_Third step._ The flap having been raised and all bleeding stopped, it is rotated and sutured in its new position, the wound made by the removal of the flap being brought together by sutures or, if it be too large for this, covered by skin grafts (see Vol. I, p. 670). BY THIERSCH’S SKIN-GRAFTING METHOD =Indications.= As has already been pointed out, this method is not so satisfactory as the method by flaps described above, but it is frequently the only one available when the surrounding skin has been destroyed, as after extensive lupus of the face. =Instruments.= Scalpel, forceps, skin-grafting razor, probes. =Operations.= _First step._ As for the previous operation. _Second step._ Grafts are cut from a situation free from hairs, such as the inner side of the upper arm (see Vol. I, p. 671). _Third step._ After all bleeding has been stopped, the grafts are applied, straightened with probes, and pressed firmly down on to the raw surface. The edges of each graft should slightly overlap the one next to it. Great care should be taken in applying the dressings not to disturb the grafts (see Vol. I, p. 673). If the whole thickness of the skin be used (Wolff’s method), care should be taken to see that the under surface is free from fat. THE REPAIR OF LARGE LOSSES OF SUBSTANCE FROM THE EYELIDS Losses of portions of the lid margins usually result from operations for malignant growths. When the loss is in the _upper lid_, some modified form of Fricke’s operation is the best method of remedying the deformity. When a large area is to be covered, transplantation of a flap from the arm by the Tagliacotian method has to be performed (see Vol. I, p. 679). Fricke’s operation is also applicable to the outer portion of the lower lid. When the inner end of the _lower lid_ is affected, De Vincentiis’ operation yields satisfactory results. When the whole lower lid has been lost, a modified Dieffenbach’s method with the use of the ear cartilage is indicated. =De Vincentiis’ operation.= The operation aims at shifting the remains of the lid bodily inwards to cover the gap left by the removal of the growth. =Instruments.= Scalpel, dissecting forceps, artery forceps, scissors, sutures. =Operation.= _First step._ The portion of the whole thickness of the lid together with the growth is excised by a V-shaped incision (Fig. 159). _Second step._ The outer canthus and orbito-tarsal ligament are divided with the scissors. The incision is then carried outwards and upwards with a scalpel, in a line with the lower margin of the lid, the incision being long enough to free the lower lid sufficiently to slide it inwards and to enable the edges of the V-shaped wound to be united (Fig. 160).