facial plastic and reconstructive surgery in Winston Salem North carolina
Reconstruction Eyelid before and after photos
Eyelids serve some very important functions. They protect our globes from injury from the environment and help keep them lubricated and moist. All this is done by a very complicated mechanism involving the thinnest most pliable skin of our body (compare this for example to the skin on your heels or on your forehead). This overlies the "tarsal plate", which gives structure to the rim of the eyelid and a surface for it to contact the other eyelid. This tarsal plate has a blood supply, eyelashes and glands that protect it and maintain healthy function of our eyes. This tarsal plate must be lifted when necessary and is therefore connected to a muscle called the levator aponeurosis. The levator aponeurosis is connected to the main muscle for opening the eye which is called the levator palpebrae. A smaller muscle connected to the tarsal plate helps to open the eye and is run by the "fight or flight" system, which is a reflex that helps open our eyes in times of extreme danger and panic. (For example, when you are walking around the supermarket and a tiger jumps out from behind the soup cans). The orbicularis oculi is the muscle we use to close our eyes. All of these muscles are controlled by different nerves yet work together in a tightly orchestrated fashion to control the function of this thin, multitasking organ called the eyelid.
Reconstruction of defects of the eyelid needs to be considered with particular attention to the structures mentioned above. It is not only a goal to recreate a nice contour of an eyelid but it is also important to retain its ability to close and open. Sometimes removing lesions of the lower eyelid can cause the lower eyelid to get pulled away. This is called an ectropion. An ectropion can be caused by scar tissue formation even when an eyelid is correctly positioned. It can also be formed by removing a large amount of skin and not leaving enough tension-free skin for the eyelid to snap back to its usual position. In order to repair an ectropion we need to release the eyelid where it is being held by scar tissue. This can be done by bringing the skin in from the side to take the place of skin that is attached to the cheek thus allowing more upward mobility without tension on the eyelid. Another method to fix ectropion is to tighten the eyelid with a suture, which lifts the corner of the eyelid. This procedure is called a tarsal strip procedure. The best correction of ectropion, of course, is prevention. A flap will release the tension off the lower eyelid and instead place the burden of reconstruction on tissues from the cheek closer to the hair and ear.
Ptosis repair is done on patients who have eyelids that droop down over their pupils blocking their vision. The most common cause of ptosis is acquired by weakening of the levator aponeurosis. This makes the eyelid look as if it is larger than normal. The eyelid comes down like a curtain shade over the pupil. This can be frustrating and can make it difficult to drive and read. Correction is done through an eyelid incision usually about 8-11 mm from the edge of the eyelid. The orbicularis muscle is opened to allow exposure of the levator aponeurosis, which is then tightened and sutured back to the tarsal plate. The net effect of this is to raise the eyelid by attaching it a little higher on the muscle that opens the eyelid. About one in five patients will require some form of touchup or have some slight asymmetry. They may either be slightly too high or too low compared to the other eye. In some cases it can actually be over-tightened and actually be difficult to close. For this reason it is important to be careful when doing this surgery on patients who don't have a severe problem with very dry eyes since the eyelids, even if they are droopy, are functioning well at keeping the eyeball lubricated. This should be discussed with every patient on an individual basis before surgery and may result in doing one side at a time for safety reasons.
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