_First step._ An incision, 2 inches long, is made in the line of the brow, and an incision of a similar length is made into the skin of the lid about half an inch below it. The tissue between these two incisions is undermined so as to produce a band of skin and subcutaneous tissue. From the ends of the lower wound vertical incisions are made into the lid, running slightly outwards and inwards respectively towards the outer and inner canthus (Fig. 141). [Illustration: FIG. 141. PTOSIS OPERATION. PANAS’.] _Second step._ The flap, C (Fig. 141), thus produced is raised, and doubly armed sutures, D D, are passed through its upper margin and are carried beneath the band of skin and subcutaneous tissue. The needles are then carried deeply beneath the upper margin of the wound A into the substance of the occipito-frontalis muscle and brought out on to the forehead. Outer and inner sutures, E E, are passed deeply into the substance of the tarsus both ends are then passed beneath the band and brought through into the upper wound, whence they are passed beneath the upper margin of the wound into the occipito-frontalis muscle and are tied over a piece of drainage tube. They hold the lid in position during the process of cicatrization. Considerable over-correction should be employed as the lid tends to drop subsequently. No dressings should be applied over the open palpebral aperture. The stitches are removed on the tenth day. A small depression is usually seen where the skin of the lid passes beneath the band. ADVANCEMENT OF THE LEVATOR PALPEBRÆ MUSCLE This is especially suitable for cases in which the levator palpebræ has some power, that is to say, when there is some movement of the lid present. It is also suitable for cases of traumatic and paralytic origin. The movement of the lid by the levator palpebræ is best estimated by eliminating the action of the occipito-frontalis by holding down the brow and asking the patient to raise the lid. [Illustration: FIG. 142. PTOSIS OPERATION. ADVANCEMENT OF THE LEVATOR PALPEBRÆ. Showing the suture passed through the tendon; the difficulty of the operation is to find it. (_Diagrammatic._)] =Instruments.= Lid spatula, knife, forceps, scissors, sutures. =Operation.= Under a general anæsthetic. _First step._ A spatula is inserted into the upper conjunctival fornix. An incision is made just below the eyebrow over the upper margin of the tarsal plate throughout its length. The skin, especially of the lower margin of the wound, is dissected up and the orbicularis muscle divided, the tarsal plate, with the superior palpebral ligament attached to it, and the orbital margin being exposed. The superior palpebral ligament is then divided carefully high up near the orbital margin and directly below, in a small quantity of fat, will be found the tendon of the levator palpebræ superioris. The tendon can usually be distinguished from the palpebral ligament by the fact that it is elastic when pulled on.