Robin Sankey North Houston Veterinary Ophthalmology, Spring, TX, USA The eyelids are very important for ocular health and have many important functions, including protection of the globe, entrapment and removal of corneal and conjunctival debris, distribution of the tear film, and the production of glandular secretions that prevent the tear film from prematurely evaporating.1 The upper and lower eyelids are lined by 30–40 small openings of the meibomian gland, which are not only important because they secrete the outer oily layer of the tear film but are also an important landmark used to ensure proper apposition of the eyelid following mass removal (Figure 2.1). The meibomian glands form the “gray line” along the eyelid margin. Histologically, the eyelids consist of four parts. The outermost layer is continuous with the adjacent skin. The orbicularis oculi muscle layer is just deep to the skin, followed internally by a tarsal plate and stromal layer, and the innermost layer, the palpebral conjunctiva.2 The tarsal plate is formed of fibrous connective tissue and gives the eyelid its structure. The palpebral conjunctiva refers to the conjunctiva that lines the eyelids, whereas the bulbar conjunctiva is the conjunctiva that covers the globe (or eyeball). There are many reasons eyelid masses should be removed, including suspected or confirmed neoplasia, local or corneal irritation or ulceration, or growth of the mass that may interfere with a straightforward removal in the future. In dogs, eyelid tumors are very common, but most are benign. However, if a mass is severely ulcerated, excessively large, or appears highly invasive, then a presurgical biopsy is recommended. Eyelid tumors are much less common in cats and are more likely to be malignant. Up to 91% of eyelid tumors in cats are malignant, so biopsy or a fine needle aspirate is recommended for cats with eyelid tumors so a surgical plan can be formulated before full‐thickness surgical excision.3 The high rate of malignancy in cats is compared with that in dogs, where 92.4% of eyelid masses were benign.4 Figure 2.1 One of the many meibomian gland openings indicated by the yellow arrow used as a guide for suture placement with eyelid reconstruction. Source: © Robin Sankey. There are multiple methods in the literature utilized for eyelid mass removal including, hyperthermic therapy, carbon dioxide laser therapy, radiation therapy, chemotherapy, immunotherapy, and photodynamic therapy, in addition to the surgical techniques discussed in this chapter. However, these methods often require expensive equipment and have not proven to offer better results than surgical methods.5 Two main surgical techniques for removing eyelid masses affecting less than one‐third of the eyelid margin are a V‐shaped blepharoplasty and a pentagonal (house‐shaped) blepharoplasty. According to current literature, as long as the excised portion of the eyelid margin does not exceed 1/4–1/3 of the affected eyelid length, it can be removed by one of these techniques.5 If a mass approaches one‐third or more of the eyelid margin, it is better to consider referral to an ophthalmologist for a grafting procedure that will prevent excessive shortening of the eyelid margin length. Many grafting techniques are described, but that is beyond the scope of this chapter. This technique is very straightforward to perform for masses that affect less than one‐third of the eyelid margin. General anesthesia is typically needed, and the patient is prepped by clipping the hair from the surgical area and cleaning the area with a dilute betadine solution. A 1:50 solution is prepared by diluting betadine solution with a sterile fluid, such as 0.9% sodium chloride or sterile water. Avoid the use of betadine scrub, chlorhexidine, or agents containing alcohol, as these products cause corneal injury.6 A small amount (0.1–0.3 mL) of local anesthetic, such as lidocaine, bupivacaine, or ropivacaine, injected subdermally around the mass to be excised allows the patient to be maintained under a lighter plane of anesthesia. Figure 2.2 Two instruments used to stabilize the eyelid margin during mass excision. (a) Jaeger eyelid plate; (b) chalazion clamp. Source: © Robin Sankey. A Jaeger Eyelid Plate or chalazion clamp is used to stabilize the eyelid margin (Figure 2.2), while calipers are used to measure the length of the eyelid margin that will be removed, which is most easily done while the eyelid is stabilized. The height of the excision should be twice that of the length of the eyelid margin to be excised. This can be marked using a sterile surgical marker, or a mental note can be made based on the measurement. Next, while holding the eyelid taut over the eyelid plate or within the chalazion clamp, a half‐thickness skin incision is made with a surgical blade (usually a #15 Bard‐Parker blade, a #64 Beaver blade, or a #69 Beaver blade) in the shape of a V, which is inverted for the removal of upper eyelid masses. Remember, the height of the V should be twice that of the length of the eyelid margin to be removed. This is important to prevent puckering of the skin when the incision is closed. For example, if the length of the area of the eyelid margin to be removed is 4 mm, then the height of the incision would be 8 mm (Figure 2.3). As long as the eyelid mass is expected to be benign, 0.5–1 mm of the eyelid should be removed on either side of the mass. After the partial‐thickness cut has been made using the blade, the lid plate or chalazion clamp is removed, the eyelid is stabilized with forceps, and scissors are used to create the full‐thickness incision of the incised area. Steven’s tenotomy scissors or delicate Metzenbaum scissors are ideal for this step. There are a few ways to effectively close the defect. The most effective way to close the eyelid margin is with a figure‐of‐8 suture, which is named because it is shaped like the number eight. The eyelid margin is closed first with a figure‐of‐8 suture leaving the suture tails long (Figure 2.4). This is where the gray line of the meibomian glands can be very useful. Use the meibomian gland openings to guide the placement of the suture evenly across the eyelid margin on both sides of the defect. The suture is passed through a meibomian gland opening, and the meibomian gland openings are used to confirm equidistant suture placement on both sides of the incision (Figure 2.5
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Steps for Simple Eyelid Mass Removal
Function and Anatomy
Indications
Techniques
V‐Lid Blepharoplasty
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