
Medial pterygoid muscle

Masseter muscle
Platysma muscle
(continuous with SMAS)

Diag. 1.9
Coronal section through the SMAS, temporal fascia and muscles on the lateral side of the face.


Colour Atlas of Ophthalmic Plastic Surgery

1.7.3 Sub-orbicularis oculi fat pad –
SOOF (Diags 1.10–1.12)
This fad pad lies just below the lateral half of the inferior
orbital rim and extends over the lower part of the body
of the zygoma. It is in contact with the periosteum but
its lower border overlaps the origins of the zygomatic,
levator labii and levator anguli oris muscles, deep to the

lower part of the orbicularis oculi muscle in the upper
cheek. It is posterior to the deep layer of the SMAS lining
the deep surface of the orbicularis muscle. As the SMAS
descends from the lower lid tissues, it is thickened into
a supporting sheet, the orbitomalar ligament (also known
as the orbicularis retaining ligament), which has attachment also to the inferior orbital rim periosteum. This has
to be cut to expose the SOOF from above (Diag. 1.10).

Superficial galea
Deep galea
Anterior and posterior
deep galea

Sub-brow fat pad (ROOF)
Frontalis muscle

Preaponeurotic fat
Orbital septum
Preseptal fat (ROOF)
Orbicularis oculi muscle
Müller's muscle
Levator aponeurosis
Superior tarsus

Inferior tarsus

Orbital septum
Orbital fat
Orbitomalar ligament
Orbicularis muscle
Malar fat pad
Suborbicularis oculi
fat (SOOF)

Diag. 1.10
Sagittal section through the fascia, muscles and fat of the eyelids, forehead and upper cheek.

Anatomy 15


Orbital fat


Orbitomalar ligament

Diag. 1.10, cont’d

Levator labii superioris
alaeque nasi
Levator labii

Zygomaticus minor
Zygomaticus major
Levator anguli oris

Diag. 1.11
Mimetic muscles of the cheek with the SOOF and ROOF fat

1.7.4 The retro-orbicularis oculi fat pad
– ROOF (Diags 1.10–1.12)
This fat pad, which is generally more prominent in males,
lies deep to the hair-bearing skin and thin subcutaneous
fat layer of the brow, the orbital part of the orbicularis
muscle and the lower fibres of the frontalis muscle. It
is enclosed between the superficial and deep layers of
the deep galea aponeurotica as these descend into the
upper lid. An additional deep attachment of the brow fat
to the supraorbital periosteum is more secure medially
than laterally. The brow fat may extend inferiorly on
the anterior surface of the orbital septum where it can
be confused with the preaponeurotic fat pad which is
posterior to the septum at the same level. The supraorbital
nerve and vessels emerge from the supraorbital foramen
at the junction of the central and medial thirds of the
superior orbital rim. The supratrochlear nerve emerges
medially (see Diags 1.4, 1.23, 1.24). These sensory nerves
pass superiorly between the periosteum and the overlying
ROOF and then pierce the frontalis muscle to reach the
skin of the scalp.
The SOOF and ROOF pads communicate at their lateral
ends through fat overlying the lateral orbital rim and
the lateral canthal tendon. These fat pads are separated
from the orbital fat pads by the orbital septum and, in
the lower lid, also by the layers of the SMAS (orbitomalar
ligament) at the orbital rim.

Orbicularis oculi


Diag. 1.12
Orbicularis oculi muscle and its relationship to the underlying
muscles and fat of the cheek.


Colour Atlas of Ophthalmic Plastic Surgery

1.7.5 The retaining ligaments (Diag. 1.13)
The retaining ligaments of the face are fibrous connective
tissue condensations that originate on the bones of the facial
skeleton and support the overlying soft tissues. There are
three retaining ligaments in the orbital region; each arises
from one of the bony sutures of the zygoma. In addition,
the orbitomalar ligament (also known as the orbicularis
retaining ligament) supports the cheek (see 1.7.3).
The orbital retaining ligament lies at the anterior end of
the superior temporal line (temporal fusion line) and

bridges the zygomatico-frontal suture. It inserts into the
overlying muscles and skin close to the tail of the brow.
The zygomatic retaining ligament, also known as
McGregor’s patch, is centred on the zygomatico-temporal
suture at the anterior end of the zygomatic arch. This
ligament supports the tissues of the upper lateral cheek.
One of the rami of the zygomatic branch of the facial
nerve passes inferiorly and deep to it. The buccal-maxillary
retaining ligament covers most of the zygomaticomaxillary suture and inserts as a line into the tissues of
the mid cheek above the nasolabial fold.

Orbital retaining ligament
retaining ligaments
Zygomatic retaining
ligaments (McGregor’s patch)
Zygomatic major muscle

Diag. 1.13
Retaining ligaments of the periocular region and cheek.

1.8 Orbital fat and fascia
(Diags 1.14, 1.23)
The muscle cone divides the orbital fat into two parts,
the intraconal and extraconal fat, which are separated
by fascia anteriorly, between the rectus muscles, but
communicate posteriorly as the fascia becomes thinner.
The fat is supported by a complex meshwork of delicate
connective tissue septa elaborated, by Koornneef (1976,
1979). This system of interlocking septa, which effectively
links the various orbital components, is well formed in
the anterior orbit but is weaker posteriorly.
The intraconal fat is exposed by enucleation of the eye
or by surgery in the intraconal space. The extraconal fat
is frequently seen in lid surgery and is divided into four
lobes or fat pads.

In the upper lid, there are two extraconal fat pads: a
smaller medial fat pad and a larger central fat pad, the
preaponeurotic fat pad (see Figs 9.3e,f, 10.2c,d). These
fat pads are separated by a fascial septum in the region
of the trochlea. Lateral to the preaponeurotic fat pad lies
the lacrimal gland (see Fig. 10.3a).
In the lower lid, there are also two fat pads (see
Fig. 6.4c). The larger medial fat pad is often subdivided
into two smaller collections – the medial and central fat
pads – separated by the inferior oblique muscle and a
fine fascial septum in the region of the inferior oblique
muscle origin. Care must be taken not to damage the
inferior oblique muscle during reduction of this fat pad
at blepharoplasty (see 10.4c). The smaller lateral fat pad
is separated from the medial fat pad(s) by a fascial septum.

Anatomy 17
Whitnall’s ligament

Levator muscle

Lacrimal gland

Preaponeurotic fat pad
Medial fat pad of upper lid

Lateral horn of
levator aponeurosis
Levator aponeurosis
inserting into superior tarsus

Medial horn of
levator aponeurosis

Lateral canthal tendon

Medial canthal tendon

Lateral fat pad of lower lid
Lower lid retractors
inserting into inferior tarsus

Medial fat pad

Diag. 1.14
The extraconal fat pads and the insertions of the upper and lower eyelid retractors.

1.9 The retro-orbicular

fascia and related
spaces (Diags 1.15–1.17)

Posterior to the orbicularis muscle within the lids is areolar
tissue containing the vessels and nerves of the lids and
a small, variable amount of fat. Dissection in this space
splits a lid into its two lamellae (see Fig. 8.2b).

Inferior suspensory
ligament of the fornix

Inferior rectus muscle

Muscle of Riolan

Orbicularis muscle
Inferior tarsal muscle
Retro-orbicular fascia
Orbital septum
Central fat pad of lower lid
Arcus marginale

Inferior oblique muscle
Lockwood’s ligament
Capsulopalpebral fascia

Diag. 1.15
Section through the lower eyelid.


Colour Atlas of Ophthalmic Plastic Surgery

Arcus marginale
Orbital septum

fat pad

Orbicularis muscle

Whitnall’s ligament

Retro-orbicular fascia
Levator aponeurosis
Postaponeurotic space
Level of skin crease
Levator aponeurotic
insertion into orbicularis

Accessory lacrimal glands

Levator muscle
Common sheath
Superior rectus

Müller's muscle

Levator aponeurotic
insertion into tarsus
Muscle of Riolan

Diag. 1.16
Section through the upper eyelid.

In the lower lid (Diag. 1.15) the relations of this space
are the orbicularis muscle anteriorly and the tarsal plate
and septum posteriorly.
In the upper lid (Diag. 1.16) the equivalent space posterior
to the orbicularis muscle is subdivided by the levator
aponeurosis which passes between the inferior border
of the septum and the superior border of the tarsal plate
to insert into the orbicularis muscle and the anterior
surface of the tarsal plate.
A well-defined surgical space can be identified posterior
to the aponeurosis – the postaponeurotic space. It is
limited anteriorly by the aponeurosis, posteriorly by the
tarsal plate below and Müller’s muscle above, superiorly
by the attachment of Müller’s muscle to the levator and
inferiorly by the attachment of the aponeurosis to the
lower anterior surface of the tarsal plate. When the upper
lid is in the anatomical position, this space is shallow
and Müller’s muscle lies in close approximation to the
levator aponeurosis. However, if the lid is everted
the space changes shape, separating the lower ends of
the two upper lid retractors (see Figs 9.2a–c).
A less well-defined, potential space is present anterior
to the aponeurosis below and the septum above (see
Figs 9.3c,d). It is limited anteriorly by the orbicularis
muscle, posteriorly by the septum and aponeurosis,
inferiorly by the lid margin and superiorly by the preseptal
fat extending inferiorly from beneath the brow. This space
is interrupted at the level of the skin crease by the insertion
of the aponeurosis into the orbicularis muscle. In ptosis

Levator aponeurosis
Müller's muscle
Postaponeurotic space

Diag. 1.17
Section through the everted upper eyelid.

surgery from the anterior approach it is important, at
this stage, that the dissection upwards to expose the
septum remains in this space (see Fig. 9.3c), immediately
posterior to the orbicularis muscle, and does not stray
into the space posterior to the aponeurosis (see Figs 9.3i,j)
where the dissection is deceptively easier.

Anatomy 19

1.10 The septum and

tarsal plates

The junction of the periorbita and the periosteum at the
orbital rim is thickened to form the arcus marginalis. From
this curved line of attachment around the orbital rim the
septum (as the posterior layer of the deep galea) passes
into the lids. In each lid the septum does not reach the
proximal border of the tarsal plate as an independent layer
but fuses with the upper or lower lid retractors – about
3 to 4 mm from the tarsus (see Diags 1.15, 1.16), but may
be up to 10 mm. This insertion is generally a little lower
in Asians than in Caucasians (Diags 1.25a–c).
Starting on the superior orbital rim, the origin of the
septum crosses the supraorbital notch, descends just
within the lateral orbital rim to enclose the structures
inserted into Whitnall’s tubercle and then descends to
the inferotemporal angle of the orbit. Here the origin
passes just anterior to the rim and turns medially across
the inferior orbital rim to the lower part of the anterior
lacrimal crest. It passes posteriorly attached to the lacrimal
fascia approximately at the middle of the sac to reach
the posterior lacrimal crest. It encloses the deep heads
of the orbicularis muscle and ascends the posterior
lacrimal crest to the superomedial angle of the orbit where
it turns laterally to regain the superior rim.
The septum is related to the orbicularis muscle anteriorly
and the orbital fat posteriorly (see Diags 1.15, 1.16,
Figs 9.3c,d). Sometimes the retro-orbicularis oculi fat pad
(1.7.4) migrates inferiorly from the brow, separating the
upper septum from the orbicularis muscle. The septum
is pierced by vessels and nerves.
The tarsal plates form the skeleton of the eyelids. They
are made of dense fibrous tissue with some elastic tissue.
The Meibomian glands lie within the substance of the
tarsal plates. The vessels and nerves of the lids lie partly
on the anterior tarsal surfaces, and partly superior to
them, within loose connective tissue. In the upper lid
the lower fibres of the levator aponeurosis insert into the
lower part of the tarsal plate and Müller’s muscle is
attached to the proximal border (see Fig. 10.2g). In the
lower lid the lower lid retractors insert into the proximal
border (see Fig. 6.4d). The tarsal conjunctiva is firmly
attached to their posterior surfaces.

1.11 The conjunctiva
Mucus-secreting goblet cells are plentiful everywhere in
the conjunctiva. The accessory lacrimal glands of Wolfring
and Krause are found mainly between the upper tarsal
border and the upper fornix, especially laterally (see Diag.
1.16). The lacrimal gland ducts empty into the lateral
part of the upper fornix.
The superior and inferior fornices extend almost to the
orbital rims. The lateral fornix extends to approximately
14 mm from the limbus but the medial fornix is shallower.
Fibrous tissue support reaches the fornices and in the
superior and inferior fornices ‘suspensory ligaments’ can
be identified (see Diags 1.15, 1.16). They are extensions
of the common sheaths between the upper or lower lid
retractors and the superior or inferior rectus muscles.

1.12 The upper lid


(Diag. 1.16)

The normal position of the upper lid is maintained by
the levator palpebrae muscle and Müller’s muscle working
The levator muscle arises from the roof of the orbit
immediately in front of the optic foramen and above the
superior rectus muscle (see Diag. 1.23). It passes forwards
for about 40 mm where it ends just behind the septum
as an aponeurosis. Close to the origin of the aponeurosis
the muscle sheath is thickened above the muscle to form
a band, Whitnall’s ligament (see Diags 1.14, 1.16, Figs
9.4c, 9.8e). This may be a definite structure, easily identified, or a more diffuse thickening. It inserts into the
trochlea medially and the capsule of the lacrimal gland
and orbital wall laterally. It acts as a fulcrum for the
action of the levator.
The levator aponeurosis descends into the lid and the
septum inserts onto its anterior surface, often as a thickened band, about 8 mm below Whitnall’s ligament and
3 to 4 mm above the tarsus (see Figs 9.3d, 9.4a). This
insertion is generally lower in Asians than in Caucasians.
The angle between the posterior surface of the septum
and the anterior surface of the levator aponeurosis
contains the preaponeurotic fat pad, an important surgical
landmark (see Figs 9.3d–f, 10.2c,d). As the aponeurosis
descends, it becomes thinner and fans out. It inserts
anteriorly into the orbicularis muscle at the level of the
skin crease and below into the lower anterior surface of
the tarsal plate. Its medial and lateral insertions are as
two ‘horns’ into the region of the canthal tendons (see
Diag. 1.14, Figs 9.3j,k,l). The lacrimal gland is wrapped


Colour Atlas of Ophthalmic Plastic Surgery

around the posterior edge of the lateral horn, dividing
the gland into an orbital lobe and a palpebral lobe. An
extension of the common muscle sheath, between the
levator muscle and the superior rectus muscle, inserts
into the superior fornix (see Diag. 1.16) as the superior
suspensory ligament of the fornix.
Müller’s smooth muscle arises from the under surface
of the levator muscle (see Fig. 9.2c) close to the junction
of striated muscle and aponeurosis. It is 15 to 20 mm
wide and it descends between the levator aponeurosis
and the conjunctiva for about 15 to 20 mm to insert into
the upper border of the tarsal plate (see Figs 9.3h–j). Note
that the lower ends of Müller’s muscle and the levator
aponeurosis are separated if the upper lid is everted (see
Diag. 1.17, Fig. 9.2c).

1.13 The lower lid


(Diag. 1.15)

The retractors of the lower lid are equivalent to the
retractors of the upper lid (the levator and Müller’s
muscles). They develop from the capsulopalpebral head
of the inferior rectus muscle. But unlike the upper lid
retractors, they are vestigial, containing little muscle.
They arise from the sheath of the inferior rectus muscle
and consist of the capsulopalpebral fascia (equivalent to
the levator) and the inferior tarsal muscle (equivalent to
Müller’s muscle).
As they pass forwards the lower lid, retractors split to
enclose the inferior oblique muscle, and where they
reunite, they blend with thickened fascia on their inferior
aspect. This is Lockwood’s suspensory ligament (Diag.
1.15) which inserts into the orbital walls close to the
canthal tendons. The septum fuses with the lower lid
retractors about 2 to 3 mm below their insertion into the
lower tarsal border (see Figs 6.2c, 6.4d, 11.8b,c). The angle
between the posterior aspect of the septum and the lower
lid retractors contains a pad of orbital fat – the medial
fat pad – similar to the preaponeurotic fat in the upper
lid (see Fig. 6.4c).
The pull of the lower lid retractors depresses the lid in
downgaze and helps to maintain the upright position of
the tarsal plate (see Fig. 6.3j).

1.14 The lacrimal


1.14.1 The lacrimal gland
The lacrimal gland is wrapped around the posterior border
of the lateral horn of the levator aponeurosis (see Diags
1.14, 1.23). The superior, orbital part of the gland lies in
the lacrimal (gland) fossa. Anteriorly, it is in contact
with the septum and posteriorly, with orbital fat. Inferiorly,
the lateral rectus muscle lies laterally and the levator lies
medially. Its secretory ducts pass down into the inferior,
palpebral part of the gland which is one-third the size
of the orbital part. The anterior border of the palpebral
part can be seen laterally in the upper fornix and its
secretory ducts emerge there.

1.14.2 The lacrimal sac
The lacrimal canaliculi, surrounded by the orbicularis
muscle immediately medial to the puncta, pass medially
and posteriorly between the limbs of the medial canthal
tendon to pierce the fascia overlying the lacrimal sac (see
Diag. 1.7). They usually join to form a common canaliculus
before entering the sac.
The sac lies in the lacrimal (sac) fossa which is bounded
anteriorly and posteriorly by the anterior and posterior
lacrimal crests. Periosteum at the posterior lacrimal crest
splits to enclose the sac and reunites at the anterior
lacrimal crest. The lateral leaf is the stronger and it is
reinforced further by the posterior limb of the medial
canthal tendon. The anterior part of the tendon crosses
the upper part of the sac and the septum covers the lower
part. The inferior oblique muscle arises just behind and
lateral to the orifice of the nasolacrimal canal. Anterior
to the medial canthal tendon, about 8 mm medial to the
medial canthus, is the angular vein (see Diag. 1.19).

Anatomy 21

1.15 Blood supply to the


Medial palpebral

(Diags 1.18, 1.19)

Dorsal nasal

1.15.1 Arterial supply


The ophthalmic artery arises from the internal carotid
artery just medial to the anterior clinoid process. It passes
through the optic canal below the nerve and within its
dural sheath and enters the orbit lateral to the nerve. It
gives origin to the lacrimal artery lateral to the optic
nerve and to the supraorbital artery as it crosses the optic
nerve to reach the medial wall. It terminates by dividing
into the dorsal nasal and supratrochlear arteries. It may
give origin to the two medial palpebral arteries before
it terminates. Other branches supply the orbit.
The lacrimal artery passes forward on the upper border
of the lateral rectus muscle accompanied by the lacrimal
nerve. It supplies the lacrimal gland, then pierces the
septum, and divides into two lateral palpebral arteries
in the lids.


Anterior ethmoidal
artery and nerve

Posterior ethmoidal
Nasociliary nerve
Optic nerve
in optic canal

Posterior ciliary
Central retinal

The supraorbital artery joins the supraorbital nerve in
Internal carotid
the roof of the orbit and accompanies it through the
supraorbital notch. It passes upwards deep to the brow
fat pad (ROOF, see 1.7.4) and then pierces the frontalis
muscle. Its branches contribute to the supply of the Diag. 1.18
Arterial supply to the ocular adnexa and globe.
forehead, scalp and upper lid.
The dorsal nasal artery pierces the septum above the
medial canthal tendon to supply the skin of the root of
the nose and the lacrimal sac. It gives origin to the medial
palpebral arteries if these have not arisen separately from
the ophthalmic artery. The two medial palpebral arteries
enter the lids above and below the medial canthal tendon.

Supraorbital artery and vein
Tarsal arcades upper lid
Lacrimal artery
Lacrimal artery
Lateral palpebral artery
Tarsal arcade lower lid

Frontal vein
Supratrochlear artery
Medial palpebral artery
Angular artery and vein

Facial artery and vein
Infraorbital artery

Diag. 1.19
Blood supply to the eyelids.


Colour Atlas of Ophthalmic Plastic Surgery

In the lids the medial and lateral palpebral arteries
anastomose to form arcades within the submuscular
connective tissue on the surface of the upper and lower
tarsal plates 2 to 4 mm from the lid margins. In the upper
lid a second arcade is formed at the upper border of the
tarsal plate (see Fig. 9.1c).

The angular vein is formed by the anastomosis of the
supraorbital and supratrochlear or frontal veins at the
upper inner angle of the orbit. It drains posteriorly into
the superior orbital vein and inferiorly into the facial
vein. It lies about 8 mm medial to the inner canthus where
it can often be seen through the skin.

The supratrochlear artery pierces the septum with the
supratrochlear nerve, winds upwards into the mid
forehead and supplies it. It anastomoses with the supraorbital artery.

Venous blood also drains to the inferior ophthalmic vein.

Blood from the external carotid system reaches the lids
through anastomoses with the infraorbital and facial
arteries, mainly via the angular artery, and the superficial
temporal artery.

of the lids

1.15.2 Venous drainage
The veins of the lids are found mainly in the region of
the fornices (Diag. 1.19). They drain to the venous network
of the middle third of the face.

1.16 Lymphatic drainage
(Diag. 1.20)

The lateral two-thirds of the upper lid and the lateral
third of the lower lid drain to the preauricular and parotid
lymph nodes. The medial third of the upper lid and the
medial two-thirds of the lower lid drain to the submandibular nodes.

Preauricular and parotid
lymph nodes

Submandibular lymph nodes

Diag. 1.20
Lymphatic drainage of the eyelids.

Anatomy 23

1.17 Nerve supply to the

lids and face

1.17.1 Motor supply (Diag. 1.21)
The muscles of facial expression, as noted previously,
develop from the second branchial arch and are supplied
by branches of the facial nerve. Within the face the
branches lie deep to the muscles of facial expression then
penetrate the deep layer of the SMAS to innervate the
orbicularis muscle and the other muscles of facial
Having emerged from the stylo-mastoid foramen the
nerve gives origin to its posterior auricular branch which
passes upwards and posteriorly to supply the occipitalis
muscle and posterior auricular muscles. The trunk passes
forward and enters the substance of the parotid gland

Frontal branch
of facial nerve

Trunk of facial

Diag. 1.21
The branches of the facial nerve.

where it divides into branches that emerge from the
anterior border of the gland to supply the muscles of
facial expression, including the frontalis and platysma
Two of these branches, sometimes known as the upper
and lower zygomatic branches, are of particular importance
in the periocular region. The upper branch crosses the
zygoma approximately at its midpoint, halfway between
the outer canthus and the tragus, and enters the temporoparietal (superficial temporal) fascia (part of the SMAS;
see 1.7.1 and Diag. 1.9) and travels within it into the
forehead, passing about 1.5 cm above the tail of the brow.
Here it is known as the frontal branch of the facial nerve.
Its surface marking is important during surgery in the
forehead. It innervates the frontalis and orbicularis
muscles, also the corrugator and procerus muscles, just
above the superior orbital rim. The lower branch crosses
the zygomatic bone to supply the orbicularis fibres of the


Colour Atlas of Ophthalmic Plastic Surgery

lower lid and the upper fibres of the elevators of the
upper lip. Having reached the lids, the terminal branches
of the nerve turn at right angles to the muscle bundles
to approach the lid margins, except medially where they
run in the line of the muscles (see Diag. 1.6).
There is extensive cross innervation between the branches
of the facial nerve.
The levator palpebrae superioris muscle is supplied by
the third cranial nerve. It enters the orbit from the lateral
wall of the cavernous sinus. It passes through the tendon
ring lateral to the optic nerve and divides into superior
and inferior branches. The superior division of the nerve
traverses and supplies the superior rectus muscle before
supplying the levator at the junction of its middle and
posterior thirds.
Müller’s muscle is supplied by sympathetic nerves.
Cranial preganglionic sympathetic fibres leave the CNS
in the anterior spinal nerve roots of the intermediate
region of the spinal cord, T1 to L1, and ascend the
sympathetic chain to the superior cervical ganglion level
with the second and third cervical vertebrae. Cranial
postganglionic sympathetic fibres originate in the superior
cervical ganglion and travel with the internal carotid
artery and its branches to supply the structures of the
cranial cavity and the orbit.

Infratrochlear nerve

The ciliary ganglion is attached anatomically to the
nasociliary nerve lateral to the optic nerve near the back
of the orbit. Preganglionic parasympathetic fibres originate
in the Edinger Westphal nucleus in the midbrain and
travel to the orbit with branches of cranial nerve III. They
synapse in the ciliary ganglion and the postganglionic
fibres travel in the multiple short ciliary nerves to pierce
the sclera around the optic nerve and supply the sphincter
muscle of the iris. Sympathetic postganglionic fibres from
the superior cervical ganglion pass through the ciliary
ganglion without further synapse and travel in the long
and short ciliary nerves to enter the eye and supply the
dilator muscle of the iris.

1.17.2 Sensory supply (Diags 1.22–1.24)
The lids and the contents of the orbit are supplied by
the ophthalmic and maxillary divisions of the trigeminal
(fifth cranial) nerve.
The ophthalmic division of the trigeminal nerve divides
in the lateral wall of the cavernous sinus into the lacrimal,
frontal and nasociliary nerves. These pass through the
superior orbital fissure into the orbit.
The lacrimal nerve runs forward along the superior border
of the lateral rectus muscle to supply the lacrimal gland.

Lacrimal gland

Supraorbital nerve
Supratrochlear nerve

Anterior ethmoidal
Lacrimal nerve

Frontal nerve
Ciliary ganglion
Optic nerve

Maxillary nerve
Mandibular nerve

Diag. 1.22
Branches of the ophthalmic division of the fifth cranial nerve.

Nasociliary nerve

Ophthalmic nerve

Anatomy 25

Anterior cranial fossa

Infratrochlear nerve
Supratrochlear nerve

Supraorbital nerve

Medial rectus muscle
Superior oblique muscle

Levator palpebrae
superioris muscle
Lacrimal gland

Nasociliary nerve
Temporalis muscle
in temporal fossa
Superior rectus muscle

Lacrimal nerve
Lateral rectus

Trochlear nerve

Middle cranial

Frontal nerve
Optic nerve

Diag. 1.23
The orbit from above.





Diag. 1.24
Sensory nerve supply to the eyelids.

In its anterior two-thirds, it is accompanied by the lacrimal
artery. It pierces the septum and supplies sensation to
the lateral part of the upper lid and conjunctiva (Diag.
1.23). The parasympathetic innervation of the lacrimal
gland travels with the zygomatic nerve from the sphenopalatine ganglion and joins the lacrimal nerve just
posterior to the gland.

The frontal nerve is the largest of the three branches. It
passes forward between the periosteum of the orbital
roof and the levator muscle. Anteriorly, it divides into
the supratrochlear and supraorbital nerves.
The supratrochlear nerve ascends over the medial orbital
rim with the artery, deep to the orbicularis muscle, to


Colour Atlas of Ophthalmic Plastic Surgery

supply the medial part of the lid and conjunctiva and
the skin of the forehead. The supraorbital nerve continues
to the supraorbital notch which it passes through with
the artery medial to it. It divides into superficial and
deep branches (see Diag. 1.4). The superficial branch
winds around the corrugator muscle and ascends more
medially, superficial to the frontalis. The deep branch
remains deep to the corrugator and ascends more laterally,
deep to or through the frontalis. These branches supply
the upper lid and conjunctiva, and the forehead and scalp
as far as the vertex.
The nasociliary nerve (Diags 1.22–1.24) crosses medially
above the optic nerve with the ophthalmic artery. It gives
origin to several branches and then divides into the
anterior ethmoidal nerve and the infratrochlear nerve.
The anterior ethmoidal nerve passes via the anterior
cranial fossa to terminate as nasal nerves. These supply
the tip of the nose including the anterior part of the nasal
septum. The infratrochlear nerve passes below the trochlea
to supply the medial ends of the lids and conjunctiva,
the lacrimal sac and the root of the nose.
There are several communications between the terminal
branches of the ophthalmic nerve around the eye. They
also communicate with the infraorbital nerve, a branch
of the maxillary division of the fifth cranial nerve.
The maxillary division of the trigeminal nerve passes
forward from the trigeminal ganglion to the foramen
rotundum through which it enters the pterygopalatine
fossa. The infraorbital nerve branches forward and travels
in a groove, then a canal, in the floor of the orbit to reach
the infraorbital foramen. It branches to supply the skin
and conjunctiva of the lower lid, the lower part of the
side of the nose and the upper lip.

1.18 The eyelids of


(Figs 1.6–1.10) (Diag. 1.25)

The main difference from the Caucasian upper lid is the
absent skin crease in about 50% of Asians. The absent
skin crease results in a low skin fold (Figs 1.6–1.8). When
a skin crease is present, it is formed in the same way as
a Caucasian skin crease by the insertion of the levator
aponeurosis into the orbicularis muscle and skin at the
level of the crease. However, the insertion is lower in
Asians – at about 6.5–8.0 mm from the lashes rather than
6 to 10 mm in the adult Caucasian upper lid (Diag. 1.25),
lower in children. In the absence of this forward insertion
by the levator aponeurosis, no skin crease can form.
When a skin crease is present, its shape can vary. A
medially tapering skin crease approaches the lashes
medially, sometimes merging with a medial epicanthal
fold. A parallel skin crease remains parallel to the lid
margin throughout its length.
The septum also inserts lower on the aponeurosis than
in the Caucasian upper lid. In most lids, this insertion
is 2 to 3 mm superior to the upper tarsal border; but in
a few it may extend further down anteriorly to the tarsal
plate. As a result the preaponeurotic fat is also found at
a lower level within the Asian lid at surgery.
The presence of a medial epicanthal fold can cause lash
ptosis, especially medially. In the lower lid, epiblepharon
may occur.

The zygomatic nerve, a branch of the maxillary nerve,
enters the orbit through the inferior orbital fissure. It
follows the lower part of the lateral orbital wall where,
after communicating with the lacrimal nerve, it divides
into the zygomatico-facial and zygomatico-temporal
nerves. The zygomatico-facial nerve exits anteriorly on
the zygomatic bone to supply sensation to the malar area
of the cheek. The zygomatico-temporal nerve exits in the
temporal fossa and supplies sensation to the anterior
temporal region.

Fig. 1.6
Asian eyelid without upper lid skin crease. Primary position
– note the low upper eyelid fold.

Anatomy 27

Fig. 1.7

Fig. 1.8
Downgaze – note the low or absent upper eyelid skin crease.

Fig. 1.9
Asian eyelid with upper lid skin crease. Primary position.

Fig. 1.10
Downgaze – note the skin crease.


Müller’s muscle

Tarsal plate


Levator aponeurosis



Diag. 1.25a-c
The branches of the facial nerve. (a) Caucasian eyelid. (b) Asian eyelid with a skin crease. (c) Asian eyelid with no skin crease.


Colour Atlas of Ophthalmic Plastic Surgery

1.19 Age changes in the

lids and face

(Figs 1.11, 1.12)

The eyelid and facial tissues lose tone and volume with
age. The skin becomes loose and inelastic as the collagen
thins and the dermis becomes atrophic. The effects of
sun exposure and probably smoking add to these changes.
The mechanisms of repair and replacement of tissues
become less efficient. Wrinkles and folds in the skin
appear, usually at right angles to the action of the
underlying muscles. Lost eyebrows and lashes are
replaced less efficiently but they retain their pigmentation
long after grey hair has appeared on the scalp.
The retaining ligaments and other fascial layers of the face
stretch, reducing support for the fat and muscles. The
brows may droop as the epicranial aponeurosis stretches
and the action of the frontalis muscle weakens. This adds
to any redundant skin already present in the upper lid.
The canthal tendons relax. As a result, the palpebral fissure
shortens horizontally and the tension which holds the lids
against the globe is gradually lost. The lateral canthus
drops, eliminating or reversing the natural angle of the
canthi. As the facial tissues sag the nasolabial folds are
accentuated. The descent of the cheek fat also deepens
the naso-jugal fold – the so-called ‘tear trough deformity’
– and the profile of the lower orbital rim becomes more
pronounced – the ‘supramalar sulcus’. These hollows along
the lower orbital rim often merge into one another producing so-called ‘skeletonisation’ of the rim.

Orbital fat atrophy causes a small and variable degree
of enophthalmos. Fat elsewhere in the face may occasionally increase with age but in general it follows the pattern
of loss of tissue bulk observed elsewhere. The orbital
septum weakens and some fat prolapse may occur into
the lids.
The levator aponeurosis may become attenuated, stretch
and lose its firm attachment to the tissues of the upper
lid, especially to the tarsal plate, resulting in ptosis. The
lower lid retractors may also become lax or disinsert from
the lower tarsus, resulting in entropion or ectropion.
These changes lead to many of the conditions which
present to the ophthalmic plastic surgeon.

Fig. 1.12

Anderson RL, Beard C 1977 The levator aponeurosis. Arch
Ophth 9:1437
Chen WPD, Khan JA, McCord CD 2004 Color atlas of
cosmetic oculofacial surgery. Butterworth Heinemann,
Chen WPD 2006 Asian blepharoplasty and the eyelid crease.
Butterworth Heinemann, Elsevier
Kakizaki H, Malhotra R, Selva D 2009 Upper eyelid
anatomy: An update. Ann Plast Surg 63:336–343
Koornneef L 1976 Spatial aspects of orbital musculofibrous
tissue in man. Swets & Zeitlinger, Amsterdam
Koornneef L 1979 Orbital septa: Anatomy and function.
Ophthalmol 86:876
Saonanon P 2014 Update on Asian eyelid anatomy and
clinical relevance. Curr Opin Ophthalmol 25:436–442
Whitnall SE 1921 Anatomy of the human orbit and accessory
organs of vision (facsimile of 1921 edition) Robert E. Krieger,
Huntington, NY
Fig. 1.11
The aging face.

Zide BM, Jelks GW 1985 Surgical anatomy of the orbit.
Raven Press, New York


Basic techniques in
ophthalmic plastic
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 position for dissection and the placement of
sutures. The drapes should leave both eyes exposed and,
if under local anaesthesia, the mouth as well. Any standard
skin preparation solution which is safe around the eyes
may be used for ophthalmic plastic surgery. Aqueous
povidone iodine 10% is safe (providing there is no sensitivity to iodine) but care is needed with chlorhexidine, some
preparations of which can be toxic to the cornea.

At the end of the operation a traction suture to close the
lids beneath the dressing is not essential but may be
inserted if there is any risk of the dressing abrading the
cornea, or to stabilise the lids if a graft or flap has been
placed. Put antibiotic ointment into the eye and apply a
dressing of a single layer of paraffin gauze and two eye
pads onto the closed lids. Secure this with firm adhesive
tape. The dressing in children, in particular, needs to be
firmly secured if it is to stay in place. Some surgeons
prefer to avoid a dressing, especially for smaller operations. The advantages of a dressing are that the wound
is protected in the early hours after the operation and
secretions are absorbed without the need for constant
wiping by the patient. Swelling may also be reduced.



There is a choice of instruments for making incisions in
the periocular region. A traditional scalpel is still a good
choice in all situations. Alternatives include the cutting
diathermy, for example the Colorado needle, and the
radiofrequency knife, for example the Ellman Surgitron.
These have less tactile feedback than a scalpel but give
some haemostasis. The radiofrequency knife causes less
wound edge damage than the cutting diathermy. A CO2
laser is expensive; there is no tactile feedback from the
skin but there is more efficient haemostasis. Laser wounds
heal slightly more slowly and sutures should be left in
situ for a few days longer.
Scars are least obvious if incisions are made in, or parallel
to, skin creases, in the so-called relaxed skin tension lines,
which form at right angles to the direction of action of
the underlying muscle group and across which the tension
is low (Diag. 2.1).
This general rule about the placement of incisions is
modified in the lower lid when small lesions, not involving
the lid margin, are excised. Unless there is an excess of
loose skin the ellipse should be placed across the skin
creases, at right angles to the lid margin, to avoid an
The skin around the eyes is thin and mobile and it is
helpful to stretch it along the intended incision line to
ensure a clean cut at right angles to the skin. Incisions
must be marked before distortions such as local anaesthetic infiltration, or stretching, are introduced.

Diag. 2.1
Relaxed skin tension lines around the eye.


Wound closure


Colour Atlas of Ophthalmic Plastic Surgery

2.1 Routine wound

Sutures in the range 4/0 to 8/0 are preferred (see Fig.
5.5). Absorbable or nonabsorbable interrupted or continuous sutures may be used for skin closure but fine absorbable sutures are convenient and effective in children.

Superficial wounds no deeper than the dermis and
superficial subcutaneous fat may be closed with skin
sutures alone (see Figs 2.2, 10.1x,y). In deeper wounds,
for example in the forehead or cheek, subcutaneous
absorbable sutures must first be inserted to close the
deep tissues to avoid a sunken scar (see Figs 10.7e–h,

Needle bites in each layer of the wound closure must be
of equal depth on each side of the wound or a distorted
or stepped closure will result. At the skin the needle
should enter and leave at right angles. This will heap
up the tissues slightly when the knots are tied and help
to prevent a sunken scar.


Closure of incisions made into the skin crease of the
upper lid often requires an additional, deep, bite into
the deeper tissues to anchor and re-create the skin crease
(see Fig. 9.1h).

Undermining the skin on either side of a wound will
reduce tension across the closure. It is not necessary in
most situations of simple wound closure. However,
undermining is always necessary to create a skin flap.
In the face the dissection should be within the fat layer,
just deep to the dermis, to avoid damage to the facial
nerve branches which are situated deep to the muscle
layer. Lift the wound edge with skin hooks or a small
retractor and dissect with a scalpel or scissors to undermine the skin.
Closure of a wound may result in a dog-ear at one or
both ends.

Fig. 2.1a
Needle entry at right angles to the skin.

Fig. 2.1b
Needle exit at right angles to the skin.

Fig. 2.1c
Slightly heaped-up wound edges at closure.

Basic techniques in ophthalmic plastic surgery 33

2.2 Continuous sutures
A continuous interlocking suture often gives a more even
closure (see Figs 10.7h, 10.8e) than a simple ‘over-andover’ continuous suture which can cause distortion at
the skin edges.

Fig. 2.2a
Interlocking suture before tightening.

Fig. 2.2b
Interlocking suture, wound closed.


Colour Atlas of Ophthalmic Plastic Surgery

2.3 Intradermal sutures
To avoid stitch marks a continuous intradermal (‘subcuticular’) suture allows adequate closure but a few interrupted sutures, or sterile adhesive dressing strips, may
be needed to achieve perfect skin apposition.

Fig. 2.3a
Needle bites into the dermis in the plane of the skin.

Fig. 2.3b
Intradermal continuous suture before tightening.

Fig. 2.3c
Wound closed by pulling suture ends.

Fig. 2.3d
Wound supported by sterile adhesive strips; suture ends tied

Basic techniques in ophthalmic plastic surgery 35

2.4 Mattress sutures
(Fig. 2.4)
If there is a tendency for the skin edges to invert, when
closing thicker skin, this can be overcome by the use of
interrupted vertical mattress sutures.

Fig. 2.4
Vertical mattress sutures.

2.5 Three-point suture
(Fig. 2.4)
Where a V-shaped wound is to be closed or two wounds
join at a T the ‘three-point’ suture is an effective method
of closing the tip of the V or the junction at the T. The
deep part of the suture captures the apex of the V.

The healing process starts with an obvious hard,
red scar and ends with a much less obvious, soft,
relatively avascular scar. This process may take up
to a year in adults and longer in children. It is usually
quicker in the thin skin of the lids. If an unsightly
scar persists, massage often helps to hasten softening. It can be started after 10 days and should be
gently but firmly applied for 5 minutes three times
daily until the scar is seen to be soft. A bland moisturising ointment may be used at the time of massage.
For management of a hypertrophic scar, see 2.21
Complications and management. A sunken or distorted scar can be avoided by accurate closure of
the original wound. A poor scar, once healed, may
be excised and carefully resutured. Distortion due
to contraction of a linear scar may be corrected with
a Z-plasty where possible (see 2.23).

Fig. 2.5
The three-point suture for corners.

Key diag. 2.5
Excising a dog ear.


Colour Atlas of Ophthalmic Plastic Surgery

2.6 Full-thickness
eyelid margin excision
and repair (Fig. 2.6)
This basic technique, with variations, is described in 14.1
and 14.2.

Fig. 2.6 pre
Tumour at lower lid margin.

Fig. 2.6 post
Two months after excision and direct closure.

2.7 Horizontal lid

tightening (Fig. 2.7)

Correction of horizontal lid laxity is required in several
situations. Common techniques include lid shortening
(see 14.1, 14.2), lateral tarsal strip (see 7.2) and the Bick
procedure (see 7.3).

Fig. 2.7 pre
Lax lateral canthal tendon causing ectropion.

Fig. 2.7 post A
Three months after left lateral tarsal strip; ectropion corrected.

Fig. 7.2 post B
Three months after lateral tarsal strip; canthus in a good


Skin grafts


Colour Atlas of Ophthalmic Plastic Surgery

Taking full-thickness
skin grafts
2.8 Upper lid skin
The ideal donor site for a graft to the upper lid is the
opposite upper lid. Use a paper template of the recipient
site to be grafted. The graft is taken as for an upper lid
blepharoplasty and the same principles apply (see 10.1;
Figs 7.10e,f, 7.10A,B post, 15.1b,c, 15.2b,c).

Full-thickness skin can often be harvested just inferior
to the lateral end of the brow. In younger patients, it may
be possible to harvest skin from this site even if there is
no excess skin in the central lid.

Fig. 2.8a
Incision marked to include the area of the template.

Fig. 2.8b
Skin excision without muscle.

Fig. 2.8c
Skin harvested from below lateral brow.

Fig. 2.8d
Sub-brow skin graft.

Basic techniques in ophthalmic plastic surgery 39

2.9 Postauricular skin
Skin from this site gives an acceptable colour match with
eyelid skin. However, it is thicker than lid skin so the
recipient site must be chosen with care. In the preseptal
part of the upper lid, in particular, skin from the opposite
upper lid, or split skin, is preferable.
Cut a paper or foil template of the area to be grafted and
mark out the graft behind the ear. The mark should be
1 to 2 mm outside the template to allow for the slight
shrinkage of the graft when the tension on the ear is
relaxed. Inject saline subcutaneously to help in removal
of the graft and to reduce bleeding. Adrenaline 1 : 200,000
(with 2% Lignocaine/lidocaine local anaesthetic) will
further reduce bleeding. It may be helpful to suture the
pinna forward to the cheek to help the dissection.

Incise around the mark. Begin dissection of the graft
superiorly. Hold the free edge of the graft with skin hooks,
exerting gentle traction upwards with minimum bending
of the graft. Dissect parallel to the plane of the skin with
a rounded blade (e.g., No. 10 or No. 15 Bard Parker) and
include as little of the subcutaneous tissue as possible