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The O-to-Z plasty, devised by Marvin Quickert, is a rotational flap, which can be used in the reconstruction of the anterior lamella of a lower eyelid or medial canthus after tumor excision or trauma. In this procedure, a circular defect is repaired by forming two triangular rotational skin flaps along normal tension lines and aligning them in a diagonal fashion to create a Z closure (Colour Atlas of Ophthalmic Plastic Surgery, Boston, 2008). This technique minimizes vertical tension which could lead to lower lid retraction or ectropion. The procedure requires mild to moderate laxity of the eyelid skin and is best suited for small- to medium-sized defects of the lower eyelid or medial canthus. This procedure is not suited for defects involving the eyelid margin, tarsus, or lacrimal drainage system.

The lateral tarsal strip operation is a procedure used to address eyelid laxity by horizontally shortening the lower eyelid at the lateral canthus. Evaluation of horizontal eyelid laxity includes the eyelid distraction test and the eyelid snap test (Techniques in ophthalmic plastic surgery. Philadelphia: Saunders Elsevier, 2010). Patients with incipient involutional ectropion often complain of tearing, especially in the wind and cold. In such patients, it is important to evaluate the lacrimal system. When punctal eversion accompanies involutional ectropion, one must determine whether shortening the lower eyelid horizontally will reposition the punctum to its correct anatomical position alone. If stretching the lower eyelid laterally at the slit lamp does not correct punctal eversion, a medial spindle procedure may be used in combination with a lateral tarsal strip procedure to address both the involutional ectropion and punctal eversion (Nerad, Techniques in ophthalmic plastic surgery. Philadelphia: Saunders Elsevier, 2010). In a medial spindle procedure, the posterior lamella is shortened vertically and pulled inwards to tip the punctum back into globe apposition.

Orbital inflammatory disease encompasses a large collection of entities which can be grouped into infectious and noninfectious inflammations. Infectious causes can be bacterial, fungal, or viral. Noninfectious causes may be autoimmune, vasculitic, granulomatous, inflammatory, drug-related, and idiopathic. Orbital inflammation can be vision and life-threatening and is often intimidating and challenging to the clinician. The paragraphs below divide orbital inflammation into infectious and noninfectious categories and provide the clinician with a framework for accurate diagnostic work-up and management.

Contracture of the conjunctiva of an anophthalmic socket is a common complication following enucleation (Int J Oral Maxillofac Surg 29(2):96–98, 2000; Ophthal Plast Reconstr Surg 9(4):267–272, 1993; Colour atlas of ophthalmic plastic surgery. 3rd ed. Boston: Butterworth-Heinemann/Elsevier, 2008). The lower fornix is typically affected before the upper fornix (Int J Oral Maxillofac Surg 29(2):96–98, 2000; Ophthal Plast Reconstr Surg 9(4):267–272, 1993; Colour atlas of ophthalmic plastic surgery. 3rd ed. Boston: Butterworth-Heinemann/Elsevier, 2008). Loss of forniceal depth can make it impossible for an ocularist to fit a prosthetic. In such cases, forniceal reconstruction may be considered (Int J Oral Maxillofac Surg 29(2):96–98, 2000; Ophthal Plast Reconstr Surg 9(4):267–272, 1993; Colour atlas of ophthalmic plastic surgery. 3rd ed. Boston: Butterworth-Heinemann/Elsevier, 2008). If the conjunctiva is sufficiently elastic, fornix deepening sutures can be used to recreate the upper and lower fornices. However, if the conjunctiva is scarred and inelastic, mucous membrane grafting may be considered (Colour atlas of ophthalmic plastic surgery. 3rd ed. Boston: Butterworth-Heinemann/Elsevier, 2008). Buccal mucosa is similar in consistency to conjunctiva, consisting of non-keratinized squamous cell epithelium and a thin lamina propria (EAU-EBU Update Series 5(5):179–187, 2007). When harvesting buccal mucosa, care must be taken to avoid the parotid (Stensen) duct, located on the inner cheek, across from the second superior molar tooth. Additionally, damage to the underlying buccinator muscle should be avoided. When choosing the size of the graft to harvest, one should overestimate the amount of mucosa required, as oral mucosal grafts can shrink up to 20 % from their original size (EAU-EBU Update Series 5(5):179–187, 2007). After harvesting the graft, it is important to use a second set of sterile surgical instruments and replace the surgeons’ gloves in order to prevent contamination of the eye socket with oral bacteria (EAU-EBU Update Series 5(5):179–187, 2007).

Lower eyelid retraction secondary to thyroid eye disease or prior lower eyelid blepharoplasty can be addressed by disinserting the lower eyelid retractors and employing a spacer graft between the tarsus and lower eyelid retractors (Colour Atlas of Ophthalmic Plastic Surgery, Boston, 2008). Graft materials include hard palate, ear cartilage, sclera, or alloplastic materials. When using ear cartilage or sclera, the graft must be covered with conjunctival epithelium (Colour Atlas of Ophthalmic Plastic Surgery, Boston, 2008). Hard palate has the benefit of combining the structural rigidity of tarsus with the mucous membrane epithelium similar to that of the conjunctiva. The biggest disadvantage of hard palate grafting is donor site morbidity. Preoperative fitting of a palate protector and postoperative oral viscous lidocaine (2 %) gel can be used to improve patient discomfort. Anesthesia during hard palate grafting can be obtained with a greater palatine nerve block (Ophthalmic Plastic and Reconstructive Surgery 8:183–195, 1992) and direct infiltration of the hard palate. Local anesthesia is injected by the greater palatine foramen, medial to the alveolar process by the third molar. The hard palate is composed of epithelium, lamina propria, and submucosa. Hard palate harvesting is done in the submucosal plane and the submucosa is removed from the graft before implantation. The area of the alveolar process and midline raphe are devoid of submucosa and should therefore be avoided (Ophthalmic Plastic and Reconstructive Surgery 8:183–195, 1992). After harvesting the graft, the graft is rinsed in a 10 % betadine solution, a second set of sterile surgical instruments are opened, and the surgeon’s gloves are changed in order to prevent contamination of the eye socket with oral bacteria.

Involutional brow ptosis is generally more pronounced in the lateral brow than the medial brow (Techniques in Ophthalmic Plastic Surgery, Philadelphia, 2010). Brow ptosis can become visually significant, restricting the superior and lateral field of vision. The internal lateral browpexy can be used to correct mild lateral brow ptosis through an eyelid crease incision (Colour Atlas of Ophthalmic Plastic Surgery, Boston, 2008). This procedure may be performed in combination with an upper eyelid blepharoplasty and browplasty without additional incisions (Plastic and Reconstructive Surgery 86:248–254, 1990). Moderate amounts of brow ptosis are better corrected with a direct, mid-forehead, pretrichial, or endoscopic brow lift (Colour Atlas of Ophthalmic Plastic Surgery, Boston, 2008).

Entropion of the lower eyelid can lead to ocular surface irritation due to the lashes and eyelid skin rubbing against the cornea. If not corrected, permanent scarring of the cornea and loss of vision can result. Involutional entropion is believed to occur secondary to dehiscence of the lower eyelid retractors, horizontal eyelid laxity, and overriding of the preseptal orbicularis over the pretarsal orbicularis (Techniques in ophthalmic plastic surgery. Philadelphia: Saunders Elsevier, 2010). In spastic entropion, ocular irritation or inflammation leads to spasm of the eyelids, resulting in entropion (Techniques in ophthalmic plastic surgery. Philadelphia: Saunders Elsevier, 2010). The Quickert suture technique, first described by Quickert and Rathbun (Arch Ophthalmol 85:304–305, 1971), temporarily corrects lower eyelid entropion by plicating the lower eyelid retractors. This technique does not address the horizontal laxity component that contribute to involutional entropion and is not a permanent solution for involutional or spastic entropion. It is, however, a powerful tool to temporarily relieve patient discomfort and prevent scarring of the cornea until definitive surgery can be performed.