Basic Blepharoplasty Techniques

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Vol. 21, No. 10 October 1999

Refereed Peer Review

FOCAL POINT ★Blepharoplasty procedures to correct eyelid defects range from simple techniques to complex tissue flaps.

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

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.

ABSTRACT: The principles of blepharoplasty are similar to those of other plastic and reconstructive 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 blepharoplastic 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 lacerations, eyelid mass removal, and extensive eyelid reconstruction using various skin flaps and grafts are discussed.

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he word blepharoplasty is derived from the Greek blephar(o), which denotes eyelids or lashes, and plasty, which refers to formation or plastic repair of.1 In veterinary medicine, blepharoplasty encompasses a variety of procedures ranging from laceration repair to mass excision to repair of poor eyelid 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 reconstruction; 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 palpebral 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 connective tissue (the tarsal plate) that provides some rigidity to the eyelid margin. Eyelid tissue is richly vascularized, which contributes to rapid healing of surgical incisions.

PATIENT PREPARATION Gentle tissue handling during patient preparation and surgery is essential. Because eyelid skin is thin and loose (to allow mobility) and highly vascular, substan-

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tial swelling can occur with Orbital septum minimal trauma. The hair and lashes should be carefully Levator palpebrae removed with small clippers. superioris muscle The skin around the eye Orbicularis oculi muscle Conjunctival fornix should be gently wiped, not scrubbed, alternating beBulbar conjunctiva tween sponges soaked in Sweat gland povidone–iodine solution Müller’s muscle and in saline. The cornea and Palpebral conjunctiva conjunctival sac should be flushed with both saline and Tarsal gland dilute (1:50 with saline) 13 povidone–iodine solution. Cilium Povidone–iodine scrub and alcohol can lead to corneal ulceration and thus should Figure 1—Cross-section of the normal canine upper eyelid. not be used around the eyes. The patient should be placed on the surgery table in lateral recumbency with its head near the end of the table.

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(5-0 to 9-0) absorbable suture material, depending on the size of the animal, the surgical instruments, and the skill and experience of the surgeon. The skin is closed with 4-0 to 6-0 nonabsorbable sutures in a simple interrupted pattern. Because silk has excellent handling properties and knot security, some ophthalmic surgeons prefer it for closing skin.14 Silk is soft, the cut ends are less likely to injure the cornea,5 and it is less likely to harbor adherent Staphylococcus epidermidis than is nylon suture.15 Other ophthalmic surgeons prefer to use polypropylene or nylon (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 The palpebral conjunctiva instrument pack, an eyelid is closed first, and the knots instrument pack should must be buried to prevent contain large and small formechanical irritation of the ceps (Adson-Brown and Bishop-Harmon, respective- Figure 2—A full-thickness eyelid defect, whether created by cornea (Figure 2C). An inlaceration, 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 conmanipulation, 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 first skin suture is placed at to stabilize the eyelid during ture pattern is used (D and E). the eyelid margin to ensure skin incision. Small dissectaccurate anatomic apposiing scissors (e.g., Stevens tetion. A figure-of-eight suture decreases the chance of notomy scissors) are useful for procedures requiring corneal trauma by moving the suture knot away from conjunctival dissection. A needle holder with fine jaws the eyelid margin while providing anatomic apposition (e.g., Castroviejo) is needed for suturing the conjunctiand alignment (Figures 2D and 2E). The needle is va with 5-0 to 9-0 suture material. A magnifying head inserted 2 to 3 mm from the wound edge at the loop facilitates accurate placement of these fine sutures. haired–nonhaired junction and exits the wound edge. CLOSURE TECHNIQUES The second needle pass starts at the edge of the opA 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 blethird and fourth suture passes should be symmetric to pharoplastic procedures. Their elasticity decreases tenthe 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

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as the first needle pass and exits through the wound edge. The fourth needle pass is parallel to the first, starts at the opposite wound edge, and exits through the skin at the haired–nonhaired junction. The remainder of the incision is closed with simple interrupted sutures. The ends from the figure-of-eight suture can be incorporated into the knot of the first simple interrupted suture to prevent them from contacting the cornea.

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needed relaxation. The V is closed in the shape of a Y (Figure 4). The result is relaxation or lengthening in the area at the top of the Y. Z-plasty and V-to-Y–plasty are used most commonly on the eyelids to correct cicatricial ectropion.5,19 Figure 3—A Z-plasty can be used to repair cicatricial ectropi-

Skin Flaps and Grafts If an eyelid defect cannot be closed by undermining and walking sutures, various skin flaps and grafts can be used to reconstruct eyelids or repair adjacent tissue defects that have caused disAvoidance of tortion of the eyelids.20–29 A Skin Tension flap is skin or conjunctiva Avoiding skin tension is one with an attached blood supof the most important prinply. A single-pedicle adciples in preventing dehisvancement flap is mobilized cence and/or distortion of by undermining and is then the eyelid margins. Skin tenadvanced without altering sion can be diminished by the plane of the flap.20 PediFigure 4—A V-to-Y–plasty can be used to repair mild cicatrisuch 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 surtension-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. Walkdistance the tissue can be ing sutures are absorbable, advanced. interrupted, deep dermal, or fascial sutures that are Transposition flaps, which are composed of a rectancombined 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, disand 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 deat 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–plascover a triangular defect.20,21,26 Grafts, which consist of 5,17,18 These procedures can be ty, also decrease tension. 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 transas 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 inEYELID 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. Eyewith the point of the V pointing away from the area of lids have an extensive vascular supply, making limited on. The central limb of the Z coincides with the line of traction of the scar. The two arms are equal in length and at 60˚ angles to the central limb so that two flaps (a and b) are created (A). The skin flaps are transposed (B), and half-buried horizontal mattress sutures are placed at the flap tips (C). The skin is closed with simple interrupted sutures (D).

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

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debridement acceptable in most cases. Lacerations parallel to but not involving the eyelid margin can be apposed with one layer of skin sutures. Lacerations perpendicular to and including the eyelid margin should be closed with the standard two-layer closure of conjunctiva and skin (Figure 2). Corneal irritation may occur with first-intention healing if there is poor apposition (a step malalignment) at the eyelid margin. Healing by second intention may cause keratitis or corneal ulcers as a result of granulation tissue coming into contact with the cornea. Trauma resulting in loss of a large amount of tissue may require skin flaps for reconstruction.

erally reserved for masses 4 mm in diameter or smaller,3 so that removal of the mass along with 1 to 2 mm of unaffected tissue does not result in removal of more than one fourth of the eyelid length. Figure 5— Small eyelid masses can be removed by a pieFor masses that are widest shaped resection (A). Slightly larger masses can be removed at the eyelid margin, a pieby a four-sided excision (B). For either technique, closure of shaped excision is prefull-thickness wedge resection is as described in Figure 2. ferred.5 A V-shaped wedge of tissue with the apex pointing away from the eyelid margin is excised with scissors or a scalpel blade (Figure 5A). 5,7,8,36 A Jaeger lid plate (or sterile tongue depressor) can be placed between the eyelid and the Figure 6—A single-pedicle advancement flap can be used to cornea to provide skin tenrepair eyelid defects larger than one fourth of the eyelid mar- sion for scalpel blade incigin. After full-thickness excision of the eyelid neoplasm, two sions. The defect is closed 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 miniquently 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 redogs is meibomian gland moved (Figure 5B).3,5,37 This 30,31 a benign mass that does not require wide technique is useful for slightly larger eyelid masses, adenoma, 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 conforhorses,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, reconstrucanatomy,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 Advancement flaps are better suited to the lower eyelid breeds, most cats). In breeds with macropalpebral fissure because it is less mobile and has less contact with the (e.g., cocker spaniels, St. Bernards, shih tzus), up to one cornea than does the upper eyelid. The mass is excised third of the eyelid length may be removed and the deas a square or rectangle, leaving as much conjunctiva as fect closed primarily. possible. A flap is created that is twice as long as the exMasses that cannot be excised with adequate margins cised mass and diverges slightly outward at the base should be diagnosed via biopsy before being excised. (Figure 6). At the base of the flap, two equal-sided triSome large eyelid neoplasms may be reduced in size by angles (Burrow’s triangles) can be removed to avoid forchemotherapy, immunotherapy, cryotherapy, or radiamation of a dog ear when the flap is advanced.5,7,20 The tion before excision. skin and subcutaneous tissue are undermined and adEYELID REPAIR TECHNIQUES vanced; conjunctiva should be undermined and adSmall eyelid masses can be removed by a full-thickvanced to be slightly longer than the skin flap. To creness wedge resection (Figure 5). This procedure is genate a new, hairless eyelid margin, the conjunctiva is EYELID LACERATION ■ MEIBOMIAN GLAND ADENOMA ■ SQUAMOUS CELL CARCINOMA

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sewn over the edge of the skin flap with absorbable suture in a simple continuous pattern with buried knots. If adequate conjunctiva is not available, a flap may be created from the nonaffected Figure 7—A rotational flap can be used to repair an eyelid with a large mass removed by a foureyelid8 or nictitating mem- sided excision (A). A curvilinear incision approximately the length of the eyelid margin is started 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 interrupted pattern. A rotational (semicircular) flap can be used to repair defects in the upper or lower eyelid.26 This one-stage procedure 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 approximately 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 undermined until it can be rotated and advanced without tension. 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 agenesis. This schematic illustrates harvesting the pedieyelid margin is closed in the standard two layers. Where cle flap from the lower (A–C) and upper (D–F) eyelids. The the eyelid margin ends, at the previous lateral canthus, flap is sutured to the skin, and conjunctiva is sewn over the conjunctiva is advanced and sewn over the rotational flap edge of the pedicle flap to create a new eyelid margin. The with small, absorbable sutures in a continuous pattern to donor site is closed with simple interrupted sutures. create a new eyelid margin. The skin is closed with simple interrupted nonabsorbable sutures. A transposition pedicle flap is useful to repair the laterthe recipient bed with simple interrupted nonabsorbal upper eyelid of cats with congenital eyelid agenesis or able sutures. Palpebral conjunctiva is sutured to the deep to repair a defect from a long, narrow lateral upper eyelid aspect of the pedicle flap with small absorbable sutures mass.3,4,7,22,25 A pedicle flap can be harvested from the 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 latcan be avoided by extending the incision with a fusierally 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 paralto 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 bethe 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 eyewider than the defect. Flap width is limited because a lid results in hair growth away from the eyelid margin.22 An upper eyelid pedicle flap is created by making an inlarge flap may result in ectropion of the lower eyelid. cision 10 to 12 mm above and parallel to the eyelid deThe skin flap is undermined until it can be rotated to fect (Figures 8D, 8E, and 8F). The base of the flap is cover the defect in the upper eyelid. dorsotemporal to the defect, and the flap should be The skin of the pedicle flap is sutured to the skin of ROTATIONAL FLAP ■ TRANSPOSITIONAL PEDICLE FLAP ■ EYELID AGENESIS

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Figure 9—A bucket-handle flap can be used for reconstruction of an eyelid with a defect larger than one half of the eyelid 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 dorsal to the eyelid margin (red a and b). The upper eyelid flap is advanced under (deep to) the remaining upper eyelid margin toward the defect in the lower eyelid (B). The donor conjunctiva 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 create 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).

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).

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 removal of the majority of the eyelid margin and conjunctiva, 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 lower eyelid (Figure 9).6,24 The mass is excised, and a singlepedicle advancement flap is created as described previously. 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, leaving 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

suture, and the knots are buried to prevent corneal contact. 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 eyelid to allow for flap contraction. Both eyelids are reconstructed in two layers. The new eyelid margin in the recipient eyelid is created by pulling conjunctiva over the edge of haired skin (Figure 9D) as described for the single-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 eyelid 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 (depending on which side has more tissue), with the base of the flap centered below the lesion. The flap is cut

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Figure 11— A lip-to-lid flap (mucocutaneous subdermal

full thickness on 2.5 sides, rotated 180˚, and sutured in two layers (Figure 10B). The conjunctiva is sutured with 6-0 to 7-0 absorbable suture in a simple continuous pattern, and the skin is closed with nonabsorbable, simple interrupted sutures. The second stage of the procedure is performed in 14 to 21 days. The flap is severed at the base, rotated upward, and sutured into position. The previous lower eyelid margin is now the upper eyelid margin. The flap is closed in two layers as described previously. A single-pedicle advancement flap or lip-to-lid flap can be used to reconstruct the lower eyelid.5,27 A lip-to-lid flap (mucocutaneous subdermal plexus flap from the lip) can be used to repair large, full-thickness, lower eyelid defects.27 Defects encompassing the entire length of the lower eyelid can also be repaired with this technique. The eyelid mass is excised as a rectangle or square. Two parallel incisions are made in the upper lip slightly greater than the width of the lower eyelid defect (Figure 11). The incisions are made rostral to the oral commissure and at a 45˚ to 50˚ angle to a line bisecting the medial and lateral ocular canthi. The flap is full thickness for about 3 cm, creating a segment consisting of skin, oral mucosa, and muscle; this segment will replace the excised eyelid margin. The dissection is continued more superficially, in-

cluding only skin and subcutaneous tissue, until the 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 portion 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 results 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 eyelid margin. The skin is closed with nonabsorbable simple interrupted sutures.

POSTOPERATIVE CARE Postoperative care for blepharoplasty patients typically includes topical, broad-spectrum ophthalmic antibiotic ointment or solution three to four times daily and, in some cases, broad-spectrum systemic antibiotics. In small animals, an Elizabethan collar is important to prevent self-trauma and premature suture removal. Corneal epithelial integrity should be evaluated with fluorescein dye after surgery and any time there is blepharospasm or increased ocular discharge. CONCLUSION The techniques described in this article are the most frequently performed blepharoplastic surgeries in veterinary medicine. The most appropriate procedure depends on the eyelid abnormality, instruments and suture material available, and skill and experience of the surgeon. The important first step is to diagnose all of the prob-

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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 bisecting the lateral and medial canthi of the eyelids. A fullthickness lower eyelid defect is created by excising the mass in a rectangular shape (A). A lip flap that is full thickness distally 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 eyelid defect (B). The remaining lower eyelid conjunctiva is sewn to oral mucosa on the lip flap, and skin edges are apposed. The lip incision is closed in two layers (mucosa and skin). An optional second stage excises the partial-thickness portion of the flap (below the blue line) to improve cosmesis by removing hair that was growing in a different direction (C).

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A LookBack Although the general principles of surgical techniques for blepharoplasty have not changed significantly in the past 20 years, many new procedures (e.g., the Stades procedure to correct trichiasis and entropion) have been described. In addition, such innovative eyelid grafting procedures as the lip-tolid and rotational flaps have been developed. Variations that move the suture line away from the eyelid margin have been introduced. Information has become more widely disseminated in the past two decades, and numerous quality book chapters and review articles are now available.

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

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lems; the defect can then be repaired or reconstructed following the principles of reconstructive surgery. ACKNOWLEDGMENT

All illustrations are by Michael Broussard, Louisiana State University.

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About the Authors When this article was written, Dr. Hamilton was affiliated with the Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana. She is now at the Animal Eye Center, Fort Collins, Colorado. Drs. Whitley, McLaughlin, and Swaim are affiliated with the Department of Small Animal Surgery and Medicine and Dr. Swaim is also with the Scott-Ritchey Research Center, College of Veterinary Medicine, Auburn University, Auburn, Alabama. Drs. Hamilton, Whitley, and McLaughlin are Diplomates of the American College of Veterinary Ophthalmology.