Periocular plastic surgery

Abstract

Background: Good vision depends on the normal anatomy and function of the eyelids and orbital structures. The goals of periocular ophthalmic plastic surgery are the anatomical and functional preservation and restoration of the lids, orbits, and periorbital structures when they are affected by congenital or acquired malpositions, defects and mass lesions. In this region, functional and esthetic considerations are closely linked.

Method: This review is based on selected articles retrieved by a PubMed search, the guidelines of the German Ophthalmologists' Association (Bundesverband der Augenärzte, BVA) and German Ophthalmological Society (Deutsche Ophthalmologische Gesellschaft, DOG), and the authors' own clinical and scientific experience.

Results: The surgical correction of eyelid malpositions is based on the restoration of normal anatomy with attention to function. Eyelids are reconstructed with a combination of local flaps and free grafts, preferably from the periorbital structures. Orbital procedures are usually performed in specialized centers, by multidisciplinary surgical teams if necessary. The surgical approaches are becoming ever smaller and cosmetically less noticeable. For patients with acquired anophthalmos, the use of orbital implants is essential for optimal fitting of the prosthesis.

Conclusion: Modern periocular plastic surgery exploits an extensive range of specialized surgical techniques to treat a wide variety of abnormalities and diseases in this region. The success of such procedures depends on thorough knowledge of the complex anatomy and physiology of these structures as well as on the surgeon's expertise in microsurgical techniques.

Figure 1

a) This 3-year-old girl had severe, bilateral congenital ptosis, right esotropia, and amblyopia. She was able to look out from under her drooping eyelids only by holding her head in the abnormal position seen in the picture. b) The patient’s appearance after correction of the ptosis with a bilateral frontalis suspension employing alloplastic material (threads). Autologous fascia lata was not used, because her legs were still very short.

Figure 2

a) After two surgical procedures for the histologically guided excision of a tumor, this patient had an extensive tissue defect involving all layers of the left upper lid; b) View of the operative field showing the free tarsomarginal graft from the contralateral upper lid; c) After tarsomarginal grafting and the creation of a plastic myocutaneous flap, the reconstructed upper lid has a smooth edge and a normal configuration

Figure 3

a) The principles of orbital decompression (schematic diagram): enlargement of the bony orbit by bone resection (left), reduction of the soft-tissue content of the orbit by resection of fatty tissue (right); b, c) This woman with Graves’ orbitopathy had severe exophthalmos and lid retraction, without any impairment of optic nerve function or ocular motility; d, e) The patient’s appearance after bilateral three-wall bony decompression of the orbit through a swinging-eyelid approach and upper lid lengthening with anterior blepharotomy

Figure 4

a) Dermis and fat grafting (schematic diagram): Deepithelialized dermis from the gluteal region, with fatty tissue attached, is transplanted into the orbit, and the straight extraocular muscles are fixed to the edge of the dermis and to the connective tissue on its surface; b) This young man suffered from painful phthisis bulbi as a sequela of neonatal retinopathy; c) The patient’s appearance ten years after enucleation and primary dermis and fat grafting. He has been fitted with an ocular prosthesis made out of glass