34th Annual Scientific Meeting proceedings

The eyelid margin is a highly specialised mucocutaneous junction and its importance should not be under-estimated. It is responsible for producing components of the tear film from the meibomian glands opening along the margins providing lipid, and conjunctival goblet cells producing mucins. The eyelid margin also distributes the tear film, along with the third eyelid, and in cats and dogs the upper eyelid has a greater role in blinking than the lower lid (therefore arguably a priority for reconstruction).

The reconstruction of the eyelid margin after resection of tissue (e.g. oncological surgery) is no easy task. As a rough rule of thumb, loss of more than one third of eyelid length requires reconstructive blepharoplasty rather than primary closure. Borrowing margin from an opposing eyelid can sometimes be employed, such as with the two-stage Mustardé procedure (Esson D 2001). The Pavletic ‘lip to lid’ subdermal plexus flap can also result in a very cosmetic outcome (Hunt 2006, Whittaker et al 2010). More recently, free lip and tarsal mucocutaneous grafts have been described (with or without subdermal hyaluronic acid injection adjunct) (Warren et al 2020, Irving et al 2024, Poinsard et al 2019, Caruso et al 2022). Epithelial necrosis at the distal tip is a common complication in both lip techniques and gentle tissue handling is important. Where bilateral reconstruction is required (e.g. feline eyelid agenesis) the two eyes may need to be staged to avoid over-reducing the lip commissures and risk of wound breakdown at the donor site.

In some cases a sliding graft can release more skin for the eyelid but these do not afford a new margin and trichiasis (and subsequent keratitis) remains a risk. Similarly rotational flaps can be utilised to reconstruct part of the eyelids, with or without palpebral conjunctival transposition (Jacobi et al 2008, Lew at al 2010, Albernaz et al 2021, Safarty et al 2023, Occelli and Neaderland 2011). Consequently, choosing the non-margin section of the eyelid to be medial or lateral is worthwhile, to limit the impact of the margin absence where any undesirable trichiasis is more likely to contact conjunctiva than cornea.

H-plasty and the two -stage ‘bucket handle’ advancement flaps can be beneficial but lining these with conjunctiva and avoiding cicatricial post-operative contraction are hazards (van der Woerdt 2004, Aquino 2007, Giordano et al 2017). A split lid procedure has been described to reconstruct the upper eyelid in a cat (Hagard 2005). Y to V plasty can help release contracture but does not address conjunctival shortening (Donaldson et al 2005). In human surgery, and sporadically described in veterinary literature, conjunctival conformers can be used to limit contracture and maintain functional conjunctival fornices (Groot et al 2022). Amniotic membrane is frequently deployed as a scaffold for conjunctival migration and can assist in reconstruction of the conjunctival fornices (Tseng et al 1997, Bandeira 2019).

References

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