Lash disorders, facial palsy and lid reconstruction

The eyelid protects the cornea through structure and movement

The anterior lamella consists chiefly of skin and orbicularis; the posterior lamella includes tarsus and conjunctiva. The septum, fat and retractors contribute additional anatomical relationships. Orbicularis closure is supplied by the facial nerve, while levator elevation is supplied by the third nerve and Müller muscle receives sympathetic supply. Loss of closure and loss of elevation therefore have different neurological implications.

The lid margin contains lashes, gland openings and the mucocutaneous junction. Tarsal meibomian glands contribute lipid to the tear film. Medial and lateral canthal attachments position the lids against the globe, and blinking spreads tears and assists drainage. An operation that restores appearance but leaves poor apposition or exposure may fail the patient's functional need.

Lash disorders and congenital folds

Trichiasis means misdirected lashes with an otherwise normally positioned lid margin; entropion means inward margin rotation. Distichiasis is an additional lash row, often near meibomian openings. Examine lash origins and the whole margin before choosing treatment. Epilation removes offending lashes temporarily, while electrolysis, cryotherapy or selected surgical approaches can address recurrent lashes. Each has risks, including scarring and injury to neighbouring tissue, and treatment depends on the number and location of lashes.

An extra row can occur in a congenital or acquired setting. Ask about family history and associated features when a syndromic diagnosis is possible. Repeatedly removing lashes without recognizing a scarred or rotating lid leaves the cause untreated. Cicatrising disease must be controlled alongside mechanical treatment.

Epiblepharon is a skin–muscle fold that redirects lashes, often more apparent on downgaze. It differs from true congenital entropion. Assess symptoms, staining, refraction and visual development. Some children can be observed; persistent corneal injury may justify repair. Avoid removing excessive skin, which can create a different malposition or exposure problem.

A congenital lid coloboma leaves a defect that may expose the cornea. Examine its size and associated developmental anomalies. Urgency follows protection and visual-development risk, not appearance alone. Cryptophthalmos and ankyloblepharon require a broader developmental assessment and specialist planning. Detailed involutional and cicatricial entropion/ectropion repair is taught with the original lid-malfuction section; here identify the lash or fold mechanism and its specific threat to the cornea.

Facial palsy and functional protection

Assess complete versus incomplete closure, Bell phenomenon, corneal sensation and exposure. Preserved upward rotation does not guarantee safety if closure is poor or the cornea is anaesthetic. Start lubrication and appropriate physical protection, then consider temporary or definitive procedures according to severity and expected nerve recovery. Tarsorrhaphy, upper-lid loading and lower-lid support can be selected; weights require attention to allergy, migration and contour.

Investigate an acute facial palsy in its neurological and systemic context. A new palsy with other deficits is not automatically idiopathic Bell palsy. Reduced corneal sensation may compound the risk and alter management. Document exposure and give clear follow-up instructions because progression can occur despite modest symptoms.

Floppy eyelid syndrome produces an easily everted lax upper lid with chronic surface irritation and has an association with obstructive sleep apnoea. Ask about sleep and arrange appropriate systemic assessment. Blepharospasm involves involuntary closure; distinguish it from hemifacial spasm, reflex closure due to surface irritation and apraxia of opening. Botulinum toxin can be useful in selected patients but has temporary effects and risks including ptosis and exposure.

Wounds and reconstruction

A lid wound needs assessment of margin alignment, canthal attachments, levator and canalicular involvement. Exclude globe injury and retained foreign material before definitive repair. A laceration medial to a punctum should raise concern for canalicular injury and prompt specialist evaluation. Tissue preservation and accurate layered repair can be more valuable than aggressive trimming of apparently irregular edges.

For a full-thickness defect, reconstruct both lamellae and maintain vascular support. A free graft cannot simply be placed on another unsupported free graft and expected to survive; at least one component generally needs a vascularized bed or flap. The choice of local flap, tarsoconjunctival support, skin graft or staged repair depends on size, location and remaining tissue. Keep the lid margin smooth and the cornea protected.

Congenital coloboma can cause exposure and may need early repair according to extent. Burns can progressively contract and require repeated assessment and later reconstruction. Following tumour excision, clear margins and oncological planning precede an elaborate reconstruction that would obscure residual disease.

Case response

A patient with watering and lower-lid laxity needs assessment of apposition as well as irrigation. A scarred inward margin needs posterior-lamellar treatment rather than epilation alone. A new facial palsy with staining requires immediate corneal protection while the cause and expected recovery are assessed.

Source: EBO eyelid, lacrimal and orbital curriculum.

Choosing the anatomical repair