_Second step._ A V-shaped portion is removed from the margin of the lower lid near the outer canthus, the base of the V being of sufficient length to produce the shortening of the lid required when the edges of the incision are brought together. _Third step._ The strap of skin is pulled upwards to the extent required to replace the lid in position, and sutured there. The raw area must be enlarged upwards so as to accommodate the upper end of the strap. It is better to do this than to shorten the strap, since a firm hold is thus obtained (Fig. 153). OPERATIONS FOR THE ACTIVE OR CICATRICIAL FORM OF ECTROPION The numerous operations which have been devised for this condition are divided into two groups: (1) the transplantation of flaps in the neighbourhood of the lesion, and (2) the grafting of skin flaps from other parts of the body. The latter method is usually only undertaken when the employment of flaps from the neighbourhood of the deformity is impossible, as the cicatricial contraction which follows the grafting of flaps from other parts of the body is usually attended by considerable shrinkage and therefore does not yield such satisfactory results. [Illustration: FIG. 154. VY OPERATION FOR ECTROPION OF THE LOWER LID DUE TO A SCAR. _First step._ Showing incision.] [Illustration: FIG. 155. VY OPERATION FOR ECTROPION. _Final step._ Showing the lid in position.] BY THE TRANSPLANTATION OF FLAPS =VY operation= (Wharton Jones). =Indications.= This operation is useful for cases of ectropion affecting the middle parts of the lower lid, generally due to a scar such as would result from a healed sinus after tuberculous periostitis of the lower orbital margin. =Instruments.= Dissecting forceps, scalpel, artery forceps, sutures. =Operation.= The operation is performed under a general anæsthetic. A V-shaped incision, with the apex downwards, is made to embrace the whole margin of the lower lid. The upper ends of the V should skirt the outer and inner canthus and roughly lie over the lower orbital margin, enclosing the scar, the apex of the V falling rather below the orbit. The incision should include the skin and subcutaneous tissue. The V-shaped flap is dissected up and the lid liberated from the underlying scar tissue. The incision is then sewn up in the form of a Y (Fig. 155). Temporary tarsorrhaphy (see p. 266) is always desirable. Subsequent shortening of the lid margin by the Argyll Robertson method is sometimes necessary. =Denonvillier’s operation.= This procedure is useful to remedy an ectropion of the outer portion of the lower lid by the transposition of flaps at the outer canthus. [Illustration: FIG. 156. DENONVILLIER’S OPERATION FOR ECTROPION OF THE LOWER LID. By reversed flaps at the outer angle. _First step._ The flap B C D is brought down to form the outer part of lower lid.] [Illustration: FIG. 157. DENONVILLIER’S OPERATION FOR ECTROPION. Showing the operation completed after transposition of the flaps.]