In larger defect of more than 66% of the horizontal dimension. Two methods are commonly used.

Figure 3a

• Cutler-Beard's technique (Figure 3b): In the first stage, the flap is designed 4 to 5 mm below the lid margin (so that marginal artery is kept in the bridging flap) and advanced upward and sutured to the defect. After 6 to 8 weeks, the second stage involves dividing the flap and rotates the conjunctiva over the reconstructed upper lid to prevent skin from coming into contact with the eye.

Figure 3b. Cutler-Beard's technique. The  red line represents the marginal artery.

• Mustarde total lid switch. This is similar to the lid switch technique mentioned in the previous chapter. Except that the flap is bigger and the reconstruction fo the lower lid requires a cheek rotation flap. The operation is carried out in two stages: the first stage 

is the lid rotation and after about two weeks, the base of the pedicle is divided and the 
lower lid is repaired with a cheek rotation flap.

Figure 3c. Total lid switch with cheek rotation flap. The first stage  involves lid rotation. To increase the success, the flap should include the marginal artery (represented by the red line in the flap).

Figure 3d.