Oculoplastic surgery is a subspecialty that handles reconstruction, functional restoration, and cosmetic treatment of the eyelids, tear ducts, orbit, and surrounding eye area. Its origins overlap with the history of human civilization.
The Hammurabi Code, around 2250 BCE, includes one of the oldest descriptions of treatment for an infected lacrimal sac. It also says that if a doctor successfully performs eye surgery with a bronze knife, he may receive a large reward; if he fails, his hand will be cut off, showing that eye surgery was considered a socially serious matter.
Aulus Cornelius Celsus (25 BCE–50 CE) described advancement flaps, sliding flaps, and island pedicle flaps, and established reconstructive principles that remain valid today. He also regarded the eyeball as being made up of three membranes and improved couching. Galen (around 150–200 CE) is said to have treated nasolacrimal duct obstruction by cauterizing through the lacrimal bone into the nasal cavity, and this theory dominated medicine for more than 1,000 years.
In 1583, Georg Bartisch performed the first recorded enucleation and carried out couching with a silver needle. In the early 19th century, Carl Ferdinand von Graefe revived and refined the classic techniques of eyelid reconstruction.
The turning point that defined modern oculoplastics was World War II. The amount and severity of facial trauma and burns exceeded what plastic surgeons could manage, so eyelid and orbital injuries were left to ophthalmologists. Ophthalmologists, mainly trained in cataract, glaucoma, and strabismus, developed new soft tissue reconstruction techniques, and oculoplastics became established as an independent subspecialty. Today it covers reconstructive eyelid and orbital surgery, management of lacrimal drainage disorders, treatment of orbital disease and anophthalmic sockets, and periocular cosmetic surgery.
QWhy did oculoplastics become an independent subspecialty?
A
During World War II, the number of facial injuries and burns exceeded what plastic surgeons could handle, and ophthalmologists came to manage eyelid and orbital injuries. This prompted the development of new techniques and led to the establishment of oculoplastics as an independent field.
The pioneer of modern periocular reconstructive surgery was von Graefe.
Timeline of major procedures:
1809 (von Graefe): The first blepharoplasty. He reconstructed a gangrenous lower eyelid with a pedicled cheek flap.
1829 (Fricke): Described a single-pedicle flap based in the temple (Fricke flap). It moves skin from above the eyebrow to cover anterior lamellar defects. It is raised in the subcutaneous plane to reduce the risk of injury to the temporal branch of the facial nerve.
Hughes tarsoconjunctival flap: A two-stage procedure for full-thickness lower eyelid defects in which upper eyelid tissue is attached to the lower eyelid. The posterior lamella is replaced with tarsus and conjunctiva, and the anterior lamella with skin and muscle. A semicircular flap is designed while preserving 4 mm of tarsus from the upper eyelid margin, the tarsus is incised through its full thickness, turned over, and sutured, and then divided after 3 to 4 weeks.
Cutler-Beard procedure: A two-stage procedure in which a flap is advanced from the lower eyelid to the upper eyelid for upper eyelid defects. It is divided about one month later.
1975 (Tenzel): Described the Tenzel semicircular flap. After lateral canthotomy and cantholysis, a laterally based myocutaneous flap is rotated and advanced to close lower eyelid defects in one stage (up to half of the lid margin).
Tripier flap: A myocutaneous flap from the upper eyelid. Used for small defects without the posterior lamella, reducing the invasiveness of reconstruction.
switch flap: A full-thickness defect of the upper eyelid is reconstructed with a lower eyelid flap (and vice versa). Because it is rotated up and down based at the lid margin, the eye cannot be opened after surgery, and the pedicle is divided after 2 to 3 weeks.
Two-stage procedures (Hughes and Cutler-Beard) were inconvenient because they required the eye to stay closed for several weeks, so one-stage local flaps (such as the Tenzel flap) became more widely used. As posterior lamella substitute materials, hard palate mucosa, oral mucosa, auricular cartilage, and septal grafts have been studied.
The main two-stage procedures are compared below.
Procedure
Indication
Source
Timing of division
Hughes procedure
Lower eyelid defect
Upper eyelid
After 3 to 4 weeks
Cutler-Beard procedure
upper eyelid defect
lower eyelid
about one month later
switch flap
both upper and lower
contralateral eyelid
2-3 weeks later
In the latter half of the 20th century, growing demand for cosmetic surgery led eyelid surgery to evolve from reconstructive purposes toward aesthetic refinement.
QWhy did eyelid reconstruction shift from two-stage procedures to one-stage procedures?
A
The Hughes procedure and the Cutler-Beard procedure were inconvenient because they required the eye to remain closed for several weeks. The spread of one-stage local flaps such as the Tenzel semicircular flap made it possible to avoid this inconvenience in many cases. However, for extensive defects, a two-stage procedure is still chosen.
5. History of ptosis surgery, entropion, ectropion, and blepharospasm
In 1923 (Blaskovitch): described levator shortening by partial tarsal resection. It can also be used when superior rectus function is poor.
Fascia lata sling procedure: developed as a suspension operation that attaches fascia lata to the tarsus for ptosis with preserved superior rectus function.
In 1975 (Jones): aponeurotic repair was introduced. Age-related aponeurotic ptosis is the most common cause, and the aponeurosis is advanced and reattached for stretching, tearing, or disinsertion.
Posterior approach: Müller muscle-conjunctival resection (MMCR) and White-line advancement. Operate from the conjunctival side to avoid a skin incision and minimize external dissection.
Entropion and ectropion
Initial treatment for entropion (over 1,300 years ago): the first surgical correction was temporary eversion of the lid margin with vertical everting sutures. Later, anterior lamellar recession was developed, especially for trachoma cases.
Modern entropion repair: a combination of reattachment of the lower eyelid retractor and horizontal tightening (lateral tarsal strip).
Initial treatment for ectropion: suspension sutures and triangular excision of the skin and orbicularis oculi muscle.
Modern ectropion repair: correction of horizontal laxity with the lateral tarsal strip, reattachment of the lower eyelid retractor, and, in cicatricial ectropion, added scar release and skin grafting.
Blepharospasm
First literature report: described by Mackenzie in 1857. Depictions thought to be of this condition also appear in Bruegel (the Elder)‘s paintings around 1560.
Early surgical strategies: destructive approaches such as facial nerve avulsion and excessive orbicularis muscle resection were central.
1980 (Scott): Botulinum toxin A was introduced. Medical management improved dramatically, and destructive surgical therapy became a thing of the past.
1981 (Gillam-Anderson): A systematic anatomical approach was established. Procedures were organized to address brow ptosis, levator disinsertion, lateral canthal laxity, and orbicularis muscle spasm.
Frontalis suspension
Indications: Severe ptosis with levator function less than 4 mm. Used when aponeurotic repair does not provide enough lid elevation.
Materials: In addition to autologous fascia lata (the gold standard), Gore-Tex® sheets, nylon sutures, and silicone rods are established options.
Special notes: Reoperation ease and long-term outcomes differ by material, so treatment must be individualized to the patient.
QHow did botulinum toxin change the treatment of blepharospasm?
A
Before Scott introduced it in 1980, treatment for blepharospasm relied on destructive surgical strategies such as facial nerve avulsion and large-scale orbicularis muscle resection. With botulinum toxin A, symptoms could be managed with repeated medical injections, and the role of surgery became limited to selected cases.
6. History of lacrimal surgery, orbital surgery, and imaging diagnosis
Surgical attempts to create a pathway for tears date back about 2,000 years.
Ancient times (1st–2nd centuries): Celsus and Galen treated lacrimal duct obstruction by cauterization through the lacrimal bone into the nasal cavity, creating a fistula between the lacrimal sac and the nasal cavity.
18th century (Woolhouse): Developed an approach involving removal of the lacrimal sac, creation of a passage through the lacrimal bone, and placement of a metal drain. This was based on the anatomical knowledge from Maître-Jan that the lacrimal sac and lacrimal duct are ducts, not secretory glands.
1904 (Toti): Described external dacryocystorhinostomy. Through a skin incision, the lacrimal sac is accessed, and its medial wall is removed together with the adjacent bone to create a new opening into the nasal cavity.
Early 20th century (Kunt, Dupuy-Dutemps, Bourguet): Improvements were added through suturing of mucosal flaps (Kunt) and flap-based anastomosis (Dupuy-Dutemps and Bourguet).
1989 (McDonogh, Meiring): Described modern endonasal dacryocystorhinostomy using a rigid nasal endoscope.
Caldwell and others reported the intranasal approach at the end of the 19th century, but surgery with the naked eye was difficult and Toti’s external approach became mainstream in the early 20th century. Since the 1990s, the endonasal approach has been improved using rigid nasal endoscopes, and by the 21st century it reached surgical outcomes almost equivalent to the external approach. Today, both methods can be chosen depending on the case. Many reports show a re-occlusion rate of 10% or less with the external approach. Before 2000, the main approaches were the external approach and blind lacrimal tube insertion, but after 2000, the approach to epiphora has diversified greatly with the introduction of dacryoendoscopy and other techniques.
The main historical turning points in lacrimal surgery are summarized below.
Year
Procedure/Events
1st–2nd centuries
Cauterization through the lacrimal bone by Celsus and Galen
With the introduction of lacrimal endoscopy, surgical techniques became more diverse
QHow did dacryocystorhinostomy develop?
A
The starting point was the external dacryocystorhinostomy performed by Toti in 1904, followed by mucosal flap refinements by Kunt and Dupuy-Dutemps. In 1989, endonasal dacryocystorhinostomy using a rigid nasal endoscope was established, and in the 21st century the endonasal approach achieved results nearly equal to the external approach. With the introduction of lacrimal endoscopy, the surgical techniques became even more diverse.
1884 (Mules): The first orbital implant (a glass sphere) was inserted after evisceration. The search for an ideal orbital volume replacement began and continued for a century.
Over the following decades: many materials were tried, including metal, cartilage, bone, fat, and rubber.
From the 1980s onward: porous materials (coral-derived hydroxyapatite) became standard. This made it possible for fibrous tissue and blood vessels to grow into the implant, improved integration, lowered the risk of extrusion, and improved prosthetic eye movement.
Most orbital implants are placed beneath the conjunctiva, forming a barrier from the outside environment and reducing the risk of postoperative infection. The total orbital volume is estimated at about 24 mL in recent CT measurements, and the volume loss after eye removal has been reported as an average of 7.9 mL (7.0–9.0 mL).
1931 (Naffziger): removal of the orbital roof through a craniotomy approach.
1936: medial wall decompression, and 1930: orbital floor removal were described in succession.
1957: combined decompression of the medial wall and orbital floor (two-wall decompression) was introduced. It became the most widely used standard.
In the latter half of the 20th century: three-wall decompression was introduced. The concept of “balanced decompression” (symmetrical decompression of the medial and lateral walls while preserving the orbital floor) was developed, reducing the risk of double vision.
Fat-removal decompression: first proposed in the 1970s. It became an effective option for fat-predominant thyroid eye disease.
Advances in imaging have fundamentally changed the diagnosis and management of orbital diseases.
1956 (Munt and Hughes): First demonstrated the clinical usefulness of ophthalmic ultrasound.
1960s: Applications to the orbit were developed by researchers in the United States and Austria.
Early 1970s: The first commercial B-mode ultrasound systems were introduced. It became established as a safe, practical, and cost-effective diagnostic tool.
Widespread use of CT and MRI: Plain X-rays, low-cycloid polytomography, arteriography, and venography almost disappeared, and CT and MRI became standard.
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