_Third step._ The cut margin of the tarsal plate is sutured to the levator palpebræ and palpebral ligament by two sutures passed in the following manner: A thick catgut suture armed with a curved needle is passed through the upper cut margin of the orbicularis palpebrarum, palpebral ligament, and levator palpebræ (if the latter be present) at about the junction of the middle and inner thirds of the wound, a firm hold being taken on these structures. The needle is then passed through the tarsal cartilage parallel to the lid border for a distance of about 3 millimetres and out again on to its anterior surface. The needle is then again carried through the levator palpebræ, palpebral ligament, and orbicularis in the upper part of the wound. A similar suture is passed about the junction of the middle and outer thirds of the wound. When both sutures are in position they are tied sufficiently tightly to produce the retraction of the lid desired, slight over-correction being necessary. The skin wound is then closed with sutures. ATTACHMENT OF THE LID TO THE OCCIPITO-FRONTALIS MUSCLE There are three chief methods of affecting this attachment:-- (_a_) By cicatricial bands (_e.g._ Hess’s operation). (_b_) By a suture left permanently in position (_e.g._ Harman’s operation). (_c_) By the attachment of the skin of the lid to the muscle (_e.g._ Panas’ operation). =Indications.= In the majority of the cases of congenital ptosis the levator palpebræ is completely absent, as shown by the want of upward movement in the lid, and it is for this condition that one of the operations of this type is performed. In rare cases the occipito-frontalis muscle is also absent or imperfectly developed, and in these cases these operations should not be undertaken. =Hess’s operation.= The object of this operation is to insert silk stitches between the eyelid and the occipito-frontalis muscle, and to leave them in long enough for a fibrous band of union to form along the stitch tracks. =Instruments.= Scalpel, dissecting forceps, needle and holder, spatula, artery forceps. =Operation.= _First step._ The eyebrow having been shaved, an incision 2 inches long is made about in the line of the brow, and the skin is dissected down almost to the lid margin.