Diagnosis and blepharoplastic repair of conformational eyelid defects

Tags: entropion, eyelid margin, incision, palpebral fissure, suture, procedure, eyelid, technique, upper eyelid, blepharospasm, lateral canthus, triangular skin flap, conjunctiva, corneal ulceration, lateral, ectropion, conformational defects, scar tissue, eyelid laxity, Dr. Hamilton, JAAHA, Stades FC, Dr. McLaughlin, entropion in dogs, orbicularis oculi muscle, surgical correction, canthoplasty, lacrimal puncta, surgical repair, excised tissue, skin incision, Ocular irritation, Conformational entropion, eyelid abnormalities, point lateral, Spastic entropion, ectropion repair
Content: V
Vol. 22, No. 6 June 2000
CE
Refereed peer review
FOCAL POINT #Critical evaluation of all conformational defects is essential before surgical repair and should be performed in unsedated animals with minimal restraint to prevent blepharospasm and eyelid distortion. KEY FACTS I Macropalpebral fissure is an enlarged eyelid opening. I Trichiasis occurs when cilia or facial hair comes into contact with the cornea. I Entropion (inversion of the eyelid margin) can result in corneal ulceration, potentially blinding corneal scarring, and ocular irritation. I Most uncomplicated cases of entropion can be corrected by the modified Hotz-Celsus technique, but referral should be considered in complicated cases. I Ectropion (eversion of the eyelid margin) seldom requires surgical correction.
Diagnosis and Blepharoplastic Repair of Conformational Eyelid Defects* Louisiana State University Holly L. Hamilton, DVM, MS Auburn University Susan A. McLaughlin, DVM, MS R. David Whitley, DVM, MS Steven F. Swaim, DVM, MS ABSTRACT: Blepharoplasty is a general term for surgery of the eyelid. this article reviews the diagnosis and treatment of conformational defects of the eyelids, including entropion, ectropion, and macropalpebral fissure. Entropion can be repaired using many methods. It is ideal to select the simplest technique that corrects the defect; but all complicating factors, such as nasal folds, macropalpebral fissure, brow wrinkles, and lateral canthal instability, must be considered. Ectropion requires surgical repair less often than does entropion. Numerous congenital and acquired conformational defects affect the eyelids, the most prevalent being entropion (inversion of the eyelid margin), ectropion (eversion of the eyelid margin), and macropalpebral fissure (excessively large eyelid opening). Trichiasis, a condition caused by cilia or facial hair coming into contact with the cornea or conjunctiva, may occur simultaneously. Defects that affect eyelid function or cause irritation should be surgically corrected. Diagnosis and repair of conformational defects of eyelids are discussed. In any blepharoplastic procedure, the first step is to evaluate the eyelids in the normal resting position. Eyelid conformation results from many factors, including THE RELATIONSHIP between the eyelid, globe, and orbit; orbital size; muscle development; eyelid length; and stability of the lateral canthus. Many dogs develop blepharospasm (spastic closure of the eyelids) and have distorted eyelid carriage and conformation when they are handled around the face. Gentle restraint just behind the angle of the mandibles is often adequate for evaluation. Eyelid function, carriage, and conformation should always be evaluated in unsedated ani- *A companion article entitled "Basic Blepharoplasty Techniques" appeared in the October 1999 (Vol. 21, No. 10) issue of Compendium.
Compendium June 2000
Small Animal/Exotics
mals because enophthalmos induced by general anesthesia can cause entropion. A surgical plan should be based on examination findings and not altered after induction of sedation or general anesthesia. ENTROPION Description Entropion is one of the most common eyelid abnormalities requiring blepharoplasty in dogs.1 When the palpebral margin rolls in, cilia and eyelid hair may come into contact with the cornea and cause pain, keratitis, and corneal ulceration. The tarsal plate, which is poorly developed in domesticated animals, provides minimal support for the eyelids. The globe supports the eyelids; if the globe is set deeply in the orbit or retracted as a result of ocular pain, the eyelids may invert.2 There are three classifications for the causes of entropion: conformational/congenital, spastic, and cicatricial.3­5 Many canine breeds, including the chow chow, Chinese shar-pei, St. Bernard, English springer spaniel, American cocker spaniel, English bulldog, rottweiler, toy and miniature poodle, Great Dane, bullmastiff, and several sporting breeds, are predisposed to conformational entropion.1,3,6 Dogs with a palpebral fissure that is larger than normal frequently have conformational entropion.7 The disorder is seldom seen in cats; Persians are most commonly affected.4,8 Conformational entropion is probably polygenetic and presumably influenced by genes that define the skin and other structures that make up the eyelids, amount and weight of the skin covering the head and face, orbital contents, and conformation of the skull.6 Spastic entropion is acquired secondary to ocular pain (e.g., from corneal ulceration or anterior uveitis). Ocular irritation can cause contracture of the orbicularis oculi muscle, which accentuates lid margin inversion.3 A cycle of irritation and blepharospasm can result. This type of entropion usually resolves by correcting the underlying cause. Conformational entropion often has a spastic component. The inverted eyelid frequently causes corneal trauma and ocular pain. When surgical correction is being planned, overestimation of the severity of the entropion resulting from the spastic component can be minimized by using topical anesthetic (proparacaine hydrochloride). Cicatricial entropion, which is contracture of scar tissue resulting in eyelid margin inversion, is relatively uncommon in veterinary patients. Cicatricial entropion can occur secondary to scarring from trauma or surgery. Extensive disease of the palpebral conjunctiva or fornix from caustic agents or severe chronic conjunctivitis in cats can also result in cicatricial entropion. Correction of this disorder usually necessitates removal
of scar tissue in combination with corrective blepharoplastic surgiCal Techniques. Surgical Correction Uncomplicated conformational entropion in adult dogs can be repaired using the modified Hotz-Celsus technique. After the periocular area is clipped and prepared for surgery, the procedure involves resection of skin several millimeters away from and parallel to the eyelid margin. An elliptical skin incision is made slightly longer than the inverted portion of the upper and/or lower eyelid.3­5,9,10 The amount of skin resected (i.e., the width of the ellipse) is dictated by the severity of the entropion and is equal to the amount of inverted tissue. This procedure must be done close to the eyelid margin. If the incision is too far from the eyelid margin, more tissue must be excised to produce the same degree of correction. The initial skin incision is made with a scalpel blade approximately 2 mm from and parallel to the eyelid margin (at the haired­nonhaired junction), leaving just enough space to preclude the sutures from contacting the cornea3­5,10,11 (Figure 1). The incision should not be the full thickness of the eyelid or include the palpebral conjunctiva. A Jaeger lid plate or sterile tongue depressor is placed in the conjunctival cul-de-sac to provide stability and tissue tension while the incision is made. The second incision forms a slight ellipse to remove enough tissue to correct the entropion. The ellipse should be widest in the most severe area of entropion and taper toward the ends. A portion of the underlying orbicularis oculi muscle may also be excised in more severe cases. Alternatively, the skin may be grasped and crushed with the tips of strait mosquito hemostat forceps approximately 2 mm from the eyelid margin until inversion is corrected4,10,12 (Figure 2). The ridge of tissue created is then excised using scissors. This technique is more traumatic but provides some hemostasis. The pinch technique can provide an easier method for less-experienced surgeons to estimate the amount of tissue to be removed before making a skin incision because redundant tissue is grasped and pinched until the eyelid margin is in the correct position. It is important to use only the tips of the hemostats to allow proper placement of the incision along the curved eyelid margin. With either method, enough of the subcutaneous tissue should be removed to allow easy apposition of the skin edges. Regardless of the technique, the elliptical skin incision is closed in one layer with 4-0 to 6-0 nonabsorbable suture in a simple interrupted pattern. Sutures are spaced 2 to 3 mm apart, and suture bites should be small. Splitthickness cutaneous sutures allow precise apposition and
BLEPHAROPLASTY I CORNEAL ULCERATION I INVERTED TISSUE I PINCH TECHNIQUE
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A
B
C
D
Figure 1--(A) Modified Hotz-Celsus procedure to correct entropion. (B) A scalpel blade incision is made at the haired­nonhaired junction (approximately 2 mm from the eyelid margin). (C) Simple interrupted sutures are used to close the wound, starting in the center. (D) The suture tag closest to the cornea is trimmed short.
A
B
C
D
Figure 2--(A) Modified Hotz-Celsus procedure to correct entropion by the crush and cut technique. The tips of straight mosquito hemostats and forceps create a ridge of tissue by crushing. Additional tissue is incorporated to the tissue ridge until the eyelid margin is everted. The tissue ridge is excised with scissors (B), and the wound closed as in Figure 1 (C and D).
minimize scarring. The first suture is placed in the middle of the incision (Figure 1). Additional sutures are alternately placed medially and laterally to evenly divide the tissue and prevent dog-ear formation.13 The sutures should allow wound apposition without being tight because postoperative edema can occur in the eyelid. The free end of the knot closest to the eyelid margin is cut short to prevent corneal trauma. The suture end that is further from the eyelid margin is left longer to facilitate removal in 7 to 14 days. Standard postoperative care, including an Elizabethan collar, should be followed. The modified Hotz-Celsus procedure is versatile because the incision can be made in a limited area at the medial or lateral portion of the eyelid
Figure 3--Triangular Hotz-Celsus excision to correct medial entropion. The base of the triangle is incised at the haired­nonhaired junction, parallel to the eyelid margin, and equal in length to the area of entropion. The first simple interrupted suture is placed from the apex to the center of the triangle's base.
or along the entire length of the eyelid. Modifications of the modified Hotz-Celsus procedure can address specific types of entropion. Medial lower eyelid entropion is commonly found in the miniature and toy poodle, Boston terrier, pug, Pekingese, Shih Tzu, and Lhasa apso. A modified Hotz-Celsus technique removes a triangular piece of skin from the lower eyelid near the medial canthus3 (Figure 3). The base of the triangle is parallel to the eyelid margin, at the haired­nonhaired junction. The base of the triangle is equal to the area of entropion. The base­apex distance is equal to the amount of eversion needed. The skin incision is closed using nonabsorbable suture in a simple interrupted pattern. The first suture is placed from the apex to the midpoint
MODIFIED HOTZ-CELSUS TECHNIQUE I MEDIAL CANTHUS I EYELID MARGIN
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Small Animal/Exotics
of the base. The pinch technique
junctiva and skin).15 This proce-
can also be used to remove an el-
dure can decrease the palpebral fis-
lipse of tissue medially in the area
sure but does not address lateral
of entropion.
canthal tension, medial trichiasis,
Lateral upper and lower eyelid
or severe lateral canthal laxity. Skin
entropion can be repaired using a
sutures involving either canthus
modified Hotz-Celsus excision
are typically removed after 14 days
curving around the lateral can-
because it is an area of movement.
thus, which is known as the ar-
Dogs with concurrent macro-
rowhead technique (Figure 4). Figure 4--Arrowhead technique to correct lateral palpebral fissure and entropion
The width of the excised tissue is canthal entropion. An elliptical skin incision is may not be adequately repaired
equal to the amount of tissue in- made around the lateral canthus. The first sim- using a modified Hotz-Celsus
version. The first suture is placed ple interrupted suture is placed at the lateral procedure alone. Lateral cantho-
at the lateral canthus, and the up- canthus.
plasty is indicated in animals with
per and lower parts closed alter-
macropalpebral fissure and lateral
nately. This procedure is used in
lower and/or upper eyelid entropi-
dogs that have lateral canthal en-
on or inversion of the entire later-
tropion and a normal, almond-
al canthus. Many large and giant
shaped palpebral fissure, such as
dog breeds have a diamond-
the Norwegian elkhound.3 Post-
shaped palpebral fissure with cen-
operative care is the same as that
tral ectropion and lateral and/or
for other eyelid surgery.
medial entropion. These dogs can
Complicated entropion exists
also benefit from a lateral cantho-
when inversion of the eyelids is accompanied by large facial or brow
A
plasty in addition to a modified Hotz-Celsus procedure. The un-
folds, lateral canthal ligament laxi-
derlying pathologic condition is
ty or tension, macropalpebral fis-
usually lateral canthal ligament
sure, coexistent ectropion, and/or
laxity or instability and absent or
trichiasis. Complicated entropion
poorly functioning retractor an-
is more challenging to diagnose
guli oculi lateralis muscle.16
and correct. Several advanced ble-
A diamond-shaped lateral can-
pharoplastic surgical procedures
thoplasty can correct lateral can-
may be required in addition to the
thal entropion, address lateral
modified Hotz-Celsus procedure. Referral to a veterinary ophthal- B
canthal laxity, and decrease the size of the palpebral fissure. Full-
mologist should be considered for complex cases. Macropalpebral fissure can predispose to recurrent corneal ulceration, pigmentary keratitis, and globe proptosis (displacement of
Figure 5--(A) Permanent lateral tarsorrhaphy to correct macropalpebral fissure. The lateral eyelid margin is excised. (B) The palpebral fissure is narrowed by closure of conjunctiva and skin in two layers.
thickness incisions are made through the upper and lower eyelid margins several millimeters medial to the lateral canthus (Figure 6). Each incision is perpendicular to the eyelid margin. The lo-
the globe anterior to the eyelids).
cation of the perpendicular
Canthoplasty, reconstruction of either canthus, partial incision is dictated by the degree of desired palpebral
permanent tarsorrhaphy, or partial closure of the eyelids fissure shortening. A cutaneous incision is made in a
is often indicated in cases of macropalpebral fissure. The ventrolateral direction from the upper eyelid incision
easiest method of decreasing the palpebral fissure size is and the lower eyelid incision continues as a cutaneous
by permanent lateral tarsorrhaphy. The lateral upper incision in a dorsolateral direction to create dorsal and
and lower eyelid margins, including the tarsal (meibo- ventral apices. The upper and lower eyelid incisions
mian) glands, are excised (Figure 5). The length of the meet at an additional apex lateral to the lateral canthus,
incision is dictated by the desired degree of shortening. creating a diamond shape. The diamond-shaped region
The depth of the incision should include the of skin is excised to include the lateral canthus and por-
haired­nonhaired junction to prevent a hairless scar.14 tions of the upper and lower eyelid margins. To create a
The eyelids are closed in the standard two layers (con- new lateral canthus, the conjunctiva and skin are ap-
LATERAL CANTHUS I ARROWHEAD TECHNIQUE I MACROPALPEBRAL FISSURE
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posed by the standard two-layer closure. A modified Hotz-Celsus procedure may be needed in addition to the lateral canthoplasty to correct medial entropion, if present. Dogs with massive heads, broad skulls, and loose facial skin (rottweilers, adult golden retrievers, mastiffs, chow chows, and some English bulldogs) frequently have lateral canthal entropion.17,18 The lateral canthal tendon can restrict movement at the lateral canthus; as a result, enophthalmos and redundant facial skin cause entropion. Subconjunctival transection of the lateral canthal tendon addresses abnormalities in the lateral canthus dynamics and corrects the lateral canthal entropion17 (Figure 7). This is a tension-relieving technique compared with other tissue-everting procedures that rely on tension for repair. After induction of general anesthesia and placement of an eyelid speculum, the lateral canthus can be everted by grasping the eyelid margin with forceps. Stretching and spreading the eyelids allow identification of the lateral canthal tendon. The overlying palpebral conjunctiva is incised and un-
A B Figure 6--(A) Diamond-shaped lateral canthoplasty to correct macropalpebral fissure and concurrent lateral entropion. (a and b) Perpendicular full-thickness incisions are made in the lateral upper and lower eyelids. (c) The upper eyelid incision is continued ventrolaterally as a cutaneous incision. (d ) The lower eyelid incision is continued as a cutaneous incision dorsolaterally. (e) These two incisions meet at a point lateral to the lateral canthus, creating a diamond shape. The outlined tissue is undermined and excised, including the lateral canthus. (B) The incision is closed in two layers, conjunctiva and skin.
dermined over a 9-mm area. The fibrous band that courses from the lateral canthus to the orbital ligament and the zygomatic arch is identified and transected. Sharp and blunt dissection is used until the fibrous band and tension at the canthus are alleviated. The conjunctival incision is not closed. Additional procedures, such as the modified Hotz-Celsus procedure, full-thickness wedge resection (see Ectropion section), or partial permanent tarsorrhaphy, may also be needed. Medial canthal entropion is common in brachycephalic breeds.3 It is often accompanied by hair growing from the lacrimal caruncle and/or nasal fold trichiasis, which further increases ocular irritation. Mild cases of medial entropion can be repaired with a modified Hotz-Celsus procedure.19 More severely affectED patients or animals with concurrent trichiasis may benefit from medial canthoplasty (Figure 8). This procedure may also be indicated for animals with concurrent macropalpebral fissure. The nasolacrimal duct system should be avoided in surgery of the medial canthus.20
A
B
Figure 7--(A) Subconjunctival transection of the lateral canthal tendon. Stretching and spreading the eyelids allows identification of the lateral canthal tendon. The conjunctiva over the lateral canthal tendon is incised and undermined. (B) The fibrous band connecting the lateral canthus to the orbital ligament is severed. The conjunctival incision is not sutured.
SUBCONJUNCTIVAL TRANSECTION I ZYGOMATIC ARCH I TARSORRHAPHY
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Small Animal/Exotics
Placement of 2-0 prolene or
ing on the same side of the
nylon suture in the lacrimal
wound, can be placed to re-
puncta can allow adequate
lieve the tension associated
demarcation and visualiza-
with eyelid opening and
tion. The palpebral fissure is
closing.22 Nonabsorbable su-
typically closed by one quar-
ture material (3-0 to 4-0) is
ter of its length. Narrowing
placed by inserting the nee-
of the fissure is limited to the
dle 8 mm from the incision
area just medial to the A lacrimal puncta.14 The medi-
edge and passing it across the wound to exit at the corre-
al canthus and upper and
sponding point on the oppo-
lower eyelid margins are split
site side. The needle is ad-
at the level of the tarsal
vanced 4 mm toward the
glands, terminating 1 to 2
incision edge, reinserted
mm medial to the lacrimal
through the skin, and passed
puncta. Tissue is under-
back across the wound to a
mined in a medial direction
point 4 mm from the inci-
that includes resection of the B medial canthal ligament.21 A
C
sion edge on the original
side. The tension sutures are
triangular piece of conjuncti- Figure 8--Medial canthoplasty to correct medial canthal en- removed after 5 to 7 days
va between the upper and lower lacrimal puncta, including the lacrimal caruncle, is resected.20 It is important to remove all hair, which
tropion and trichiasis. (A and B) A triangular piece of conjunctiva and skin is excised external to the lacrimal puncta . The medial eyelid margin is split with a no. 64 beaver blade. (C) Closure in two layers, conjunctiva and skin, reduces the size of the palpebral fissure.
and skin sutures removed in 14 days. Medial canthoplasty can slightly alter the appearance of the dog, and the owner should be forewarned.
typically arises from the pig-
Entropion of the upper
mented conjunctiva. The medial canthus is closed in two eyelid complicated by large facial and brow folds can
layers and the conjunctiva sutured using absorbable su- often occur in shar peis, chow chows, bloodhounds,
ture. The skin is sutured in a simple interrupted pattern and some English bulldogs. Heavy forehead skin with
with 4-0 to 6-0 nonabsorbable suture after placement of large wrinkles results in hooding of the eyes. These
a figure-of-eight suture at the eyelid margin. Vertical dogs can benefit from dorsolateral frontal skinfold exci-
mattress tension sutures, a loop of suture material per- sion, which is an elliptical incision that removes the
pendicular to the incision with both suture ends emerg- skinfold or decreases its size5,23 (Figure 9). In an unsedat-
B D
A
C
Figure 9--(A) Facial fold excision to correct hooding of the eyelids. In an unsedated dog, skin is grasped over the dorsal orbital rim to determine the location and size of the elliptical incision. (B and C ) The skin incision should arc and partially encircle the eye . (D) Subcutaneous tissue and skin are closed in two layers.
LOWER LACRIMAL PUNCTA I TRICHIASIS I MEDIAL CANTHOPLASTY
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A
B
C
Figure 10--Stades procedure to correct upper eyelid entropion and trichiasis. (A) A large ellipse of tissue, including skin, hair follicles, and cilia, is removed from the upper eyelid. (B) The superior wound margin is advanced to just dorsal to the base of the tarsal glands and positioned to the palpebral subcutis with interrupted sutures. (B and C) A 3- to 4-mm strip of tissue adjacent to the eyelid margin is allowed to granulate to prevent future trichiasis (light pink). (C) The superior wound edge is sutured to the palpebral subcutis with continuous suture.
ed animal, skin is gathered with fingers dorsal to the eye until the wrinkles that are dorsal and lateral to the eye are eliminated. The area that requires maximum lift is the widest area of the excision and is typically the center point of the palpebral fissure. The base of the gathered skin is measured or marked on each side. This distance is the maximal width of the skinfold excision. A skin marker facilitates uniformity between the eyes. After induction of general anesthesia and preparation of the surgical site, incision lines can be outlined with a sterile marker. The area to be excised should form an arc that partially encircles the eye and tapers at the ends. The incision should include skin only and be closed in two layers: 3-0 to 4-0 absorbable suture in the subcutaneous tissue and interrupted 4-0 to 6-0 nonabsorbable suture in the skin. A modified Hotz-Celsus procedure or additional procedures may also be needed. A stellate-shaped excision of skin from the dorsal head (stellate rhytidectomy) has been described in the shar pei as an alternative method for treatment of frontal facial folds.24 Severe trichiasis and upper eyelid entropion in dogs can be corrected by a technique described by Stades.25,26 This procedure everts the eyelid margin and removes the irritating cilia and eyelid hairs. The first incision is made between the meibomian glands and the cilia (0.5 to 1 mm from the eyelid margin), resulting in cilia excision (Figure 10). The incision begins 2 to 4 mm lateral to the medial canthus and continues 5 mm beyond the lateral canthus. Another incision is made over the dorsal orbital rim (15 to 25 mm from the eyelid margin) and tapers at the edges for a medial and lateral connection to the first incision. The outlined skin is undermined and excised. Hair or cilia follicles that have not
been removed should be scraped with a scalpel blade or electroepilated.5 The inferior and superior wound margins are not apposed.25,26 The superior skin edge is sutured to the subcutis 5 to 6 mm dorsal to the eyelid margin with 4-0 to 5-0 simple interrupted and continuous nonabsorbable suture. The open portion of the wound heals by second intention, causing mild ectropion. The cutaneous scar tissue is hairless. Brow suspension with polyester mesh has recently been described as an alternative therapy.27 Cicatricial entropion can be corrected by a Y-toV­plasty2,5,12 or the modified Hotz-Celsus technique, depending on the amount of affected eyelid margin.28 Cicatricial areas that are less than one third the length of the eyelid margin are best repaired with a Y-toV­plasty.28 A Y-shaped skin incision is created over the area of entropion (Figure 11). A Jaeger lid plate or sterile tongue depressor is placed in the conjunctival fornix for support. The arms of the Y begin at the haired­nonhaired junction and extend just beyond the scar tissue. The length of the Y stem is dictated by the degree of eyelid margin eversion needed. The triangular-shaped skin flap is undermined from apex to base toward the eyelid margin. The scar tissue is excised by subcutaneous dissection. To evert the eyelid margin away from the cornea, the incision is closed in the shape of a V with 4-0 to 6-0 nonabsorbable skin sutures. The first suture, placed at the apex of the V, is a half-buried horizontal mattress suture to preserve the blood supply to the flap. The arms are closed alternately with simple interrupted sutures. Lesions that are larger than one third of the eyelid margin are better corrected by the elliptical modified Hotz-Celsus incision.28
STELLATE RHYTIDECTOMY I FRONTAL FACIAL FOLDS I JAEGER LID PLATE
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A
B
C
D
E
Figure 11--(A) Y-to-V­plasty to correct cicatricial entropion. (B) A Y-shaped incision allows creation of a V-shaped flap (c). (C ) Cicatricial tissue is removed under the flap. (D) A half-buried horizontal mattress suture is placed at the apex of the V (c and d), then the arms are closed alternately with simple interrupted nonabsorbable sutures. (E) The wound is closed in the shape of a V to evert the eyelid margin.
ECTROPION Description Ectropion often has fewer detrimental effects on the globe and eyelid function than does entropion. Most animals with ectropion do not require surgical correction. Severe ectropion can result in chronic conjunctivitis and keratitis from exposure; these cases should be surgically corrected. Owners sometimes request surgery because of epiphora or because they find the appearance of ectropion unacceptable. Ectropion occurs more frequently in dogs than in cats and is normal according to some breed standards. Ectropion can be a congenital defect caused by excessive eyelid length or lateral canthus laxity.7,14 In some breeds, ectropion may be acquired later in life from laxity of the orbicularis oculi muscle. Ectropion can also be secondary to scar tissue (cicatricial) from trauma or previous overcorrection of entropion.3 Surgical Correction The simplest method to repair ectropion is by a pie- shaped, full-thickness wedge resection of the everting tissue2 (Figure 12). A V-shaped wedge of tissue with the apex pointing away from the eyelid margin is excised with scissors or scalpel blade. A Jaeger lid plate (or sterile tongue depressor) can be placed between the eyelid
and the cornea to provide skin tension for scalpel blade incisions. This procedure is similar to techniques used to remove small eyelid masses, and a four-sided excision will also correct ectropion.15 The defect is closed in the standard two-layer closure of conjunctiva and skin. Severe cases of eyelid laxity in dogs with combined ectropion and entropion of the lower eyelid can be repaired using the Kuhnt-Szymanowski procedure. The two most frequently described variations in dogs differ in the location of the initial incision.12,29 In both procedures, a partial-thickness incision is made in the lateral one half of the lower eyelid to separate the skin and orbicularis muscle from the tarsoconjunctiva. The incision follows the natural upward curve of the lower eyelid past the lateral canthus and is continued laterally to a length equal to the width of the central ectropion. An incision is then made downward and angled slightly medially. The resulting triangular skin flap is undermined. The two procedures differ in the location of the incision that separates the skin and orbicularis muscle from the tarsoconjunctiva (eyelid splitting). Munger and Carter split the eyelid at the haired­ nonhaired junction (approximately 2 mm below the eyelid margin), and a triangle of tarsoconjunctiva is removed centrally from the lower eyelid29 (Figure 13).
ORBICULARIS OCULI MUSCLE I CORNEA I FOUR-SIDED EXCISION
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A
B
C
Figure 12--Full-thickness wedge resection for ectropion repair. (A and B) A triangular wedge of tissue that is equal to the area of ectropion is excised from the eyelid. (C) The incision is closed in two layers--conjunctiva and skin.
A
B
C
C
E
F
Figure 13--(A) Kuhnt-Szymanowski procedure to correct concurrent entropion and ectropion as described by Munger and Carter.29 (B) A cutaneous incision parallel to the lower eyelid at the haired­nonhaired junction is continued dorsolaterally past the lateral canthus and then directed ventromedially, creating a triangular flap of skin. (C ) A triangular wedge of tarsoconjunctiva is removed to shorten the eyelid. (D) The tarsoconjunctiva is closed with absorbable interrupted suture, and the eyelid margin is apposed with a figure-of-eight suture. (E ) The triangular skin flap is advanced into the lateral facial wound, and excessive skin is removed. (F ) The skin is closed with nonabsorbable interrupted sutures.
This modification avoids splitting the eyelid margin, thus reducing the risk for eyelid margin scarring and tarsal gland damage. Bistner and colleagues split the eyelid at its margin and remove a wedge of tarsoconjunctiva near the lateral canthus12 (Figure 14). In both procedures, a wedge the same size as the tarsoconjunctival resection is excised from the lateral portion of the skin­orbicularis flap (Figure 13). The tarsoconjunctival wedges are closed with 6-0 to 9-0 absorbable suture. In the Munger and Carter technique, the skin of the central eyelid margin defect is closed with a figure-of-eight
nonabsorbable suture (Figure 13). In both procedures, the skin is reapposed with 4-0 to 6-0 nonabsorbable suture in a simple interrupted pattern. The first suture is placed at the apex of the skin muscle flap to assure dorsolateral traction. In a technique introduced by Bistner and colleagues the split eyelid margin is reconstructed with simple interrupted nonabsorbable suture apposing tarsoconjunctiva to the skin­orbicularis flap12 (Figure 14). Methods to repair lateral canthal laxity, such as the Kuhnt-Szymanowski procedure, will restore more normal eyelid function and anatomy.
FIGURE-OF-EIGHT SUTURE I TARSOCONJUNCTIVA I SKIN­ORBICULARIS FLAP
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Small Animal/Exotics
A
B
Figure 14--Kuhnt-Szymanowski procedure to correct concurrent entropion and ectropion as described by Bistner and colleagues.12 (A) The lower eyelid is split at the margin, and the incision is continued dorsolaterally past the lateral canthus and then directed ventromedially, creating a triangular flap of skin. A triangular wedge of tarsoconjunctiva is removed to shorten the eyelid as above. The triangular skin flap is advanced into the lateral facial wound, and excessive skin is removed. (B) The tarsoconjunctiva is closed with absorbable interrupted suture, and the skin is closed with nonabsorbable interrupted sutures.
Cicatricial ectropion can be repaired by excising the scarred tissue. A V-to-Y­plasty or Z-plasty can be used. A V-to-Y­plasty advances a wider area of tissue than a Z-plasty--the entire eyelid margin.15 A V-shaped incision is made over the scar tissue with the V pointing away from the eyelid margin. The eyelid margin should not be included in the incision unless the scar tissue encompasses the eyelid margin. The scar tissue is dissected from below the skin, and the incision is closed in a Y with a simple interrupted pattern.12,30 A Z-plasty15 provides more length but in a narrower area. A Z-plasty transposes two interdigitating flaps of skin. There is a central limb with arms of equal length, and the incision angles are usually 60° to the central incision. Length is gained in the direction of the central limb as the component flaps are transposed. CONCLUSION Because of the variety of eyelid conformational defects and varying degrees of involvement, entropion and ectropion can be repaired in many ways. Most cases are best repaired with the least complicated method available. It is critical to evaluate the unsedated animal without blepharospasm to determine the true extent of the defect. All of the problems that contribute to the eyelid defect must be identified before repair, and strict principles of plastic and reconstructive surgery must be used. ACKNOWLEDGMENT All illustrations are by Michael Broussard, Louisiana State University, Baton Rouge, Louisiana.
REFERENCES 1. Rubin L: Inherited Eye Diseases in Purebred Dogs. Baltimore, Williams & Wilkins, 1989. 2. Bedford PGC: Conditions of the eyelids in the dog. J Small Anim Pract 29:416­428, 1988. 3. Gelatt KN: The canine eyelids, in Gelatt KN (ed): Textbook of Veterinary Ophthalmology, ed 2. Philadelphia, Lea & Febiger, 1991, pp 256­275. 4. Martin CL: Eyelids, in Martin CL (ed): Veterinary Ophthalmology Notes. Athens, GA, 1992, pp 150­191. 5. Moore CP, Constantinescu GM: Surgery of the adnexa. Vet Clin North Am Small Anim Pract 27:1011­1066, 1997. 6. Genetics Committee of the American College of Veterinary Ophthalmologists, in Ocular Disorders Proven or Suspected to be Inherited in Dogs. Canine Eye Registration Foundation, West Lafayette, IN, 1996. 7. Stades FC, Boeve MH, can der Woerdt A: Palpebral fissure length in the dog and cat. Prog Vet Comp Ophthalmol 2: 155­161, 1992. 8. Nasisse M: Feline ophthalmology, in Gelatt K (ed): Textbook of Veterinary Ophthalmology, ed 2. Philadelphia, Lea & Febiger, 1991, pp 529­575. 9. Menges RW: An operation for entropion in the dog. JAVMA 109:464­465, 1946. 10. Gelatt KN, Gelatt JP: Surgery of the eyelids, in Handbook of Small Animal Ophthalmic Surgery, Volume 1: Extraocular Procedures. Tarrytown, NY, Pergamon Press, 1994, pp 69­ 123. 11. Miller WW, Albert RA: Canine entropion. Compend Contin Educ Pract Vet 10:431­438, 1988. 12. Bistner SI, Aguirre G, Batik G: Entropion and ectropion, in Bistner SI, Aguirre G, Batik G (eds): Atlas of Veterinary Ophthalmic Surgery. Philadelphia, WB Saunders Co, 1977, pp 96­114. 13. Swaim SF, Henderson RA: Various-shaped wounds, in Swaim SF, Henderson RA (eds): Small Animal Wound Management, ed 2. Philadelphia, Williams & Wilkins, 1997, pp 235­274. 14. Bedford PG: Diseases and surgery of the canine eyelid, in Gelatt KN (ed): Veterinary Ophthalmology, ed 3. Philadelphia, Lippincott, Williams & Wilkins, 1999, pp 535­568. 15. Hamilton HL, McLaughlin SA, Whitley RD, Swaim SF: Basic blepharoplasty techniques. Compend Contin Educ Pract Vet 21(10):946­953. 16. Wyman M: Lateral canthoplasty. JAAHA 7:196­201, 1971. 17. Robertson BF, Roberts SM: Lateral canthus entropion in the dog, part 2: Surgical correction. Results and follow-up from 21 cases (1991­1994). Vet Comp Ophthalmol 5:162­169, 1995. 18. Robertson BF, Roberts SM: Lateral canthus entropion in the dog, part 1: Comparative anatomic studies. Vet Comp Ophthalmol 5:151­156, 1995. 19. Peiffer RL Jr, Gwin RM, Gelatt KN: Correction of inferior medial entropion as a cause of epiphora. Canine Pract 5:27­ 31, 1978. 20. Wyman M: Ophthalmic surgery for the practitioner. Vet Clin North Am Small Anim Pract 9:311­348, 1979. 21. Severin GA: Eyelids, in Severin GA (ed): Severin's Veterinary Ophthalmology Notes, ed 3. Fort Collins, CO, 1996, pp 153­206. 22. Swaim SF, Henderson RA: Management of skin tension, in Swaim SF, Henderson RA (eds): Small Animal Wound Management, ed 2. Philadelphia, Williams & Wilkins, 1997, pp 143­190.
KUHNT-SZYMANOWSKI PROCEDURE I V-TO-Y­PLASTY I Z-PLASTY
Small Animal/Exotics
Compendium June 2000
23. Kihns EL: Options for entropion repair. Vet Forum (February):36­42, 1996. 24. Stuhr CM, Stanz K, Murphy CJ, et al: Stellate rhytidectomy: Superior entropion repair in a dog with excessive facial skin. JAAHA 33:342­345, 1997. 25. Stades FC: A new method for surgical correction of upper eyelid trichiasis­entropion: Operation method. JAAHA 23: 603­606, 1987. 26. Stades FC, Boeve MH: Surgical correction of upper eyelid trichiasis­entropion: Results and follow up in 55 eyes. JAAHA 23:607­610, 1987. 27. Willis AM, Martin CL, Stiles J, et al: Brow suspension for treatment of ptosis and entropion in dogs with redundant facial skin folds. JAVMA 214:660­662, 1999. 28. McLaughlin SA, Whitley RD: Eyelid wounds, in Swaim SF, Henderson RA (eds): Small Animal Wound Management, ed 2. Philadelphia, Williams & Wilkins, 1997, pp 403­430. 29. Munger RJ, Carter JD: A further modification of the Kuhnt-Szymanowski procedure for correction of atonic ectropion in dogs. JAAHA 210:651­656, 1984.
30. Hamilton HL, McLaughlin SA, Whitley RD, et al: Surgical reconstruction of severe cicatricial ectropion in a puppy. JAAHA 34:212­218, 1998. About the Author When this article was submitted for publication, Dr. Hamilton was affiliated with thE Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana and Drs. McLaughlin, Whitley, and Swaim were affiliated with the Department of Small Animal Surgery and Medicine, College of Veterinary Medicine, Auburn University, Auburn, Alabama. Dr. Hamilton is currently with the Animal Eye Center, Fort Collins, Colorado. Dr. McLaughlin is currently with the School of Veterinary Medicine, Purdue University, West Lafayette, Indiana. Dr. Swaim is also affiliated with the Scott-Ritchey Research Center at Auburn University. Drs. Hamilton, McLaughlin, and Whitley are Diplomates of the American College of Veterinary Ophthalmology.

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