Adipose compartments of the upper eyelid: anatomy applied to blepharoplasty

Many authors have indicated the presence of ectopic or accessory upper eyelid fat pads, but the effective rate of eyelid fat variations and the corresponding clinical features are still unclear. The purpose of this study was to evaluate the variability of upper lid fat and to define the anatomical landmarks of the adipose pockets of the upper lid. From January of 1998 to January of 2002, the authors investigated the upper eyelid fat compartments of 47 patients who underwent upper blepharoplasty. To support surgical findings, 11 fresh cadavers were also investigated; the anatomy of the intraorbital fat and of the upper eyelid fat compartments was reviewed. Ten patients (21.3 percent) showed an accessory fat pad in the upper lid, which was found on both sides in nine cases. In all patients, the third fat pad was situated lateral to the two classic compartments described by Castanares, behind the orbital septum. Surgical dissections demonstrated that this fat pad derived from the preaponeurotic fat. Anatomical dissections in three cadavers demonstrated an accessory fat compartment protruding under the inferior border of the lacrimal gland. This protruding fat derived from the preaponeurotic fat in all cases and might justify the clinical appearance of a bulge or fullness in the lateral third of the upper eyelid. In the authors' experience, the presence of an accessory upper eyelid fat pad was a frequent finding during blepharoplasty; it could be found and actually resected in about 21 percent of all cases. Surgical and experimental findings put this element as a lateral physiological extension of the preaponeurotic fat that can anteriorly protrude under the inferior border of the lacrimal gland toward the orbital septum. The clinical appearance may be a bulge or fullness in the upper eyelid, and its resection can better define the lateral one third of the supratarsal fold.     

Lower eyelid reconstruction with a cheek flap supported by fascia lata.

The use of a cheek rotation flap is a well-known method for reconstruction of a large defect of the lower eyelid. In this technique, a separate lining tissue supporting the cheek flap is required for full-thickness reconstruction. Previously, a chondromucosal graft or conchal cartilage has been used to support this flap. Recently, we have used a homologous or autologous fascia lata as support for the cheek flap instead of rigid tissues like cartilages. A fascia lata strip is fixed with tolerable tension to the medial canthal tendon and lateral orbital rim. The inner surface of the fascia and the cheek flap is lined with a buccal mucosa graft to decrease irritation of the conjunctiva and cornea. We present here seven patients in whom this procedure was used for lower eyelid reconstruction following resection of a malignant skin tumor. Based on follow-ups of 7 to 22 months, the functional and aesthetic results have been good in all cases. This procedure may be applicable for total or subtotal reconstruction of the lower eyelid.     

Microstructure of the eye tunics,eyelids and ocular glands of the Sulawesi bear cuscus (Ailurops ursinus Temminck, 1824) (Phalangeridae: Marsupialia) based on anatomical,histological and histochemical studies

This study described the anatomy, histology and the histochemical analysis of the eye tunics, the upper and lower eyelid, the third eyelid, the lacrimal gland and the superficial gland of the third eyelid in adult Sulawesi bear cuscus. The eyeball and the eyelids with the orbital glands were harvested immediately post-mortem. The eyeball in the Sulawesi bear cuscus had a sphere-like shape. The pupil was round, and the lens was a circular biconvex body. There was neither tapetum lucidum nor Harderian gland. Similarly, there were no eyelashes in the lower eyelid. The lymphoid follicles and the high endothelial venules (HEV) were found in the lymphoid region only in the third eyelid and in the connective tissue of the superficial gland of the third eyelid. The third eyelid in the bear cuscus resembled the letter “T.” The lacrimal gland and superficial gland of the third eyelid were multilobar tubuloacinar glands. The histological analysis and histochemical studies showed that the lacrimal gland in the Sulawesi bear cuscus produced a mucoserous secretion with predominantly serous cells. In contrast, the superficial gland of the third eyelid produced a serous secretion with a single acinus mucous in character.     

Total eyelid reconstruction with free dorsalis pedis flap after deep facial burn

A case of severe facial and corneal burns with complete loss of upper and lower eyelids is reported together with the acute management and surgical options for total eyelid defects secondary to thermal injury. An acutely burned man with 78 percent total burn surface area presented with complete exposure of the left cornea. Because of the severe thermal injury, no facial tissues were available as donor sources for reconstructing the eyelid. A free dorsalis pedis flap was used to cover the exposed cornea after bilateral conjunctival advancement flaps, with septal cartilage graft for structural support. A conjunctivodacryocystorhinostomy was performed at the time of the coverage. The patient was unable to perform an exact visual acuity test; however, his gross vision was intact.     

Lower eyelid reconstruction with the upper eyelid rotation flap

A new technique of lower eyelid reconstruction was developed by using an ipsilateral upper eyelid rotation flap. After resection of a tumor in the lower eyelid, it is possible to replace the defect by a full-thickness upper eyelid rotation flap. Knowledge of exact eyelid anatomy is necessary to perform this kind of operation. In addition to the well-known techniques, the rotation flap constitutes a complete anatomic reconstruction of the lower eyelid with no functional loss of the upper eyelid.     

Correction of lower eyelid ptosis in the anophthalmic orbit with an autogenous ear cartilage graft

We describe the correction of lower eyelid ptosis in patients with an anophthalmic orbit, using ear cartilage grafts. This procedure has been particularly useful in the scarred or previously reconstructed lower eyelid.     

Lower eyelid reconstruction with a conchal cartilage graft

A conchal cartilage graft without skin or mucosa was used as a posterior lining for lower eyelid reconstruction in seven patients. The raw surface of the graft was smooth enough to cause no corneal irritation and was epithelialized from the surrounding mucosa about 3 to 4 weeks after the operation. The lower eyelid reconstructed in this method produced a stable lid margin.     

The differences in the eyelids microstructure and the conjunctiva‐associated lymphoid tissue between selected ornamental and wild birds as a result of adaptation to their habitat

The aim of the study was to describe the morphology of the upper, lower and third eyelid and characterize the organized lymphoid follicles and diffuse lymphocytes from ornamental and wild birds. The goal of these examinations was also to identify avian conjunctiva‐associated lymphoid tissue (CALT) and lymphoid tissue that contained specialized high endothelial venules. The upper, lower and third eyelid from 30 species of ornamental and wild birds representing 21 families were examined under light microscopy and using scanning electron microscopy. The third eyelid in all of the examined birds was composed of a free margin, which was divided into two parts. The largest tarsal plate of the third eyelid was observed in the greater rhea (Rheimorphae), the white‐tailed eagle and steppe eagle (Accipitrimorphae) and was approximately 13–15 mm wide and 9–11 mm long, respectively. In all of the examined birds, the CALT was associated with a rich network of small vessels. In addition, the presence of characteristic high endothelial venules and roundish bright endothelial cells was confirmed in the upper and lower eyelids or only in the lower eyelid (Phoenicopterimorphae, Procellariimorphae and Strigimorphae).     

Involutional entropion: a simple and stable repair

A simple technique for repair of involutional entropion is described. A 4 x 20 mm strip of cartilage is removed from the concha of the ear and placed in the lower lid, deep to the orbicularis muscle. Over the past 6 years, I have performed this procedure on 15 patients. Fourteen patients had an excellent result; one patient required a secondary lateral wedge resection. There have been no recurrences. The tarsal plate of the lower eyelid appears to soften and shrink with advancing age. As the tarsus shrinks, the lid becomes less rigid and the margin tends to roll inward. Creating a neotarsus out of ear cartilage provides a simple and stable repair for involutional entropion because it restores the structural rigidity of the lower lid. The operative procedure is technically simple. Its long-term effectiveness confirms the view, not widely held, that one primary cause of involutional entropion is a shrunken and atrophic tarsal plate.     

Histological and Ultrastructural Studies on the Conjunctiva of the Barred Owl (Strix varia)

This report is the first characterization of the histology and ultrastructure of the barred owl conjunctiva. The inferior eyelid was dominated by a large disk-shaped plate covered by a non-keratinized stratified squamous or cuboidal epithelium of variable thickness. The apical surface of the plate epithelium varied from flat to long microvilli or even short cytoplasmic extensions similar to those seen in the third eyelid. All specimens had a few goblet cells filled with mucous secretory granules in the plate region. The underlying connective tissue was a dense fibroelastic stroma. Eosinophils were surprisingly common in the epithelial layer and underlying connective tissue in the plate and more distal orbital mucosal region. The orbital mucosa contained goblet cells with heterogeneous glycosylation patterns. The leading edge and marginal plait of the third eyelid are designed to collect fluid and particulate matter as they sweep across the surface of the eye. The palpebral conjunctival surface of the third eyelid was covered by an approximately five-cell-deep stratified squamous epithelium without goblet cells. The bulbar surface of the third eyelid was a bilayer of epithelial cells whose superficial cells have elaborate cytoplasmic tapering extensions reaching out 25 μm. Narrow cytofilia radiated outwards up to an additional 15–20 μm from the cytoplasmic extensions. Lectin labeling demonstrated heterogeneous glycosylation of the apical membrane specializations but only small amounts of glycoprotein-filled secretory granules in the third eyelid.     

The inferior conjunctiva of the monkey.

Light- and electron-microscopical techniques were used to study the structure of the inferior conjunctiva of monkeys including the third eyelid (nictitating membrane). The cell layers of the conjunctival epithelium were 8-10 at the margin, 6-8 near the limbus and 2-4 in other areas except in the third eyelid where there were 1-4 layers. The epithelium was 90-100 microns thick at the margin and 35-40 microns at the other areas except at the third eyelid where it was 10-45 microns thick; near the limbus it was 55-60 microns thick. The morphological differences between the epithelia of the various areas of the inferior conjunctiva are highlighted. The similarities and differences between the human and monkey inferior conjunctivas are discussed.     

Energy dispersive X-ray diffraction by collagen fibrils in costal cartilage using synchrotron radiation

Low-angle X-ray diffraction patterns from the isotropic distribution of collagen fibrils, which occur in low concentrations in costal cartilage, were recorded using synchrotron radiation. An energy dispersive technique was used to exploit the properties of synchrotron radiation to the full. The third, fourth, fifth and sixth diffraction orders from the axial periodicity of the fibrils were recorded and used to calculate a value for this periodicity of 67 ± 1 nm. This result is in good agreement with measurements made on amianthoid areas as well as from fibrils in tendon, which consist of a chemically distinct form of collagen.     

Anatomic microstructure of the upper eyelid in the Oriental double eyelid

The anatomic differences in the microstructure of the upper eyelid between the double eyelid and the nondouble eyelid are compared to determine the mechanism of double eyelid formation. Tissue from the upper eyelids of normal adult women was categorized into three groups: in one group, the double eyelid was formed primarily (at birth); in a second group, the double eyelid was formed gradually; and those in a third group had nondouble eyelids. A total of 56 eyelids were studied using electron microscopy and light microscopy. The results indicated that there is a significant difference between the three groups using scanning electron microscopy. In the upper eyelid of the double eyelid, bunched fibers of levator aponeurosis penetrate through orbicularis muscle to fuse with the skin in palpebral sulcus. This structure was not observed in the group with nondouble eyelids. However, when using light microscopy, this disparity was not observed. It was concluded that a fiber-linked structure between eyelid skin and levator aponeurosis is essential for the formation of the double eyelid.     

Long-term comparison of a newly designed gold implant with the conventional implant in facial nerve paralysis.

Patients with complete facial nerve palsy are at risk for eye complications resulting from exposure of the cornea and loss of the blinking reflex. Failure of protection predisposes the patient to exposure keratitis, corneal abrasion and, in rare cases, blindness. The mainstays of non-surgical therapy are cumbersome, obscure vision, and are mostly helpful in patients with acute facial paralysis in whom recovery of orbicularis oculi function is expected. Methods of lid-loading using metal implants and gold eyelid weights have been reported in the literature. Between October of 1988 and March of 1995, 32 patients with lagophthalmos due to facial nerve palsy underwent a total of 34 procedures for the insertion of a gold eyelid weight. Each patient had a gold weight inserted into a small pocket between the orbicularis oculi and the tarsal plate of the upper eyelid. The gold implant is curved to fit the curvature of the eye and contains holes for fixation to the tarsus with sutures. Ingrowth of fibrous tissue through the holes may also help fix the weight in position. Between 1988 and 1991, 10 patients received 10 commercially available rectangular gold implants with 2 holes; these implants resulted in adverse effects, such as infection and exposure in up to 30 percent of the cases. Because of the high complication rate with the rectangular gold implant, the authors began using a new, elliptical gold implant with 3 holes, which is longer, thinner, wider in the center, and narrower in the peripheral portion. This new elliptical implant was used on 22 patients (24 implants) from December of 1991 through March of 1995. The mean follow-up time for the 32 patients in the study was 41.3 months (range, 6 to 63 months), 49.8 months for patients with rectangular implants and 32.8 months for patients with elliptical implants. The elliptical gold implant resulted in dynamic closure of the eyelid and in excellent protection and cosmesis. Lagophthalmos and exposure keratitis resolved, visual acuity significantly improved without complications, and most patients could dispense with eyedrops and salves. A lower eyelid supporting procedure (conchal cartilage graft) should be performed simultaneously in patients with lagophthalmos of a moderate or severe degree to achieve complete closure of the eyelid. Use of a tall pillow decreased the incidence of eyelid opening during sleep. Double eyelid fold operations'were performed on the contralateral eyelid after 6 months, resulting in a symmetrical and beautiful eyelid.     

Position-related capacity for differentiation of limb mesenchyme in cell culture.

A quantitative comparison (i.e., number of cartilage nodules) of cartilage differentiation was made between micromass cell cultures prepared with cells from different locations (core vs periphery) within prechondrogenic chick wing buds. Wing bud core cells in micromass culture exhibit a greater developmental bias toward cartilage differentiation than periphery cells from the same limbs. In addition, myogenic cells appear more frequently in cultures prepared from wing bud periphery than in those prepared from core tissue. Therefore a stage 23–24 wing bud is not a homogeneous population of multipotential mesenchymal cells. Instead, a stage 23–24 wing bud contains two classes of cells, each characterized by a bias for either cartilage or muscle differentiation, and a third class of uncharacterized mesenchymal cells.     

Effect of acetabular labral tears,repair and resection on hip cartilage strain: A 7 T MR study

BackgroundTears of the acetabular labrum are frequently present in patients with groin pain. While it is clear that the labrum contributes to the surface area articulating with the femoral head, it is not clear whether labral repair yields different load distribution in the hip compared to labral resection.PurposeDetermine whether labral repair reduces cartilage strain more effectively than labral resection.MethodsSix human cadaveric hips (mean age 37 years) were loaded in a simulated single-leg stance within the bore of a 7 T MR scanner. After cartilage had reached a steady-state thickness distribution, a scan of the cartilage was acquired with a voxel size of 0.1×0.1×0.3 mm. This method was repeated for each of six specimens when the labrum was intact, after a surgically simulated labral tear, after an arthroscopic labral repair and after labral resection. Cartilage thickness and strain in an anterosuperior region of interest were measured from the MR scans. A paired t-test was used to compare mean and maximum cartilage strain when the labrum was intact vs. torn, torn vs. repaired and repaired vs. resected. Three-dimensional patterns of cartilage strain distribution were qualitatively compared for the different labral conditions.ResultsFor the number of specimens tested we found no change in mean and maximum cartilage strain, and little obvious change in the pattern of cartilage strain distribution after a simulated labral tear. Labral repair caused a 2% decrease in mean cartilage strain compared to a torn labrum (p=0.014). Labral resection caused a 4% and 6% increase in mean and maximum cartilage strain, respectively, compared to labral repair (p=0.02), and the cartilage strain distribution was elevated throughout the region of interest.ConclusionBased on our ex vivo findings of increased cartilage strain after labral resection when compared to labral repair, we have demonstrated the associated consequences to the mechanical environment of the cartilage following surgical treatment of the labrum.     

326 例眼睑肿物的临床病理分析

目的:总结眼睑肿物的临床病理类型及特点。方法:收集2000年1月至2011年6月到青岛大学医学院附属医院眼科住院部行手术治疗眼睑肿物患者326例的临床病理资料进行分析。结果:在326例眼睑肿物中,良性肿瘤156例,占47.9%,恶性肿瘤63例,占19.3%;炎性改变98例,占30.1%。良性肿瘤的前五位分别是色素痣、乳头状瘤、囊肿、疣、血管瘤;恶性肿瘤前三位分别是基底细胞癌、睑板腺癌、鳞状细胞癌;炎性改变以炎性肉芽肿最常见。儿童多发的眼睑肿物为皮样瘤、钙化上皮瘤。结论:眼睑病变以良性肿瘤多见,其次为炎性改变。良性肿瘤中以色素痣、乳头状瘤和囊肿多见;恶性肿瘤最常见的为基底细胞癌,儿童眼睑肿瘤以皮样瘤最多见。     

Conchal cartilage and composite grafts for correction of lower lid retraction

Lower eyelid retraction may be due to vertical deficiency of the anterior lamella, supporting cartilage, or posterior lamella. We have used autologous cartilage grafts from the conchal bowl for reconstruction of the central lamella, reestablishing and augmenting support of the lower lid. The positioning of the graft is dependent on the specific anatomic deficiency, and the etiology of the lid retraction must be carefully evaluated. In patients with posterior lamella deficiency, the contracted lower lid retractors and conjunctiva are released and the graft is placed facing the bulbar conjunctiva and is allowed to reepithelialize. In patients in whom there is an associated skin deficiency, composite auricular grafts are used. We present our experience in 33 patients with lower lid retraction. Twenty-three patients required placement of a cartilage graft only, while 10 patients had an associated skin deficiency requiring placement of composite cartilage. In nine patients the cartilage graft was seated against the bulbar conjunctiva and allowed to reepithelialize. Reepithelialization was complete within 3 1/2 weeks in all but two of these patients. This technique has provided stable lid support in all 33 patients.     

Reconstruction of a three-dimensional structure using cartilage regenerated from the perichondrium of rabbits

Human tissues such as those found in the ear, nose, eyelid, lip, and larynx have complicated and delicate three-dimensional structures, which are difficult to reconstruct and restore to normal function following damage by tumor, congenital disease, or trauma. We devised a new reconstructive technique for the lost tissues by using cartilage regenerated from the perichondrium. In 12 ears of 12 rabbits, the layer between the perichondrium and the cartilage was stripped off. The exposed cartilage was punched out in large amounts to resemble a flexible, honeycomb-like structure. Then, we sandwiched the rabbit ears with two thermoplastic plates, which maintained a structure of the anterior surface of the human ear for 8 weeks. Structural change was studied in all cases, and some parts of the remodeled tissue were studied pathologically. Out of 12 ears, 8 had a rigid structure with a shape like a human ear using regenerated cartilage from the perichondrium of rabbits, 2 were infected, and 2 had a decubitus ulcer on the conchal surface as a result of compression from the plate. This study suggests that the use of the cartilage regenerated from the perichondrium may lead to a successful treatment also in humans for a variety of three-dimensional structures that have been damaged.     

The distribution of serum albumin in human normal and degenerate articular cartilage

A method for studying the distribution of a high molecular weight solute (serum albumin) between physiological saline and human articular cartilage is described. Samples of normal and fibrillated articular cartilage from both femoral condyles and femoral heads have been studied. Limited studies have also been performed where the glycosaminoglycan content of normal cartilage has been reduced by chemical or enzymatic methods. With naturally occuring cartilage large a wide range of partition coefficients (0.3 to less than 0.002) was obtained. The partition coefficients are very dependent upon proteoglycan concentration, with the partitiion coefficient decreasing with increasing fixed charge density. An attempt is made to interpret the observed partitioning in terms of the steric exclusion by the proteoglycans.