If lid retraction is more severe the posterior lamella may need to be lengthened with a graft. Hard palate mucosa (Figure 4.8) is preferable as it is stiffer than labial or buccal mucosa and is wettable. Nasal septal cartilage with its mucoperichondrium is an alternative. The upper tarsus can be incised transversely and the graft inserted between the cut edges as for a lower lid cicitricial entropion repair. The terminal tarsus usually needs to be
rotated away from the globe. Any keratinised epithelium in contact with the cornea should be excised.
Ear cartilage (Figure 4.9) is not good as a posterior lamella graft in the upper lid as it causes corneal irritation if it is not covered by conjunctiva or mucosa. Its main use in upper
lid entropion surgery is as a sandwich graft to stiffen the reconstructed lid which has, for instance, been made up from skin and mucosa. The insertion of the ear cartilage between these two lamellae will allow the lid margin to be everted satisfactorily.
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