_Third step._ A semilunar piece of skin is then removed by a curved incision above the last, joining it at the outer and inner ends, and the band carrying the lashes is stitched to the upper margin of this incision; the line of the incision along the intermarginal zone behind the lashes is allowed to heal by granulation. The subsequent contraction caused thereby pulls down the band carrying the lashes to a certain extent. It is, therefore, desirable to pull the band of lashes upwards at the time of operation to a greater extent than is required for the final result in order to overcome this tendency for the condition to re-form as a result of cicatricial contraction of the granulating area. In order to obviate the cicatricial contraction some surgeons cover the area with a graft of mucous membrane. ECTROPION OPERATIONS Ectropion may affect the upper lid, but it occurs far more frequently in the lower. Operations undertaken for its relief vary very considerably for the following reasons:-- 1. _The cause of the ectropion._ The active or cicatricial form requires different and more extensive operations than the passive form, such as occurs after facial paralysis, senile ectropion, or that occurring after blepharitis. 2. _The degree of ectropion_, whether it is partial, affecting merely the lid margin; or complete, affecting the whole lid. Ectropion of the lower lid is always accompanied by epiphora, owing to the want of application of the canaliculus to the lacus lachrymalis. The canaliculus is also apt to become obliterated as the result of marginal blepharitis. Before undertaking any of the operations described below this condition must be remedied, either by dilating the canaliculus or by slitting it inwards for a short distance (see p. 290), otherwise, even if the operation be successful in restoring the deformity, the overflow of tears causes the patient to pull down the lower lid constantly in wiping them away, and this tends to reproduce the condition. After many of the operations a temporary tarsorrhaphy is required to keep the lid in position during the process of cicatrization. The temporary bands produced by this operation are so placed on either side of the cornea as not to interfere with vision altogether. Canthorrhaphy is also desirable in some cases, especially when the ectropion affects the outer end of the lid.