Part 12  Orbit and Oculoplastics

Section 1  Orbital Anatomy and Imaging

Clinical Anatomy of the Eyelids

Jonathan J. Dutton 12.1 
tendon. It inserts onto the posterior lacrimal crest. Horner’s muscle helps
Definition:  The eyelids are mobile, flexible, multilamellar structures maintain the posterior position of the canthal angle and may aid in the
that cover the globe anteriorly. lacrimal pump mechanism.7

Key Features
• The eyelids provide protection from desiccation and airborne foreign
matter.
• The eyelids anatomically contain both superficial musculocutaneous
elements anteriorly and orbital components posteriorly.
Orbital Septum
The orbital septum is a thin, fibrous, multilayered membrane that begins
anatomically at the arcus marginalis along the orbital rim. Distal fibers
merge into the anterior surface of the levator aponeurosis (Fig. 12.1.2).8
The point of insertion usually is about 3–5 mm above the tarsal plate, but
it may be as much as 10–15 mm above it.9 In the lower eyelid the septum
fuses with the capsulopalpebral fascia several millimeters below the tarsus,
and the common fascial sheet inserts onto the inferior tarsal edge.10,11

INTRODUCTION Preaponeurotic Fat Pockets

The eyelids serve a vital function by protecting the globe. They provide
fundamental elements of the precorneal tear film and help distribute tears
evenly over the surface of the eye. The eyelids collect tears and propel them
to the medial canthus, where they enter the lacrimal drainage system. The
eyelashes sweep airborne particles from the front of the eye. Constant vol-
untary and reflex movements of the eyelids protect the cornea from injury
and glare. Any aesthetic or reconstructive surgery on the eyelids requires a
thorough knowledge of eyelid anatomy.1,2
ANATOMY OF THE EYELIDS
The eyelids undergo a complex embryonic and fetal morphogenesis involv-
ing a succession of strictly regulated episodes of proliferation, fusion, and
separation that results in functional eyelids at birth.3 In young adults the
interpalpebral fissure measures 10–11 mm vertically. With advancing age
this decreases to only about 8–10 mm. The horizontal length of the fissure
is 30–31 mm. The upper and lower eyelids meet at an angle of approx-
imately 60° medially and laterally. In primary position, the upper eyelid
margin lies at the superior corneal limbus in children and 1.5–2 mm below
it in adults. The lower eyelid margin rests at the inferior corneal limbus.
The margin is covered by cutaneous epithelium and eyelashes anteri-
orly and conjunctiva with meibomian gland openings posteriorly.
The preaponeurotic fat pockets in the upper eyelid and the precapsulopal-
pebral fat pockets in the lower eyelid are anterior extensions of extraconal
orbital fat. These are surgically important landmarks and help identify a
plane immediately behind the orbital septum and anterior to the major
eyelid retractors. In the upper eyelid, two fat pockets typically occur: a
medial pocket and a central one.12 In the lower eyelid, three pockets occur:
medial, central, and lateral.13
Major Eyelid Retractors
The retractors of the upper eyelid consist of the levator palpebrae and
Müller’s muscles.14,15 The levator palpebrae superioris arises from the
lesser sphenoid wing and runs forward just above the superior rectus
muscle. Near the superior orbital rim, a condensation along the muscle
sheath attaches medially and laterally to the orbital walls. This is the
ORBICULARIS MUSCLE –
ORBITAL, PRESEPTAL, AND PRETARSAL PORTIONS
frontalis muscle

procerus muscle
Orbicularis Muscle orbital portion
of orbicularis
The orbicularis oculi is a complex striated muscle sheet that lies just below
muscle
the skin. It is divided anatomically into three contiguous parts (Fig. 12.1.1):
orbital, preseptal, and pretarsal.4,5 superior
The orbital portion overlies the bony orbital rims. It arises from inser- preseptal portion
tions on the frontal process of the maxillary bone, the orbital process of of orbicularis
the frontal bone, and the common medial canthal tendon. Its fibers pass muscle
around the orbital rim to form a continuous ellipse.
lateral horizontal
The palpebral portion of the orbicularis muscle overlies the mobile raphe
eyelid from the orbital rims to the eyelid margins. The muscle fibers sweep
circumferentially around each eyelid as a half ellipse fixed medially and superior
laterally at the canthal tendons. It is further divided topographically into pretarsal portion
the preseptal and pretarsal orbicularis. of orbicularis
The preseptal portion of the muscle is positioned over the orbital muscle
septum in both upper and lower eyelids. Its fibers originate perpendic- anterior arm
ularly along the upper and lower borders of the medial canthal tendon. of medial
Fibers arc around the eyelids and insert along the lateral horizontal raphe. canthal tendon
The pretarsal portion of the muscle overlies the tarsal plates. Contraction
of these fibers aids in the lacrimal pump mechanism.6 Medially, the deep Fig. 12.1.1  Orbicularis and Frontalis Muscles. (Adapted with permission from
heads of the pretarsal fibers fuse to form a prominent bundle of fibers, Dutton JJ. Atlas of clinical and surgical orbital anatomy. 2nd ed. London: Elsevier 1259
Horner’s muscle, that runs behind the posterior limb of the canthal Saunders; 2011. p. 153.)

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 forms a prominent fibrous sheet that indents the posterior aspect of the

12 ORBITAL SEPTUM lacrimal gland and so defines its orbital and palpebral lobes. The medial
horn is not as well developed. Together, the two horns serve to distribute
the forces of the levator muscle along the aponeurosis and the tarsal plate.
arcus In the lower eyelid, the capsulopalpebral fascia is a fibrous sheet that
Orbit and Oculoplastics

marginalis arises from Lockwood’s ligament and the sheaths around the inferior
rectus and inferior oblique muscles.17 It passes upward and generally fuses
superior
with fibers of the orbital septum about 4–5 mm below the tarsal plate.
orbital From this junction, a common fascial sheet continues upward and inserts
septum onto the lower border of the tarsus.

levator
Sympathetic Accessory Retractors
aponeurosis Smooth muscles innervated by the sympathetic nervous system are present
in both the upper and lower eyelids and serve as accessory retractors.18
In the upper eyelid, the supratarsal muscle of Müller originates abruptly
from the undersurface of the levator muscle just anterior to Whitnall’s lig-
ament.19 It runs downward, posterior to the levator aponeurosis and inserts
onto the anterior edge of the superior tarsal border. In the lower eyelid, the
sympathetic muscle is not as well defined. Fibers run behind the capsu-
lopalpebral fascia to insert 2–5 mm below the tarsus.20

Tarsal Plates
anterior intermediate posterior inferior orbital
layer layer layer septum The tarsal plates consist of dense, fibrous tissue 1–1.5 mm thick that
imparts structural integrity to the eyelids. Each plate measures about
Fig. 12.1.2  Orbital Septum. (Adapted with permission from Dutton JJ. Atlas of 25 mm horizontally and is curved gently to conform to the contour of
clinical and surgical orbital anatomy. 2nd ed. London: Elsevier Saunders; 2011. p. 149.) the anterior globe; the central height of the tarsal plates is 8–12 mm in
the upper eyelid and 3.5–4 mm in the lower. Medially and laterally they
taper to 2 mm in height as they pass into the canthal tendons. Within
LEVATOR APONEUROSIS each tarsus are the meibomian glands, numbering about 25 in the upper
lid and 20 in the lower lid. These are holocrine-secreting sebaceous glands
that are not associated with lash follicles. They produce the lipid layer of
Whitnall's the precorneal tear film.
levator
ligament
palpebrae
superioris
muscle
Canthal Tendons
The medial canthus provides a number of important support structures
levator
that maintain alignment and orientation of the medial eyelids and allow
aponeurosis
for stability of the medial rectus muscle.21 Medially, the tarsal plates pass
into fibrous bands that form the crura of the medial canthal tendon. These
lateral horn lie between the orbicularis muscle anteriorly and the conjunctiva posteri-
orly. The superior and inferior crura fuse to form a stout common tendon
that inserts via three limbs (see Fig. 12.1.3). The anterior limb inserts onto
lateral canthal the orbital process of the maxillary bone in front of and above the ante-
tendon rior lacrimal crest. It provides the major support for the medial canthal
angle. The posterior limb arises from the common tendon near the junc-
tion of the superior and inferior crura and passes between the canaliculi.
It inserts onto the posterior lacrimal crest just in front of Horner’s muscle
and directs the vector forces backward to maintain close approximation
with the globe. The superior limb of the medial canthal tendon arises as
a broad arc of fibers from both the anterior and posterior limbs. It passes
upward to insert onto the orbital process of the frontal bone. The posterior
medial medial fascial slips to capsulopalpebral
canthal tendon horn orbicularis muscle fascia
head of the preseptal orbicularis muscle inserts onto this limb, and the
unit forms the soft tissue roof of the lacrimal sac fossa. This extension
Fig. 12.1.3  Levator Aponeurosis and Medial and Lateral Canthal Tendons. provides vertical support to the canthal angle22 and appears to play a role
(Adapted with permission from Dutton JJ. Atlas of clinical and surgical orbital in the lacrimal pump mechanism.
anatomy. 2nd ed. London: Elsevier Saunders; 2011. p. 149.) Lateral canthal anatomy is somewhat analogous to that of the medial
canthus, but in general its support structures are less defined and less
complex.23 Laterally, the tarsal plates pass into not very well-developed
superior transverse orbital ligament of Whitnall. It provides some support fibrous strands that become the crura of the lateral canthal tendon. This
for the fascial system that maintains spatial relationships between a variety is a distinct entity separate from the orbicularis muscle; it measures about
of anatomical structures in the superior orbit. 1 mm in thickness, 3 mm in width, and approximately 5–7 mm in length.24
From Whitnall’s ligament the muscle passes into its aponeurosis (Fig. The insertion of these fibrous strands extends posteriorly along the lateral
12.1.3). This sheet continues downward 14–20 mm to its insertion near the orbital wall, where it blends with strands of the lateral check ligament
marginal tarsal border. The aponeurotic fibers are most firmly attached from the sheath of the lateral rectus muscle.
at about 3–4 mm above the eyelid margin.15,16 The aponeurosis also sends
numerous delicate interconnecting slips forward and downward to insert Conjunctiva
onto the interfascicular septa of the pretarsal orbicularis muscle and sub-
cutaneous tissue. These slips maintain the close approximation of the skin, The conjunctiva is a mucous membrane that covers the posterior surface of
muscle, aponeurosis, and tarsal lamellae and integrate the distal eyelid as a the eyelids and the anterior pericorneal surface of the globe. The palpebral
single functional unit. This relationship defines the upper eyelid crease in portion is applied closely to the posterior surface of the tarsal plate and the
both white and black people. sympathetic tarsal muscle of Müller. It is continuous around the fornices
1260 As the levator aponeurosis passes into the eyelid from Whitnall’s liga- above and below, where it joins the bulbar conjunctiva. Small accessory
ment, it broadens to form the medial and lateral “horns.” The lateral horn lacrimal glands are located within the submucosal connective tissue.

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For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
 MOTOR NERVES SENSORY NERVES
12.1
supraorbital
nerve

Clinical Anatomy of the Eyelids

zygomatico-
temporal nerve

supratrochlear
nerve
lacrimal nerve
infratrochlear
temporal nerve
branch
zygomatic zygomatico-
branch facial nerve

facial nerve, infraorbital

main trunk nerve
mandibular
branch
buccal branch
cervical branch

Fig. 12.1.4  Motor Nerve Supply to the Eyelids: The Facial Nerve. (Adapted with Fig. 12.1.5  Sensory Nerve Supply From the Eyelids. (Adapted with permission
permission from Dutton JJ. Atlas of clinical and surgical orbital anatomy. 2nd ed. from Dutton JJ. Atlas of clinical and surgical orbital anatomy. 2nd ed. London:
London: Elsevier Saunders; 2011. p. 155.) Elsevier Saunders; 2011. p. 155.)

A small mound of tissue, the caruncle, is at the medial canthal angle.

The caruncle consists of modified skin that contains fine hairs, sebaceous ARTERIAL SUPPLY AND VENOUS DRAINAGE
glands, and sweat glands. Just lateral to the caruncle is a vertical fold of
conjunctiva, the plica semilunaris. Arterial supply
superior
Nerves to the Eyelids supraorbital palpebral
artery
artery
The facial nerve (seventh cranial nerve) is a unique structure that provides superior
supratrochlear
motor innervation to the muscle of facial expression and also contains peripheral
artery
special and general visceral efferent and special and general somatic affer- arterial arcade
ent fibers. It has a complex anatomical relationship to the parotid gland.25
medial superior
The motor nerves to the periorbital muscles originate in the temporal and palpebral marginal
zygomatic branches (Fig. 12.1.4). These branches innervate the frontalis artery arterial arcade
and orbicularis muscles, respectively. The buccal, mandibular, and cervical
branches innervate muscles of the lower face and neck.26 lateral
The sensory nerves to the eyelids derive from the ophthalmic and max- angular palpebral artery
illary divisions of the trigeminal nerve (Fig. 12.1.5). Sensory input from the artery
inferior
upper lid passes to the ophthalmic division primarily through its main ter-
marginal
minal branches, the supraorbital, supratrochlear, and lacrimal nerves. The arterial arcade
facial artery
infratrochlear nerve receives sensory information from the extreme medial
portion of both upper and lower eyelids. The lower eyelid sends sensory
impulses to the infraorbital nerve. The zygomaticofacial branch from the Venous drainage
maxillary nerve innervates the lateral portion of the lower lid, and part of
the infratrochlear branch receives input from the medial lower lid. superior
supraorbital
palpebral
vein
vein
Vascular Supply of the Eyelids nasofrontal
vein superior
Vascular supply to the eyelids is extensive. The posterior eyelid lamellae peripheral
receive blood through the vascular arcades. In the upper eyelid, a mar- medial venous
ginal arcade runs about 2 mm from the eyelid margin, and a peripheral palpebral arcade
arcade extends along the upper border of the tarsus between the levator veins
aponeurosis and Müller’s muscle (Fig. 12.1.6). These arcades are supplied lateral
medially by the superior medial palpebral vessels from the terminal oph- angular vein palpebral
vein
thalmic artery and laterally by the superior lateral palpebral vessel from the
lacrimal artery. The lower lid arcade receives blood from the medial and
inferior
lateral inferior palpebral vessels.
peripheral
The venous drainage system is not as well defined as the arterial system. anterior venous arcade
Drainage is mainly into several large vessels of the facial system (see Fig. facial vein
12.1.6). Lymphatic drainage from the eyelids is restricted to the region
anterior to the orbital septum. Traditional teaching is that lymphatic flow
from the lateral two-thirds of the upper eyelid and the lateral one-third of
the lower eyelid drain laterally into the deep and superficial parotid nodes, Fig. 12.1.6  Arterial Supply to and Venous Drainage From the Eyelids. (Adapted
and flow from the medial one-third of the upper eyelid and the medial with permission from Dutton JJ. Atlas of clinical and surgical orbital anatomy. 2nd 1261
two-thirds of the lower eyelid drains inferiorly into the submandibular ed. London: Elsevier Saunders; 2011. p. 156.)

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For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
 and anterior cervical nodes. However, recent studies have shown a more Nijhawan N, Marriott C, Harvey JT. Lymphatic drainage patterns of the human eyelid:

12 diffuse drainage from all areas of the eyelids into the parotid nodes.27 assessed by lymphoscintigraphy. Ophthal Plast Reconstr Surg 2010;26:281–5.
Persichetti P, Di Lella F, Delfino S, et al. Adipose compartments of the upper eyelid: anatomy
applied to blepharoplasty. Plast Reconstr Surg 2004;113:373–8.
KEY REFERENCES Poh F, Kakizaki H, Selva D, et al. The anatomy of the medial canthal tendon in Caucasians.
Clin Experiment Ophthalmol 2012;40:170–3.
Orbit and Oculoplastics

Dutton JJ. Atlas of clinical and surgical orbital anatomy. 2nd ed. London: Elsevier Saunders;
2011.
Kakizaki H, Malhotra R, Madge SN, et al. Lower eyelid anatomy: an update. Ann Plast Surg
2009;63:344–51.
Kakizaki H, Malhotra R, Selva D. Upper eyelid anatomy: an update. Ann Plast Surg
2009;63:336–43.
Lim HW, Paik DJ, Lee YJ. A cadaveric anatomical study of the levator aponeurosis and Whit-
nall’s ligament. Korean J Ophthalmol 2009;23:183–7.
Ridgway JM, Larrabee WE. Anatomy for blepharoplasty and brow-lift. Facial Plast Surg
2010;26:177–85.
Tawfik HA, Abdulhafez MH, Fouad YA, et al. Embryology and fetal development of the
human eyelid. Ophthal Plast Reconstr Surg 2016;32(6):407–14.
Access the complete reference list online at ExpertConsult.com

1262

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For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
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