How to Repair a Large Upper Eyelid Defect Witha Modified Tenzel Rotational Flap in the Field

Sarah Kuhlo, DVM; Matt Povlovich, DVM†; Nathaniel Wright, DVM;Matthew DeLisle, DVM; and Liberty Getman, DVM, Diplomate ACVS*

Authors’ address: Tennessee Equine Hospital, PO Box 189, Thompson’s Station, TN 37179; e-mail:libertygetman@gmail.com. *Corresponding author; †Presenting author. © 2012 AAEP.

1. Introduction

Eyelid defects are commonly encountered in equinepractice and may often be repaired under standingsedation and local anesthesia, with satisfactory re-sults. Larger defects (traumatic or iatrogenic) aremuch more challenging and are more difficult torepair with standard closure techniques. Smallerdefects and lacerations can be closed using a simpleinterrupted or simple continuous pattern. Forsmall areas requiring eyelid reconstruction, a Y-to-Vor a V-to-Y correction technique can be used.1 Formore extensive defects, or if more than one third ofthe eyelid margin has been damaged or needs recon-struction, a blepharoplasty is indicated.2 Facialskin tends to be inelastic and may not stretch ade-quately to cover a defect of the eyelid without theuse of a flap. Many techniques have been describedfor blepharoplasty, including sliding skin flaps, con-junctival advancement flaps, full-thickness eyelidgrafts, rhomboid graft flaps, and sliding Z flaps.1

General anesthesia is recommended in these cases ifmore than 50% of the eyelid has been damaged or ifenucleation or exenteration is going to be performedas part of the procedure.2 If eyelid function hasbeen compromised, a third eyelid flap or temporary

tarsorrhaphy may also be required to protect theglobe from further trauma.

To the authors’ knowledge, there are no reports ofan effective and economic option for repair of mod-erate-sized defects of the upper lid that can be per-formed in the field.

The Tenzel rotational flap is a commonly utilizedprocedure in human ophthalmic surgery for the re-pair of large rectangular defects of the upper lid.3–5

We describe a modification of this technique used bythe authors in a horse that sustained a large trau-matic eyelid defect. This technique allows the sur-geon equipped with basic surgical equipment andskills to restore a functional and cosmetically accept-able eyelid margin in the field after traumatic injuryor surgical resection of a mass of the upper lid.

2. Materials and Methods

Equipment

Basic surgical equipment and a selection of absorb-able and nonabsorbable suture materials should beavailable. In our practice, this procedure is per-formed under field anesthesia using xylazine,a ket-amine,b and “triple drip” (guafenisinc 50 g, xylazine500g, and ketamine 1 g).

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ProcedureAn iatrogenic defect may be repaired at the time ofthe partial lid resection. Traumatic defects may beclosed primarily, or, as in the case pictured (Fig. 1),may be repaired as a delayed primary closure after aseveral-day period of antimicrobial therapy andgranulation tissue growth.

The modified Tenzel rotational flap is performedas follows:

(1) The horse is anesthetized with xylazine (1.1mg/kg IV) and ketamine (2.2 mg/kg IV) and is placedin lateral recumbency. Anesthesia is then main-tained with triple-drip IV to effect.

(2) The affected eye is lubricated with triple anti-biotic ophthalmic ointmentd and the surroundingarea is clipped and aseptically prepared for surgerywith dilute povidone iodine solution and irrigationsaline.

(3) The upper lid is anesthetized by performingsupraorbital sensory and auriculopalpebral motornerve blocks with lidocainee 2%. The cornea is top-ically anesthetized with proparacainef 0.5%solution.

(4) A 3-inch curvilinear incision is made throughthe skin, beginning at the lateral canthus, curvingventrally, and finally toward the base of the ear,paying special attention to the location of the lacri-mal nerve as it courses over the orbital rim just deepto this incision.

(5) This skin flap is undermined bluntly from thesubcutaneous tissue, and the lid portion is carefullyseparated from the underlying palpebral conjunc-tiva to allow the flap maximum mobility. At thistime, the lateral canthal ligament is also transectedto provide additional mobility to the flap.

(6) If performing a delayed primary repair, therectangular lid defect is “freshened” and the defect isextended dorsally with two 2-cm diagonal incisionsforming an inverse V-shape to decrease the forma-tion of a “dog-ear.”

(7) The first suture is placed to form a new lateralcanthal ligament. This is a simple interrupted su-ture of 0 polydioxanoneg placed through the orbitalperiosteum entering dorsally in the periosteum atthe lateral orbital rim and exiting ventrally.

(8) The skin flap is rotated axially until the defectis covered satisfactorily. The defect in the upper lidis temporarily apposed with a simple interruptedstay suture using 1–0 supramidh to relieve tensionwhile the repair is being performed. The repairthen begins in the tarso-conjunctival layer at thenew eyelid margin junction with 4–0 polyglactin910i in a buried figure-8 pattern. Once the marginis repaired, the remainder of the defect is closed intwo layers in a simple continuous pattern using 0polygalactin 910. Alternately, a two-layer closureusing simple interrupted patterns with absorbable2–0 suture material could be performed if more pre-

Fig. 1. A, Incision (dotted line) made to excise scar tissue on the eyelid and create the rotational flap. B, Stay sutures in place; singlesimple interrupted suture used to recreate the lateral canthal ligament. C, Closure of the newly created eyelid. D, Closure of thedonor site.

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cise “sculpting” is required. After this, the staysuture is removed. It is important to ensure thatnone of the sutures in this layer are placed deeplyenough to penetrate the conjunctiva and rub thecornea.

(9) The portion of the skin flap now forming thelateral canthus is apposed to the freed portion ofpalpebral conjunctiva with a subcutaneous patternbeginning at the lateral canthus and moving towardthe center of the eye with 4–0 polyglactin 910.

(10) The curvilinear skin incision is then closedusing a simple continuous pattern with 1–0 supra-mid beginning at the new lateral canthus and pro-ceeding toward the base of the ear.

Postoperative CareAfter surgery, the cornea is treated twice daily withtopical triple antibiotic ophthalmic ointment. Sys-temic treatment with oral trimethoprim sulfame-thoxazolej (25 mg/kg, q 12 hours, PO, for 14 days)and flunixin megluminek (1.1 mg/kg, q 24 hours, POfor 7 days) is initiated. The cornea should be ex-amined frequently and stained if indicated to ensurethat no ulcerations have occurred. The sutures areremoved at 10 days after surgery.

3. Results and Discussion

The Tenzel rotational flap procedure is frequentlyutilized in human surgery for repair of large uppereyelid defects.3–5 In our practice, this procedurehas been performed once in a young Quarter Horsemare with a large (3 cm) rectangular defect in theupper lid (Fig. 2). This mare recovered unevent-fully, did not have any complications, and the defecthas completely healed (Fig. 3). The upper lid has avery small notch noticeable only on close examina-tion, but the mare has full function of her uppereyelid. Follow-up examinations—most recently at21⁄2 years after surgery—have revealed no complica-tions due to corneal exposure, and the incisions haveall healed nicely. Potential complications after per-forming this technique include exposure keratitis ifthe newly formed “eyelid” does not allow for com-

plete closure of the eyelids and corneal microtraumaor irritation from trichiasis if the hair from the flapimpinges on the cornea. However, these are alsopotential complications for horses with large eyeliddefects due to trauma or masses, and careful dissec-tion and placement of the flap should minimizethese risks. This unique technique allows the sur-geon to have another option for repairing large de-fects of the upper eyelid in the field. The use of fieldanesthesia to restore the function of the upper eyelidaffordably is an advantage of this modified Tenzelrotational flap procedure. Depending on the levelof experience and comfort of the surgeon performingthis procedure for the first time, this technique maybe slightly difficult but is not impossible to perform.Because there is a steep learning curve for thisprocedure, we recommend practicing on a cadaverbefore attempting this technique. Although notdone in this case, it might be possible to perform thissurgery with the horse standing under sedation andlocal anesthesia, especially if the clinician is experi-

Fig. 2. Repair of a large upper eyelid defect using a modified Tenzel technique. Original defect, during surgical closure, andresultant repair (left to right).

Fig. 3. Photograph of the eyelid 21⁄2 years after the repair wasperformed.

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enced in this surgical technique. The main advan-tage of this procedure is that it allows the surgeonequipped with basic surgical equipment and skills torepair large upper eyelid defects—either due totraumatic injury or after surgical resection of amass—in the field, with a functional and cosmeti-cally acceptable outcome.

References and Footnotes1. Miller TR. Eyelids. In: Auer JA, Stick JA, editors. Equine

Surgery. 3rd Edition. St Louis: Elsevier Inc; 2006:704–713.2. Brooks DE. Complications of ophthalmic surgery. Vet Clin

Equine 2009;24:697–734.3. Kim HS, Kim JW, Yu DS. Semicircular (Tenzel) flap for

malignant melanoma involving the palpebral conjunctiva andskin of an eyelid. J Eur Acad Dermatol Venereol 2008;22:102–103.

4. Gunduz K, Demirel S, Gunlap I, et al. Surgical approaches

used in the reconstruction of the eyelids after excision ofmalignant tumors. Ann Ophthalmol 2006;38:207–212.

5. Levine MR, Buckman G. Semicircular flap revisited.Arch Ophthalmol 1986;104:915–917.

aXylazine, IVS Animal Health, Inc, St Joseph, MO 64503.bKetaset, Fort Dodge Animal Health, Fort Dodge, IA 50501.cGuaifenesin, Rood and Riddle Veterinary Pharmacy, Lexing-

ton, KY 40511.dTriple antibiotic ophthalmic ointment, Fougera Pharmaceuti-

cals Inc, Melville, NY 11747.eLidocaine, Sparhawk Laboratories Inc, Lenexa, KS 66215.fProparacaine hydrochloride, Falcon Pharmaceuticals, Ltd,

Fort Worth, TX 76134.gPDS, Ethicon, Brunswick, NJ 08901.hSupramid, S. Johnson, Inc, Alexandria, VA 22303.iVicryl, Ethicon, Brunswick, NJ 08901.j Sulfamethoxazole trimethoprim, MWI Veterinary Supply,

Boise, ID 83705.kBanamine, MWI Veterinary Supply, Boise, ID 83705.

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