=Dieffenbach’s operation= (modified with the use of ear cartilage). This operation consists in shifting inwards a flap of skin and subcutaneous tissue derived from the outer side of the face to take the place of the eyelid which has been removed, the conjunctiva and tarsal plate being represented by a piece of skin and cartilage taken from the posterior surface of the ear and stitched to the inner surface of the flap. [Illustration: FIG. 159. DE VINCENTIIS’ OPERATION TO REPLACE THE LOSS OF THE INNER PORTION OF THE LOWER LID. Showing the inner portion of the lid removed by a V-shaped incision and the relief incision made outwards from the external canthus.] [Illustration: FIG. 160. DE VINCENTIIS’ OPERATION COMPLETED. The lower lid has been pulled inwards and united to the opposite side of the gap left by the V-shaped incision. The incision outwards from the outer canthus, now much diminished in length, is also sutured.] =Operation.= _First step._ The growth, together with the eyelid, is first removed by a V-shaped incision, the base of the V being formed by the margin of the lower lid. _Second step._ An incision is carried directly outwards from the external canthus. The length of this incision should be 1-1/4 times the length of the lid margin. An incision is then carried downwards from its outer end parallel to the outer limb of the V by which the lower lid has been excised. This flap is then raised freely (Fig. 161). _Third step._ The ear is turned forward and a semilunar portion of the skin is marked out and deepened down to the cartilage. The base of this semilunar portion should be equal in length to the upper margin of the flap that is to form the new lid (Fig. 162). The skin is then dissected up for about 3 millimetres from the crescentic part of the incision back towards the straight one forming the base of the semilune. When this part of the skin has been raised the cartilage is divided, first by a curved incision, 3 millimetres behind that through the skin, and then along the straight incision joining the ends of the curved one. It is separated from the skin on the anterior surface of the ear, and the semilunar piece of skin and cartilage is thus removed. The portion of cartilage removed with the skin is smaller than the latter; the two portions coincide in length along their straight margins, but the depth of the crescent of cartilage is considerably less than that of the skin (Fig. 162). The cartilage is usually too thick to form the new tarsus and must be pared down until the right thickness is obtained. It is then applied to the inner surface of the flap to form the new lid, the skin surface being directed inwards to help to form the lower conjunctival sac. It is fixed firmly by sutures at its margin, which are passed through the whole substance of both flaps, and tied on the outer surface of the new lid.