In such case, however, it is best to provide mucous-membrane grafts from the lip of the patient to overcome the loss of conjunctiva (Wolfer).
Because of the splendid success obtained with temporal flaps it is better to follow the method of Fricke in the above operation, changing the shape of the flap to suit the form of the defect to be covered.
Tripier Method.—For the restoration of an entire lid the method of Tripier is to be advocated. A bridge flap with both ends attached is taken from the healthy eyelid ([Fig. 101]). It is obtained by making the curved inferior incision in a line with the superior border of the tarsal cartilage, and the superior incision parallel to the first at a distance depending upon the size of the defect to be covered. The flap thus formed should include some of the fibers of the orbicularis muscles detached from the tarsal cartilage, making it really musculo-cutaneous.
Fig. 101. Fig. 102. Fig. 103.
Tripier Method.
This bridge or musculo-cutaneous flap, attached at both ends, is then gently drawn forward with a tenaculum and slid downward over the upper lid upon the defect of the lower lid, and there retained by interrupted silk sutures ([Fig. 102]), the superior margin of the bridge flap being sutured to the conjunctival fold freed by the previous extirpation of the lower lid.
The retention of the fibers of the orbicularis palpebrarum in the flap covering the defects is intended to take the place of the part of muscle destroyed by the incision of the faulty tissue in the lower lid, and enables the patient to open and close the lid almost as well as in the normal state.
The margins of the wound made by the removal of the flap are snugly brought together and heal without the least discomfort to the patient, inasmuch as the skin covering the lid is quite loose and elastic ([Fig. 103]).