V 20TH ANNIVERSARY
10 October 1999
CE Refereed Peer Review
FOCAL POINT
★Blepharoplasty procedures to
correct eyelid defects range from
simple techniques to complex
tissue flaps.
KEY FACTS
■ The conjunctiva is closed with
small, absorbable suture material
with the knots buried between the
conjunctiva and subcutaneous
tissue to prevent corneal injury.
■ Eyelid skin is closed with 4-0
to 6-0 nonabsorbable suture.
■ Skin tension should be
avoided when repairing
eyelid abnormalities.
■ Up to one fourth of the length of
the eyelid margin can be removed
and the defect closed primarily.
Vol. 21, No.
Basic Blepharoplasty
Techniques
Louisiana State University Auburn University
Holly L. Hamilton, DVM, MS R. David Whitley, DVM, MS
Susan A. McLaughlin, DVM, MS
Steven F. Swaim, DVM, MS
ABSTRACT: The principles of blepharoplasty are similar to those of other plastic and recon-
structive surgeries. Avoiding skin tension is essential. Care must be taken to preserve eyelid
anatomy and function. Only the palpebral conjunctiva and skin are reapposed in most ble-
pharoplastic procedures. Selection of appropriate suture material is important. Eyelid margin
defects up to one fourth of the eyelid length can typically be closed primarily, whereas larger
defects require reconstruction using local tissue flaps or grafts. This article reviews eyelid
anatomy and function and basic blepharoplastic techniques. Specific therapy for eyelid lacera-
tions, eyelid mass removal, and extensive eyelid reconstruction using various skin flaps and
grafts are discussed.
T
he word blepharoplasty is derived from the Greek blephar(o), which de-
notes eyelids or lashes, and plasty, which refers to formation or plastic re-
pair of.1 In veterinary medicine, blepharoplasty encompasses a variety of
procedures ranging from laceration repair to mass excision to repair of poor eye-
lid conformation.2–8 The most prevalent conformational abnormalities of eyelids
include entropion (inversion of the eyelid margin), ectropion (eversion of the
eyelid margin), and macropalpebral fissure (enlarged eyelid opening).2,9–11 Using
the basic principles of plastic surgery, there are numerous methods of eyelid re-
construction; however, preservation of eyelid function is the primary goal.
Eyelids protect the globe and contribute to and distribute the precorneal tear
film.12 Abnormal eyelid function can lead to keratitis and corneal ulcers, which,
if untreated, can threaten vision. Eyelid anatomy must be preserved to maintain
function. Eyelids are covered externally by haired skin and internally by palpe-
bral conjunctiva (Figure 1); the middle layers are comprised of smooth and
skeletal muscle, connective tissue, and tarsal (meibomian) glands. The eyelid
margin is the junction of nonhaired skin and conjunctiva and is where the tarsal
gland openings are located. The tarsal glands are surrounded by dense connec-
tive tissue (the tarsal plate) that provides some rigidity to the eyelid margin. Eye-
lid tissue is richly vascularized, which contributes to rapid healing of surgical in-
cisions.
PATIENT PREPARATION
Gentle tissue handling during patient preparation and surgery is essential. Be-
cause eyelid skin is thin and loose (to allow mobility) and highly vascular, substan-
Compendium October 1999 20TH ANNIVERSARY Small Animal/Exotics

tial swelling can occur with Orbital septum (5-0 to 9-0) absorbable su-
minimal trauma. The hair ture material, depending on
and lashes should be carefully Levator palpebrae
the size of the animal, the
removed with small clippers. superioris muscle surgical instruments, and
The skin around the eye Orbicularis
oculi muscle
the skill and experience of
Conjunctival fornix
should be gently wiped, not the surgeon. The skin is
scrubbed, alternating be- closed with 4-0 to 6-0 non-
tween sponges soaked in Sweat gland Bulbar conjunctiva absorbable sutures in a sim-
povidone–iodine solution Müller’s muscle
ple interrupted pattern. Be-
and in saline. The cornea and cause silk has excellent
conjunctival sac should be Palpebral conjunctiva handling properties and
flushed with both saline and knot security, some ophthal-
Tarsal gland
dilute (1:50 with saline) mic surgeons prefer it for
13
povidone–iodine solution. closing skin.14 Silk is soft,
Cilium
Povidone–iodine scrub and the cut ends are less likely to
alcohol can lead to corneal injure the cornea,5 and it is
ulceration and thus should Figure 1—Cross-section of the normal canine upper eyelid. less likely to harbor adherent
not be used around the eyes. Staphylococcus epidermidis
The patient should be placed than is nylon suture.15 Other
on the surgery table in lateral ophthalmic surgeons prefer
recumbency with its head to use polypropylene or ny-
near the end of the table. lon (braided or unbraided)
suture for skin apposition of
EQUIPMENT the eyelids because of their
In addition to the items minimal tissue reaction
found in a general surgery compared with silk.16
instrument pack, an eyelid The palpebral conjunctiva
instrument pack should is closed first, and the knots
contain large and small for- must be buried to prevent
ceps (Adson-Brown and mechanical irritation of the
Bishop-Harmon, respective- Figure 2—A full-thickness eyelid defect, whether created by cornea (Figure 2C). An in-
laceration, for eyelid mass removal, or for ectropion repair, is
ly) for skin and conjunctival closed in two layers. Conjunctiva and skin are reapposed in terrupted, mattress, or con-
manipulation, respectively. reconstruction of the eyelid margin (A and B). The conjunc- tinuous suture pattern can
A Jaeger lid plate or sterile tiva is closed first in a simple continuous pattern (C). Skin be used; continuous sutures
tongue depressor is helpful closure begins at the eyelid margin, and a figure-of-eight su- require fewer knots. The
to stabilize the eyelid during ture pattern is used (D and E). first skin suture is placed at
skin incision. Small dissect- the eyelid margin to ensure
ing scissors (e.g., Stevens te- accurate anatomic apposi-
notomy scissors) are useful for procedures requiring tion. A figure-of-eight suture decreases the chance of
conjunctival dissection. A needle holder with fine jaws corneal trauma by moving the suture knot away from
(e.g., Castroviejo) is needed for suturing the conjuncti- the eyelid margin while providing anatomic apposition
va with 5-0 to 9-0 suture material. A magnifying head and alignment (Figures 2D and 2E). The needle is
loop facilitates accurate placement of these fine sutures. inserted 2 to 3 mm from the wound edge at the
haired–nonhaired junction and exits the wound edge.
CLOSURE TECHNIQUES The second needle pass starts at the edge of the op-
A two-layer closure of skin and conjunctiva is used posite side of the wound and emerges through a tarsal
for reconstruction of any defect involving the eyelid gland opening on the eyelid margin. The suture passes
margin, such as laceration repair, reconstruction after external to or through the tarsal glands but never
mass excision, repair of ectropion, and canthoplasty through the full thickness of the eyelid where suture
(Figure 2).2–5,7 Skin and conjunctiva are the most elastic contact with the cornea could occur. Placement of the
and are the only two layers reapposed in most ble- third and fourth suture passes should be symmetric to
pharoplastic procedures. Their elasticity decreases ten- the first and second. The third needle pass crosses the
sion. The conjunctiva is apposed with small-diameter wound and starts at the tarsal glands on the same side

EYELID INSTRUMENT PACK ■ SUTURE MATERIAL ■ SUTURE PATTERN

Small Animal/Exotics 20TH ANNIVERSARY Compendium October 1999

as the first needle pass and needed relaxation. The V is

exits through the wound closed in the shape of a Y
edge. The fourth needle pass (Figure 4). The result is re-
is parallel to the first, starts laxation or lengthening in
at the opposite wound edge, the area at the top of the Y.
and exits through the skin at Z-plasty and V-to-Y–plasty
the haired–nonhaired junc- are used most commonly on
tion. the eyelids to correct cicatri-
The remainder of the inci- cial ectropion.5,19
sion is closed with simple in- Figure 3—A Z-plasty can be used to repair cicatricial ectropi-
terrupted sutures. The ends on. The central limb of the Z coincides with the line of trac-Skin Flaps and Grafts
from the figure-of-eight su- tion of the scar. The two arms are equal in length and at 60˚ If an eyelid defect cannot
ture can be incorporated angles to the central limb so that two flaps (a and b) are cre-
be closed by undermining
into the knot of the first ated (A). The skin flaps are transposed (B), and half-buried and walking sutures, various
simple interrupted suture to horizontal mattress sutures are placed at the flap tips (C). skin flaps and grafts can be
The skin is closed with simple interrupted sutures (D).
prevent them from contact- used to reconstruct eyelids
ing the cornea. or repair adjacent tissue de-
fects that have caused dis-
Avoidance of tortion of the eyelids.20–29 A
Skin Tension flap is skin or conjunctiva
Avoiding skin tension is one with an attached blood sup-
of the most important prin- ply. A single-pedicle ad-
ciples in preventing dehis- vancement flap is mobilized
cence and/or distortion of by undermining and is then
the eyelid margins. Skin ten- advanced without altering
sion can be diminished by the plane of the flap.20 Pedi-
Figure 4—A V-to-Y–plasty can be used to repair mild cicatri-
such techniques as tissue un- cial ectropion. Skin is shifted from a V to a Y pattern, which cle advancement flaps are
dermining and/or by using lengthens tissue away from the tip of the V (A). A V-shaped well suited for eyelid sur-
tension-relieving suture pat- skin flap is separated from the subcutaneous tissue and scar gery because tissue is often
terns (“walking” sutures).17 tissue and is then closed in the shape of a Y. Simple inter- available on only one side of
Undermining separates skin rupted skin sutures are placed alternately in the arms of the Y the defect. This type of flap
or conjunctiva from under- (B), and the stem is sutured when tension starts to develop tends to have more tension
lying tissue to allow ad- (C). A half-buried horizontal mattress suture is placed at the compared with other types
vancement of local tissue or junction of the three suture lines (D). of flaps, which limits the
the creation of flaps. Walk- distance the tissue can be
ing sutures are absorbable, advanced.
interrupted, deep dermal, or fascial sutures that are Transposition flaps, which are composed of a rectan-
combined with undermining to advance a wound edge. gular piece of skin and subcutaneous tissue that is freed
These sutures advance local skin to close defects, dis- and pivoted to cover an adjacent defect,20,23 are also
tribute tension around a wound, and obliterate dead practical for use around the eye. The defect is typically
space. In addition, walking sutures can be used to de- at a right angle to the axis of the flap. A rotational flap
crease tension in various skin flaps. is one half to three fourths of a circle that rotates to
Relaxing incisions, such as Z-plasty and V-to-Y–plas- cover a triangular defect.20,21,26 Grafts, which consist of
5,17,18
ty, also decrease tension. These procedures can be epidermis and dermis free of any blood supply, are
used to aid in the closure of defects created by trauma rarely used in veterinary blepharoplastic procedures.
or removal of neoplasms or to release cicatricial (scar) Mucous membrane from the oral cavity can be grafted
tissue that deforms the eyelid margin. A Z-plasty trans- as a conjunctival substitute.3,21
poses two interdigitating flaps of skin (Figure 3). There
is a central limb with arms of equal length, and the in- EYELID TRAUMA
cision angles are usually 60˚.5,17,18 Length is gained in Eyelid trauma is common in large and small animals.
the direction of the central limb as the component flaps To maintain adequate tissue for normal eyelid function,
are transposed. A V-to-Y–plasty is a V-shaped incision, debridement of injured tissue should be minimal. Eye-
with the point of the V pointing away from the area of lids have an extensive vascular supply, making limited

WALKING SUTURES ■ RELAXING INCISIONS ■ PEDICLE ADVANCEMENT FLAPS ■ TRANSPOSITION FLAPS

Compendium October 1999 20TH ANNIVERSARY Small Animal/Exotics

debridement acceptable in erally reserved for masses 4

most cases. Lacerations par- mm in diameter or smaller,3
allel to but not involving the so that removal of the mass
eyelid margin can be ap- along with 1 to 2 mm of
posed with one layer of skin unaffected tissue does not
sutures. Lacerations perpen- result in removal of more
dicular to and including the than one fourth of the eye-
eyelid margin should be lid length.
Figure 5— Small eyelid masses can be removed by a pie-
closed with the standard shaped resection (A). Slightly larger masses can be removed For masses that are widest
two-layer closure of conjunc- by a four-sided excision (B). For either technique, closure of at the eyelid margin, a pie-
tiva and skin (Figure 2). full-thickness wedge resection is as described in Figure 2. shaped excision is pre-
Corneal irritation may occur ferred.5 A V-shaped wedge
with first-intention healing of tissue with the apex
if there is poor apposition (a pointing away from the eye-
step malalignment) at the lid margin is excised with
eyelid margin. Healing by scissors or a scalpel blade
second intention may cause (Figure 5A). 5,7,8,36 A Jaeger
keratitis or corneal ulcers as lid plate (or sterile tongue
a result of granulation tissue depressor) can be placed be-
coming into contact with the tween the eyelid and the
cornea. Trauma resulting in Figure 6—A single-pedicle advancement flap can be used to cornea to provide skin ten-
loss of a large amount of tis- repair eyelid defects larger than one fourth of the eyelid mar- sion for scalpel blade inci-
sue may require skin flaps gin. After full-thickness excision of the eyelid neoplasm, two sions. The defect is closed
for reconstruction. slightly diverging skin incisions are continued from the base using the standard two-layer
of the wound. The skin incisions are twice as long as the closure.
height of the defect (A). Burrow’s triangles are excised at the
EYELID NEOPLASIA A “house-shaped” (i.e.,
base of the flap to facilitate flap advancement (B). The skin is
Eyelid neoplasms are fre- closed with simple interrupted sutures, and the conjunctiva is four-sided) incision mini-
quently encountered in vet- advanced over the leading edge of the flap and attached with mizes the amount of the
erinary medicine. The most small, absorbable suture in a continuous pattern (C). eyelid margin resected while
common eyelid neoplasm in maximizing the borders re-
dogs is meibomian gland moved (Figure 5B).3,5,37 This
30,31
adenoma, a benign mass that does not require wide technique is useful for slightly larger eyelid masses,
excisional margins. Squamous cell carcinoma, the most masses in which the widest portion is away from the
common eyelid neoplasm in cats, 32,33 cattle, 34 and eyelid margin, or for animals with taut eyelid confor-
horses,34,35 requires a wide margin of excision. Generally, mation. The incision is also closed in two layers.
up to one fourth of the eyelid length can be removed When excision of a mass results in an eyelid defect
without creating excessive tension or altering eyelid larger than one fourth of the eyelid margin, reconstruc-
anatomy,4 although this may not be true in patients tion can be accomplished using a variety of flaps or
with taut eyelid conformation (e.g., miniature poodles, with grafting. A single-pedicle advancement flap can be
collies, Doberman pinschers, fox terriers, many toy dog used to repair full- or partial-thickness eyelid defects.5–7
breeds, most cats). In breeds with macropalpebral fissure Advancement flaps are better suited to the lower eyelid
(e.g., cocker spaniels, St. Bernards, shih tzus), up to one because it is less mobile and has less contact with the
third of the eyelid length may be removed and the de- cornea than does the upper eyelid. The mass is excised
fect closed primarily. as a square or rectangle, leaving as much conjunctiva as
Masses that cannot be excised with adequate margins possible. A flap is created that is twice as long as the ex-
should be diagnosed via biopsy before being excised. cised mass and diverges slightly outward at the base
Some large eyelid neoplasms may be reduced in size by (Figure 6). At the base of the flap, two equal-sided tri-
chemotherapy, immunotherapy, cryotherapy, or radia- angles (Burrow’s triangles) can be removed to avoid for-
tion before excision. mation of a dog ear when the flap is advanced.5,7,20 The
skin and subcutaneous tissue are undermined and ad-
EYELID REPAIR TECHNIQUES vanced; conjunctiva should be undermined and ad-
Small eyelid masses can be removed by a full-thick- vanced to be slightly longer than the skin flap. To cre-
ness wedge resection (Figure 5). This procedure is gen- ate a new, hairless eyelid margin, the conjunctiva is

EYELID LACERATION ■ MEIBOMIAN GLAND ADENOMA ■ SQUAMOUS CELL CARCINOMA

Small Animal/Exotics 20TH ANNIVERSARY Compendium October 1999

sewn over the edge of the

skin flap with absorbable su-
ture in a simple continuous
pattern with buried knots. If
adequate conjunctiva is not
available, a flap may be cre-
ated from the nonaffected Figure 7—A rotational flap can be used to repair an eyelid with a large mass removed by a four-
eyelid8 or nictitating mem- sided excision (A). A curvilinear incision approximately the length of the eyelid margin is start-
ed at the lateral canthus. The semicircle of skin and subcutaneous tissue is rotated to cover the
brane25 or a graft of mucous defect (B). The four-sided excision is closed in two layers as in Figure 2, and the skin is closed
membrane can be harvested with simple interrupted sutures. Conjunctiva is sewn over the skin edge laterally where needed
from the oral cavity.3,21 The to create a new eyelid margin (C).
skin is closed in a simple in-
terrupted pattern.
A rotational (semicircular) flap can be used to repair
defects in the upper or lower eyelid.26 This one-stage pro-
cedure is useful for large central or lateral eyelid masses.
The mass is excised as for the four-sided excision. A
curvilinear incision is started at the lateral canthus and
continues lateral to the eye for a distance that is approxi-
mately equal to the length of the eyelid (Figure 7). The
incision curves upward to repair the lower eyelid and
downward for upper eyelid lesions. The flap is under-
mined until it can be rotated and advanced without ten-
sion. A Burrow’s triangle is excised from the base of the
flap to aid rotation. The incision perpendicular to the Figure 8—A transposition pedicle flap can be used to repair
eyelid margin is closed in the standard two layers. Where eyelid agenesis. This schematic illustrates harvesting the pedi-
the eyelid margin ends, at the previous lateral canthus, cle flap from the lower (A–C) and upper (D–F) eyelids. The
conjunctiva is advanced and sewn over the rotational flap flap is sutured to the skin, and conjunctiva is sewn over the
with small, absorbable sutures in a continuous pattern to edge of the pedicle flap to create a new eyelid margin. The
create a new eyelid margin. The skin is closed with sim- donor site is closed with simple interrupted sutures.
ple interrupted nonabsorbable sutures.
A transposition pedicle flap is useful to repair the later-
al upper eyelid of cats with congenital eyelid agenesis or the recipient bed with simple interrupted nonabsorb-
to repair a defect from a long, narrow lateral upper eyelid able sutures. Palpebral conjunctiva is sutured to the deep
mass.3,4,7,22,25 A pedicle flap can be harvested from the aspect of the pedicle flap with small absorbable sutures
lower3,4,7,25 or upper22 eyelid skin and does not include in a continuous pattern to create a new eyelid margin.
the eyelid margin (Figure 8). The eyelid mass is excised The defect created in harvesting the skin flap is closed
in the shape of a rectangle or square. In cats with eyelid with simple interrupted nonabsorbable sutures. When
agenesis, a perpendicular incision is made at the junction closing this rectangular defect, formation of a dog ear
of normal and abnormal eyelid margin and extended lat- can be avoided by extending the incision with a fusi-
erally to separate the haired skin and conjunctiva.3,4,7,22,25 form excision.
For a pedicle flap harvested from the lower eyelid, an In eyelid agenesis, there is rarely enough conjunctiva
incision is made approximately 7 mm below and paral- to create a new eyelid margin; therefore a conjunctival
lel to the eyelid margin, with the base of the flap lateral flap or graft may be harvested from the nictitating
to the lateral canthus (Figures 8A, 8B, and 8C). The membrane or oral mucous membrane, respectively. The
flap length should be several millimeters longer than hair on the pedicle flap will grow toward the cornea be-
the defect to allow for rotation. The second incision is cause of the direction of rotation and may cause corneal
parallel to the first. A flap is created that is slightly irritation. A pedicle flap harvested from the upper eye-
wider than the defect. Flap width is limited because a lid results in hair growth away from the eyelid margin.22
large flap may result in ectropion of the lower eyelid. An upper eyelid pedicle flap is created by making an in-
The skin flap is undermined until it can be rotated to cision 10 to 12 mm above and parallel to the eyelid de-
cover the defect in the upper eyelid. fect (Figures 8D, 8E, and 8F). The base of the flap is
The skin of the pedicle flap is sutured to the skin of dorsotemporal to the defect, and the flap should be

ROTATIONAL FLAP ■ TRANSPOSITIONAL PEDICLE FLAP ■ EYELID AGENESIS

Compendium October 1999 20TH ANNIVERSARY
Figure 9—A bucket-handle flap can be used for reconstruc-
tion of an eyelid with a defect larger than one half of the eye-
lid length. The eyelid mass is excised (A), and a single-pedicle
advancement flap is created in the lower eyelid (black a and
b). A full-thickness flap is created from the upper eyelid dor-
sal to the eyelid margin (red a and b). The upper eyelid flap
is advanced under (deep to) the remaining upper eyelid mar-
gin toward the defect in the lower eyelid (B). The donor con-
junctiva is sutured to recipient conjunctiva, and donor skin is
sutured to recipient skin (C). After 14 to 21 days, the flap is
severed approximately 2 mm above the lower eyelid margin.
The conjunctiva is sewn over the cut edge of the flap to cre-
ate a lower eyelid margin. The remaining portion to the
donor flap is minimally debrided, pushed back through the
upper incision, and sutured in two layers (D).
slightly longer and wider than the defect. The skin flap
is rotated down to fill the defect, and closure is similar
to that described previously.
When excision of a large eyelid mass results in re-
moval of the majority of the eyelid margin and conjunc-
tiva, a flap constructed of mucous membrane and skin
will be required. The bucket-handle (Cutler–Beard)
technique can be used to repair either the upper or low-
er eyelid (Figure 9).6,24 The mass is excised, and a single-
pedicle advancement flap is created as described previ-
ously. The margin of the donor eyelid remains intact; an
incision is made parallel to and 5 mm from the margin
(Figure 9B). The incision made in the donor eyelid
should be slightly wider than the width of the defect in
the affected eyelid. Two full-thickness, 10- to 15-mm,
slightly diverging incisions are made perpendicular to
the eyelid margin. A full-thickness flap is created, leav-
ing a “bucket handle” of intact eyelid margin. The flap
is split into two layers: conjunctiva and skin–orbicularis.
The conjunctiva is closed with absorbable 5-0 to 7-0
BUCKET-HANDLE TECHNIQUE ■ CROSS-LID FLAP
Small Animal/Exotics
Figure 10—A cross-lid flap rotates a full-thickness flap from
the lower eyelid to reconstruct the more mobile upper eyelid.
After the upper eyelid mass is excised in a square or rectangle
(black a, b, c, and d), a flap is created from the lower eyelid
to be transposed to the upper eyelid defect. The first incision
is made perpendicular to the eyelid margin (red incision
a–b); it then continues at a right angle, making the second
side of the square or rectangle parallel to the eyelid margin
(red incision b–c). To create the third side, the incision is
continued at a right angle but only one half the length of this
side is cut (red incision c–d); this is a back cut to aid rotation.
The lower eyelid flap is rotated into the upper eyelid defect (A).
Donor conjunctiva is sutured to recipient conjunctiva and
donor skin to recipient skin (B). After sutures are removed in
14 to 21 days, the second stage of the procedure severs the
flap along its base (red d to black d) (C). The flap is allowed
to continue upward rotation (red and black c’s and d’s
aligned), and a single-pedicle advancement flap is created to
reconstruct the lower eyelid (D). The severed flap is apposed
to the upper eyelid defect in two layers (E).
suture, and the knots are buried to prevent corneal con-
tact. The skin is apposed with nonabsorbable sutures in
a simple interrupted pattern. The flap is left intact for
14 to 21 days and then excised closer to the donor eye-
lid to allow for flap contraction. Both eyelids are recon-
structed in two layers. The new eyelid margin in the re-
cipient eyelid is created by pulling conjunctiva over the
edge of haired skin (Figure 9D) as described for the sin-
gle-pedicle advancement flap.
A cross-lid flap is harvested from the lower eyelid in a
two-stage procedure and used to repair large defects in
the upper eyelid.28 The upper eyelid mass is excised as a
square or rectangle. A full-thickness pedicle flap—equal
in depth and three fourths the width of the upper eye-
lid defect—is created from the lower eyelid (Figure 10).
Stretching of the remaining upper eyelid tissue can
close one fourth of the width of the defect. The lower
eyelid flap is made medial or lateral to the defect (de-
pending on which side has more tissue), with the base
of the flap centered below the lesion. The flap is cut
Small Animal/Exotics 20TH ANNIVERSARY Compendium October 1999

cluding only skin and subcutaneous tissue, until the

Figure 11— A lip-to-lid flap (mucocutaneous subdermal
plexus flap) can be used to repair defects as large as the entire
length of the lower eyelid. Two parallel incisions slightly
wider than the defect in the lower eyelid are created in the
upper lip. The incisions are at a 45˚ to 50˚ angle to a line bi-
secting the lateral and medial canthi of the eyelids. A full-
thickness lower eyelid defect is created by excising the mass
in a rectangular shape (A). A lip flap that is full thickness dis-
tally and partial thickness proximally (skin only) is created. A
bridging incision is made between the proximal end of the
flap and the eyelid defect. The flap is rotated to fill the lower
flap can be rotated to the lower eyelid defect. A bridge
incision is made between the eyelid defect and the base
of the flap (Figure 11B). The mucous membrane por-
tion of the flap is sutured to the remaining conjunctiva
with buried absorbable 6-0 to 7-0 suture material. The
oral mucosal defect is closed with absorbable suture,
and the skin is closed with nonabsorbable suture in a
simple interrupted pattern. An optional second-stage
procedure can be performed to improve cosmetic re-
sults by restoring a normal hair-growth pattern. The
skin containing misdirected hair (the partial-thickness
portion of the flap) can be excised 4 to 6 weeks after
the initial surgery. An incision is made below the
haired–nonhaired junction and parallel to the new eye-
lid margin. The skin is closed with nonabsorbable sim-
ple interrupted sutures.
POSTOPERATIVE CARE ENDIU
MP
Postoperative care for

M’
20th

CO

S

eyelid defect (B). The remaining lower eyelid conjunctiva is
sewn to oral mucosa on the lip flap, and skin edges are ap-
blepharoplasty patients 1 9 7
9 - 1
9 9 9

typically includes topical, ANNIVERSARY

posed. The lip incision is closed in two layers (mucosa and
skin). An optional second stage excises the partial-thickness broad-spectrum ophthal-
portion of the flap (below the blue line) to improve cosmesis by
removing hair that was growing in a different direction (C).
mic antibiotic ointment or
solution three to four times
A LookBack
daily and, in some cases, Although the general principles
broad-spectrum systemic of surgical techniques for
full thickness on 2.5 sides, rotated 180˚, and sutured in antibiotics. In small ani-
blepharoplasty have not
two layers (Figure 10B). The conjunctiva is sutured mals, an Elizabethan col-
changed significantly in the past
with 6-0 to 7-0 absorbable suture in a simple continu- lar is important to prevent
ous pattern, and the skin is closed with nonabsorbable, self-trauma and premature 20 years, many new procedures
simple interrupted sutures. suture removal. Corneal (e.g., the Stades procedure to
The second stage of the procedure is performed in 14 epithelial integrity should correct trichiasis and entropion)
to 21 days. The flap is severed at the base, rotated up- be evaluated with fluores- have been described. In
ward, and sutured into position. The previous lower eye- cein dye after surgery and addition, such innovative eyelid
lid margin is now the upper eyelid margin. The flap is any time there is blepharo- grafting procedures as the lip-to-
closed in two layers as described previously. A single-pedi- spasm or increased ocular lid and rotational flaps have
cle advancement flap or lip-to-lid flap can be used to re- discharge. been developed. Variations that
construct the lower eyelid.5,27 move the suture line away from
A lip-to-lid flap (mucocutaneous subdermal plexus CONCLUSION the eyelid margin have been
flap from the lip) can be used to repair large, full-thick- The techniques described
introduced. Information has
ness, lower eyelid defects.27 Defects encompassing the en- in this article are the most
become more widely
tire length of the lower eyelid can also be repaired with frequently performed ble-
this technique. The eyelid mass is excised as a rectangle pharoplastic surgeries in disseminated in the past two
or square. Two parallel incisions are made in the upper veterinary medicine. The decades, and numerous quality
lip slightly greater than the width of the lower eyelid de- most appropriate proce- book chapters and review
fect (Figure 11). The incisions are made rostral to the dure depends on the eyelid articles are now available.
oral commissure and at a 45˚ to 50˚ angle to a line bi- abnormality, instruments
secting the medial and lateral ocular canthi. The flap is and suture material avail-
full thickness for about 3 cm, creating a segment consist- able, and skill and experi-
ing of skin, oral mucosa, and muscle; this segment will ence of the surgeon. The
replace the excised eyelid margin. important first step is to
The dissection is continued more superficially, in- diagnose all of the prob-

LIP-TO-LID FLAP ■ ORAL MUCOSAL DEFECT ■ CORNEAL EPITHELIAL INTEGRITY

Compendium October 1999 20TH ANNIVERSARY Small Animal/Exotics

lems; the defect can then be repaired or reconstructed JAAHA 34(3):212–218, 1998.
following the principles of reconstructive surgery. 20. Swaim SF, Henderson RA: Various-shaped wounds, in Swaim
SF, Henderson RA (eds): Small Animal Wound Management,
ed 2. Philadelphia, Williams & Wilkins, 1997, pp 235–274.
ACKNOWLEDGMENT 21. Tenzel RR: Ophthalmic plastic surgery, in Clayman HM
All illustrations are by Michael Broussard, Louisiana (ed): Atlas of Contemporary Ophthalmic Surgery. St Louis,
State University. Mosby, 1990, pp 745–880.
22. Whitley RD, Gilger BC, Whitley EM, et al: Diseases of the
orbit, globe, eyelids, and lacrimal system in the cat. Vet Med
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with the Department of Veterinary Clinical Sciences,
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Am Small Anim Pract 27(5):963–986, 1997. School of Veterinary Medicine, Louisiana State Universi-
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143–190.
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(eds): Atlas of Veterinary Ophthalmic Surgery. Philadelphia, Medicine, Auburn University, Auburn, Alabama. Drs.
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19. Hamilton HL, McLaughlin SA, Whitley RD, et al: Surgical American College of Veterinary Ophthalmology.
reconstruction of severe cicatricial ectropion in a puppy.