Nidhi Pandey1, Anuradha Jayaprakasam2, Ilan Feldman3, Raman Malhotra3. 1. Department of Orbit and Oculoplasty, Indira Gandhi Eye Hospital, Lucknow, Uttar Pradesh, India; Department of Corneo Plastics, Queen Victoria Hospital, East Grinstead, Surrey, United Kingdom. 2. Department of Corneo Plastics, Queen Victoria Hospital, East Grinstead; Department of Ophthalmology, Frimley Park Hospital, Surrey, United Kingdom. 3. Department of Corneo Plastics, Queen Victoria Hospital, East Grinstead, Surrey, United Kingdom.
Sir,We thank the authors[1] for taking the time to read our paper[2] and for their valuable observations. The authors suggest a skin-crease approach which improves navigation to the lid margin. We would agree that for inexperienced surgeons, a combined approach improves accuracy. However, this technique is an option for more experienced surgeons interested in avoiding a skin incision. In our experience, accurate dissection at the lid margin can only be initiated with accurate placement of a lid margin incision. Approaching the lid margin purely through a skin crease leads to inadvertent exit through the skin or tarsus. With more experience, once past the lid margin, lamella dissection can be easily continued purely through a lid margin approach, thus avoiding a skin-crease incision. This approach is mainly indicated for cicatricial margin entropion. In such cicatricial cases, we would question the rationale for performing concurrent blepharoplasty as mild/moderate dermatochalasis would have no consequence to the outcome of correcting cicatricial margin malposition. This approach is obviously inappropriate for cases with severe dermatochalasis, and we specifically excluded cases from this series who required a concurrent blepharoplasty. We agree that the case with dermatochalasis in your report would perhaps benefit from a small concurrent blepharoplasty, and therefore, a skin-crease incision would provide further exposure.[34] A skin-crease reformation, if required, is not necessarily an indication for a skin-crease incision. This can easily be performed without a skin-crease incision in a “closed” manner by simply passing double-armed sutures from the aponeurosis through to the skin crease.We presented our series purely to remind readers that septum release and levator recession can be performed through a grey - line approach, where a blepharoplasty is not planned.