since the 19 century , different types of lid margin rotation have been used to correct the upper eyelid cicatricial entropion.1 anterior approach procedures are typically performed with a through - and - through incision placed 4 mm from the lash line .
variations of this procedure have been described by green , pannas , hotz12 and recently by wies3 and ballen.4 the world health organization has renamed the wies / ballen procedure  bilamellar lid margin rotation  and recommended it as standard modality to correct trachomatous cicatricial entropion.5 trabut6 in 1949 was , likely , the first to use a different approach to manage cicatricial entropion .
a conjunctival incision is used to divide the tarsal plate into two fragments . after creating a plane between the orbicularis and both tarsal fragments ,
the distal tarsus is advanced over the marginal tarsal fragment with sutures exiting on the lash line .
this simple procedure creates a downward vector on the marginal portion of the tarsus , which rotates the margin upward .
neither of these two basic lid margin rotation procedures addresses other common lid problems such as dermatochalasis , retraction , or ptosis . in this study
, we use a lid crease incision to combine both basic mechanisms of lid margin rotation and if necessary , to concomitantly correct a variety of lid abnormalities .
if desired , a standard blepharoplasty skin or skin + muscle resection can be outlined the lid is then infiltrated with a local anesthetic solution and a 4 - 0 silk traction suture is inserted through the tarsal edge of the lid margin .
a pretarsal skin muscle flap is raised exposing the whole tarsal plate to the level of the lash roots [ figure 1a ] .
the lid is everted over a cotton - tipped applicator with care to place the applicator under and not over the skin - muscle flap . using a number 15 bard - parker scalpel blade and westcott scissors
, a curved incision parallel to the lid margin is performed through the full thickness of the tarsus 3 mm posteriorly to the margin [ figure 1b ] .
three double - armed 6 - 0 polyglactin ( vicryl ) sutures are then passed through half thickness of the central , medial , and lateral aspects of the distal cut edge of tarsus [ figure 1c ] and attached to the orbicularis near the lash line [ figure 1d ] .
the noncentral sutures should be placed in a radial fashion similar to corneal transplant stitches .
as the sutures are tied , the distal portion of the tarsus is advanced over the marginal tarsus [ figure 1e ] , and the marginal orbicularis is pushed backward rotating outward both lamellae of the lid margin [ figure 1f ] .
if necessary , the levator aponeurosis can be recessed or advanced to correct any retraction or ptosis .
main surgical steps of the lid crease approach to upper lid margin rotation : ( a ) using a standard blepharoplasty incision a pretarsal skin - muscle flap is raised exposing the whole tarsal flap until the lash roots are visualized , ( b ) tarsotomy is performed with a conjunctival incision 34 mm from the lid margin , ( c ) a 6 - 0 vycril suture is inserted first through the distal segment of the tarsus , ( d ) the suture is passed on the orbicularis muscle close to the lash roots , ( e ) as the suture is tied the distal tarsal fragments is slightly advanced over the marginal tarsus and traction is exerted on the orbicularis , ( f ) final aspect of the lid rotation
we have used the lid crease approach to manage trachomatous cicatricial entropion at the king khaled eye specialist hospital on a regular basis .
we have treated 60 upper lids of 40 patients ( 23 females and 17 males ) with a mean age of 70.9  13.01 years .
the follow - up ranged from 1 to 12 months ( mean 3.0 months  2.71 ) .
forty percent of the patients ( 24 lids ) had > 3 months of follow - up .
trichiasis was corrected in all but one lid , with two inward lashes touching the cornea medially despite adequate margin position .
this patient had cicatricial entropion , trichiasis , and a loose pretarsal anterior lamella with no clear lid crease preoperatively [ figure 2 ] .
it should be noted that the lid crease approach is not new but has been largely overlooked . in a pioneering article sadiq and
pai7 documented their approach of combining the traditional lid margin rotation with a blepharoplasty incision .
we believe that the technique we have described has several advantages compared to the classic wies / ballen surgery.34 first , the anterior lamella incision is not on the same level as the tarsotomy . with this approach , the vascularization of the marginal portion of the orbicularis is not compromised , and the chances of ischemia and necrosis of the margin are significantly reduced .
second , as the tarsal plate is completely exposed , it is easy for the surgeon to distribute the forces of the sutures arranging the lateral and medial stitches radially .
it is well known that one of the most common complications of lid margin rotation is contour abnormality.8 as recommended in the manual of the so - called bilamellar lid rotation ( wies / ballen surgery ) published by the world health organization , the anterior lamella incision follows a straight line.5 in this setting , the external sutures tends to be parallel and not radially distorting the central portion of the margin .
as the marginal orbicularis is completely dissected up to the lash follicles and the distal tarsal fragment is advanced over the marginal , a downward vector moves the edge of the marginal tarsus downward , which rotates the margin upward .
finally , incising the anterior lamella on the lid crease position allows the surgeon to address a variety of common lid problems such as aponeurotic ptosis , lid retraction , laxity of the pretarsal lamella , dermatochalasis , and so on .
 lid margin rotational procedures have been used to correct cicatricial trachomatous entropion since the 19th century . 
 there are two basic types of surgeries used for lid margin rotation . 
 the first type is based on through - and - through approach combining tarsotomy and the use of sutures on the anterior lamella . 
 the second type of surgery was suggested by trabut , who proposed a tarsal advancement by posterior approach . 
 we demonstrate that using a lid crease incision combines the basic mechanisms of the anterior and posterior approaches and in addition , addresses a variety of lid problems commonly found in the aged population with cicatricial entropion . 
 after tarsal plate exposure , a tarsotomy through conjunctiva is performed as described by trabut . 
 then , instead of using external sutures secured by bolsters , internal absorbable sutures can be used to simultaneously advance the distal tarsal fragment and exert strong tension on the marginal orbicularis muscle . 
 sixty lids of 40 patients underwent surgery with a lid crease incision . 
 the follow - up ranged from 1 to 12 months ( mean 3.0 months  2.71 ) . 
 forty percent of the patients ( 24 lids ) had more than 3 months of follow - up . 
 adequate margin rotation was achieved in all lids but one that showed a medial eyelash touching the cornea . 
INTRODUCTION
SURGICAL TECHNIQUE
RESULTS
DISCUSSION
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