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
■ Macropalpebral fissure is an
enlarged eyelid opening.
■ Trichiasis occurs when cilia or
facial hair comes into contact
with the cornea.
■ Entropion (inversion of the eyelid
margin) can result in corneal
ulceration, potentially blinding
corneal scarring, and ocular
irritation.
■ Most uncomplicated cases of
entropion can be corrected by the
modified Hotz-Celsus technique,
but referral should be considered
in complicated cases.
■ 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, ectropi-
on, 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 con-
sidered. Ectropion requires surgical repair less often than does entropion.
N
umerous congenital and acquired conformational defects affect the eye-
lids, 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 simultane-
ously. 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, includ-
ing the relationship between the eyelid, globe, and orbit; orbital size; muscle de-
velopment; 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 func-
tion, 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
mals because enophthalmos induced by general anes-
thesia can cause entropion. A surgical plan should be
based on examination findings and not altered after in-
duction of sedation or general anesthesia.
ENTROPION
Description
Entropion is one of the most common eyelid abnor-
malities 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 re-
sult of ocular pain, the eyelids may invert.2
There are three classifications for the causes of entro-
pion: conformational/congenital, spastic, and cicatri-
cial.3–5 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 conforma-
tional 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; Per-
sians are most commonly affected.4,8 Conformational
entropion is probably polygenetic and presumably in-
fluenced by genes that define the skin and other struc-
tures 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 orbicu-
laris oculi muscle, which accentuates lid margin inver-
sion.3 A cycle of irritation and blepharospasm can re-
sult. This type of entropion usually resolves by
correcting the underlying cause. Conformational entro-
pion often has a spastic component. The inverted eye-
lid frequently causes corneal trauma and ocular pain.
When surgical correction is being planned, overestima-
tion 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 tis-
sue resulting in eyelid margin inversion, is relatively un-
common 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 conjunc-
tivitis in cats can also result in cicatricial entropion.
Correction of this disorder usually necessitates removal
BLEPHAROPLASTY ■ CORNEAL ULCERATION ■ INVERTED TISSUE ■ PINCH TECHNIQUE
Small Animal/Exotics
of scar tissue in combination with corrective blepharo-
plastic 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 pre-
pared for surgery, the procedure involves resection of
skin several millimeters away from and parallel to the
eyelid margin. An elliptical skin incision is made slight-
ly longer than the inverted portion of the upper and/or
lower eyelid.3–5,9,10 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 mar-
gin. 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 haired–nonhaired junction), leaving just
enough space to preclude the sutures from contacting
the cornea3–5,10,11 (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 depres-
sor 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 se-
vere cases. Alternatively, the skin may be grasped and
crushed with the tips of strait mosquito hemostat for-
ceps approximately 2 mm from the eyelid margin until
inversion is corrected4,10,12 (Figure 2). The ridge of tis-
sue created is then excised using scissors. This tech-
nique is more traumatic but provides some hemostasis.
The pinch technique can provide an easier method for
less-experienced surgeons to estimate the amount of tis-
sue to be removed before making a skin incision be-
cause 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 mar-
gin. 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 su-
ture in a simple interrupted pattern. Sutures are spaced
2 to 3 mm apart, and suture bites should be small. Split-
thickness cutaneous sutures allow precise apposition and
Small Animal/Exotics Compendium June 2000

A B C D
Figure 1—(A) Modified Hotz-Celsus procedure to correct entropion. (B) A scalpel blade incision is made at the haired–nonhaired
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 al-
ternately placed medially and laterally
to evenly divide the tissue and prevent
dog-ear formation. 13 The sutures
should allow wound apposition with-
out being tight because postoperative
edema can occur in the eyelid. The
free end of the knot closest to the eye-
lid 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, in-
cluding an Elizabethan collar, should
be followed.
The modified Hotz-Celsus proce-
dure 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 exci-
sion to correct medial entropion. The
base of the triangle is incised at the
haired–nonhaired junction, parallel to
the eyelid margin, and equal in length
to the area of entropion. The first sim-
ple interrupted suture is placed from the
apex to the center of the triangle’s base.
or along the entire length of the eye-
lid. 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 poo-
dle, Boston terrier, pug, Pekingese,
shih tzu, and Lhasa apso. A modified
Hotz-Celsus technique removes a tri-
angular piece of skin from the lower
eyelid near the medial canthus3 (Fig-
ure 3). The base of the triangle is par-
allel to the eyelid margin, at the
haired–nonhaired junction. The base
of the triangle is equal to the area of
entropion. The base–apex distance is
equal to the amount of eversion need-
ed. The skin incision is closed using
nonabsorbable suture in a simple in-
terrupted pattern. The first suture is
placed from the apex to the midpoint

MODIFIED HOTZ-CELSUS TECHNIQUE ■ MEDIAL CANTHUS ■ EYELID MARGIN

Compendium June 2000 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 ac- plasty in addition to a modified
companied by large facial or brow
A
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. canthal laxity, and decrease the
Referral to a veterinary ophthal- B size of the palpebral fissure. Full-
mologist should be considered for thickness incisions are made
complex cases. Figure 5—(A) Permanent lateral tarsorrhaphy to
through the upper and lower eye-
Macropalpebral fissure can pre- correct macropalpebral fissure. The lateral eyelid lid margins several millimeters
margin is excised. (B) The palpebral fissure is
dispose to recurrent corneal ulcer- narrowed by closure of conjunctiva and skin in medial to the lateral canthus (Fig-
ation, pigmentary keratitis, and two layers. ure 6). Each incision is perpendic-
globe proptosis (displacement of ular 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-
haired–nonhaired 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 ■ ARROWHEAD TECHNIQUE ■ MACROPALPEBRAL FISSURE

Small Animal/Exotics Compendium June 2000

posed by the standard two-layer dermined over a 9-mm area. The

closure. A modified Hotz-Celsus
procedure may be needed in addi-
tion to the lateral canthoplasty to
correct medial entropion, if present.
Dogs with massive heads, broad
skulls, and loose facial skin (rottweil-
ers, adult golden retrievers, mastiffs,
chow chows, and some English bull-
dogs) frequently have lateral canthal
entropion.17,18 The lateral canthal
tendon can restrict movement at the
lateral canthus; as a result, enoph-
thalmos and redundant facial skin
cause entropion. Subconjunctival
transection of the lateral canthal ten-
don addresses abnormalities in the
lateral canthus dynamics and cor-
rects the lateral canthal entropion17
(Figure 7). This is a tension-relieving
technique compared with other tis-
sue-everting procedures that rely on
tension for repair.
After induction of general anes-
thesia 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 can-
thal tendon. The overlying palpe-
bral conjunctiva is incised and un-
A conjunctival incision is not closed.
B from the lacrimal caruncle and/or
Figure 6—(A) Diamond-shaped lateral cantho-
plasty to correct macropalpebral fissure and con-
current lateral entropion. (a and b) Perpendicu-
lar full-thickness incisions are made in the lateral
upper and lower eyelids. (c) The upper eyelid in-
cision is continued ventrolaterally as a cutaneous
incision. (d ) The lower eyelid incision is contin-
ued 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, in-
cluding the lateral canthus. (B) The incision is
closed in two layers, conjunctiva and skin.
fibrous band that courses from the
lateral canthus to the orbital liga-
ment 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
Additional procedures, such as the
modified Hotz-Celsus procedure,
full-thickness wedge resection (see
Ectropion section), or partial per-
manent tarsorrhaphy, may also be
needed.
Medial canthal entropion is com-
mon in brachycephalic breeds.3 It is
often accompanied by hair growing
nasal fold trichiasis, which further
increases ocular irritation. Mild cas-
es of medial entropion can be re-
paired with a modified Hotz-Celsus
procedure.19 More severely affected
patients or animals with concurrent
trichiasis may benefit from medial
canthoplasty (Figure 8). This proce-
dure may also be indicated for ani-
mals with concurrent macropalpe-
bral 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 ■ ZYGOMATIC ARCH ■ TARSORRHAPHY

Compendium June 2000 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 edge and passing it across the
lacrimal puncta.14 The medi- 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 C sion edge on the original
medial canthal ligament.21 A 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 tropion and trichiasis. (A and B) A triangular piece of con- and skin sutures removed in
lower lacrimal puncta, in- junctiva and skin is excised external to the lacrimal puncta . 14 days. Medial canthoplasty
cluding the lacrimal carun- The medial eyelid margin is split with a no. 64 beaver blade. can slightly alter the appear-
cle, is resected.20 It is impor- (C) Closure in two layers, conjunctiva and skin, reduces the ance of the dog, and the own-
size of the palpebral fissure.
tant to remove all hair, which er 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 ■ TRICHIASIS ■ MEDIAL CANTHOPLASTY

Small Animal/Exotics Compendium June 2000

A B C
Figure 10—Stades procedure to correct upper eyelid entropion and trichiasis. (A) A large ellipse of tissue, including skin, hair fol-
licles, 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 nonab-
sorbable 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 fa-
cial 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 exci-
sion (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 dor-
sal orbital rim (15 to 25 mm from the eyelid margin)
and tapers at the edges for a medial and lateral connec-
tion to the first incision. The outlined skin is under-
mined 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 mar-
gins are not apposed.25,26 The superior skin edge is su-
tured to the subcutis 5 to 6 mm dorsal to the eyelid
margin with 4-0 to 5-0 simple interrupted and contin-
uous nonabsorbable suture. The open portion of the
wound heals by second intention, causing mild ectropi-
on. The cutaneous scar tissue is hairless. Brow suspen-
sion with polyester mesh has recently been described as
an alternative therapy.27
Cicatricial entropion can be corrected by a Y-to-
V–plasty2,5,12 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-to-
V–plasty.28 A Y-shaped skin incision is created over the
area of entropion (Figure 11). A Jaeger lid plate or ster-
ile tongue depressor is placed in the conjunctival fornix
for support. The arms of the Y begin at the
haired–nonhaired 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 triangu-
lar-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 su-
tures. 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 alternate-
ly with simple interrupted sutures. Lesions that are
larger than one third of the eyelid margin are better
corrected by the elliptical modified Hotz-Celsus inci-
sion.28

STELLATE RHYTIDECTOMY ■ FRONTAL FACIAL FOLDS ■ JAEGER LID PLATE

Compendium June 2000 Small Animal/Exotics

A B C

D E
Figure 11—(A) Y-to-V–plasty 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 correc-
tion. Severe ectropion can result in chronic conjunctivi-
tis 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 fre-
quently in dogs than in cats and is normal according to
some breed standards. Ectropion can be a congenital de-
fect caused by excessive eyelid length or lateral canthus
laxity.7,14 In some breeds, ectropion may be acquired lat-
er in life from laxity of the orbicularis oculi muscle. Ec-
tropion 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 ster-
ile 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 re-
paired 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 proce-
dures, a partial-thickness incision is made in the lateral
one half of the lower eyelid to separate the skin and or-
bicularis muscle from the tarsoconjunctiva. The inci-
sion follows the natural upward curve of the lower eye-
lid 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 under-
mined. 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 re-
moved centrally from the lower eyelid29 (Figure 13).

ORBICULARIS OCULI MUSCLE ■ CORNEA ■ FOUR-SIDED EXCISION

Small Animal/Exotics Compendium June 2000

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 haired–nonhaired 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 tarsocon-
junctiva near the lateral canthus12 (Figure 14). In both
procedures, a wedge the same size as the tarsoconjuncti-
val resection is excised from the lateral portion of the
skin–orbicularis 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 cen-
tral 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 su-
ture in a simple interrupted pattern. The first suture is
placed at the apex of the skin muscle flap to assure dor-
solateral traction. In a technique introduced by Bistner
and colleagues the split eyelid margin is reconstructed
with simple interrupted nonabsorbable suture apposing
tarsoconjunctiva to the skin–orbicularis flap12 (Figure
14). Methods to repair lateral canthal laxity, such as the
Kuhnt-Szymanowski procedure, will restore more nor-
mal eyelid function and anatomy.

FIGURE-OF-EIGHT SUTURE ■ TARSOCONJUNCTIVA ■ SKIN–ORBICULARIS FLAP

Compendium June 2000
A B
Figure 14—Kuhnt-Szymanowski procedure to correct concur-
rent entropion and ectropion as described by Bistner and col-
leagues.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 ad-
vanced into the lateral facial wound, and excessive skin is re-
moved. (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-Y–plasty or Z-plasty can be used.
A V-to-Y–plasty advances a wider area of tissue than a
Z-plasty—the entire eyelid margin.15 A V-shaped inci-
sion 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 en-
compasses the eyelid margin. The scar tissue is dissect-
ed from below the skin, and the incision is closed in a Y
with a simple interrupted pattern.12,30 A Z-plasty15 pro-
vides 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 com-
ponent flaps are transposed.
CONCLUSION
Because of the variety of eyelid conformational defects
and varying degrees of involvement, entropion and ec-
tropion can be repaired in many ways. Most cases are
best repaired with the least complicated method avail-
able. It is critical to evaluate the unsedated animal with-
out 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 princi-
ples of plastic and reconstructive surgery must be used.
ACKNOWLEDGMENT
All illustrations are by Michael Broussard, Louisiana
State University, Baton Rouge, Louisiana.
KUHNT-SZYMANOWSKI PROCEDURE ■ V-TO-Y–PLASTY ■ Z-PLASTY
Small Animal/Exotics
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Compendium June 2000
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About the Author
When this article was submitted for publication, Dr. Hamil-
ton was affiliated with the Department of Veterinary Clini-
cal 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, Col-
lege 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.