involutional entropion is a common condition in asian countries , including japan.1 one cause of involutional entropion is weakening of the capsulopalpebral fascia ( cpf).2 the aged , thin , membranous nature of the cpf limits the results of correction by the original jones procedures alone , so we added the modified hotz procedure to the entropion repair .
our modified hotz procedure binds the dermis to the tarsus and corrects the ciliary orientation . to determine the efficiency of the additional hotz procedure , we compared the recurrence rates and operation times in corrections performed with and without this additional procedure .
from april 2010 to december 2011 , one surgeon performed lower - lid surgeries using jones cpf - tightening procedure with the addition of the modified hotz procedure ( ciliary - everted suture ) .
fifteen patients ( six male and nine female ) underwent this combined procedure for a total of 21 eyes ( six right eye only , three left eye only , six both eyes ) . from january 2010 to september 2010 , the same surgeon performed the jones procedure alone on eight patients ( four male and four female ) for nine eyes ( six right eye only , one left eye only , one both eyes ) .
after injection of 1% xylocaine with 0.01% epinephrine , the lower - eyelid skin pinch is cramped .
a horizontal skin incision is made 5 mm below the eyelash line , and the orbicularis under the skin is exposed .
the layer of the orbicularis is identified by 4 - 0 silk - suture traction .
the portion of the orbicularis over the tarsus is removed , and the layer between the orbicularis and the septum - cpf complex is separated . prior to dissection of the posterior cpf layer ,
the cpf complex is cut at tarsal height , and the conjunctiva is visible at the bottom layer of the lower eyelid . between the cpf and conjunctiva , a sparse red tissue layer resembling the mller muscle sometimes exists
this is thought to be the posterior layer of the cpf . without puncturing the conjunctiva ,
next , the orbital fat layer beneath the septum is identified , and the layer is dissected inferiorly approximately 78 mm from the tarsus ( figure 1b ) .
the anterior cpf layer exists just under the fat layer . after the exposure of the anterior layer ,
an advancement of approximately 5 mm ( tarsus - cpf tightening ) is performed with three mattress sutures of 6 - 0 polysorb ( figure 1c and d ) .
after the jones procedure with cpf is completed , the modified hotz procedure ( ciliary - everted suture ) is performed between the tarsus and solid dermis tissue ( figure 1e ) .
the ciliary directions are shown to be corrected after the operation ( figure 1f ) .
figure 2 shows the cpf advancement on the tarsus ( green line ) and the hotz rotation suture ( blue line ) .
the average age of two groups was 76.4 years , with an age range of 6685 years .
the cases in which the jones procedure alone was used ( average age 76.0 years , nine eyes total ) reported three recurrences , which corresponds to a recurrence rate of over 30% at a follow - up duration of at least 6 months .
the recurrent cases required an eyelid margin split or a lateral tarsal split for additional correction .
the cases in which the combination method was used ( average age 76.7 years , 21 eyes total ) reported two cases of complications ( one recurrence and one ectropion ) , which corresponds to a recurrence rate of 5% .
the one instance of recurrence occurred 9 months after surgery and required an eyelid margin split and an additional hotz procedure for correction .
the instance of ectropion presented with severe horizontal laxity before surgery that developed into ectropion 3 months after surgery .
although the direction of the cilia was corrected , this eyelid required a lateral tarsal strip ( lts ) .
the jones procedure used an eyelid pinch and required an average of 22.6 minutes to complete ; the combined method required an average of 33.4 minutes to complete .
the jones procedure was first reported in 1963.3 however , this procedure was not popular in japan until it was disseminated by kakizaki et al.4 the jones procedure tightens the cpf by plication , thus reinforcing the vertical traction power of the lower - lid ligaments
. however , the cpf often presents as a thin and membranous structure in aged patients and is not strong enough to correct the lower - lid direction permanently .
kakizaki recommended an anterior posterior double - layer advancement by means of this weakness.5 another study has reported rates of recurrence of 7%15% after cpf plication.6,7 the jones procedure in our hospital resulted in a higher recurrence rate of 30% , indicating that this an unreliable procedure .
the surgical videos showed that the former case had a slightly thin cpf and the latter one had a slightly thick cpf .
however , the direction of the cilia at the end of the surgeries was not different between these cases .
thus , cpf thickness is not an appropriate tool for making decisions about additional procedures .
the vertical laxity is corrected by the jones procedure , and the horizontal laxity is corrected by the lts.8 however , the lts is not an easy technique , and the operation is painful and bloody .
the wheeler procedure is a more popular technique for horizontal plication of the eyelid orbicularis.9 however , the utility of this procedure is also decreased by the aging process , and the experimental recurrence rate is high.10 moreover , the original jones procedure removes the orbicularis situated over the tarsus and is incompatible with the wheeler procedure .
previous studies , including our own , report recurrence rates of less than 10% in congenital entropion patients.11,12 jones et al introduced a modified procedure 10 years after the establishment of the original technique . his modified method tied skin 
cpf  skin.13 in 1974 , schaefer recommended connecting the lid skin to the tarsus by taking a bite through the lower edge of the skin muscle.14 we selected dermis just under the side of the cilia to tarsus suture , which is a relatively solid tissue - binding site .
this combination method results in a significantly higher success rate than when the jones procedure alone is used .
the p - value was 0.034 , as calculated by the chi - square test for independence .
a 5% recurrence rate is a much more desirable result compared to the 30% recurrence rate resulting from application of the simple procedure .
the additional hotz procedure requires only 10 additional minutes in surgery , making it one of the best choices among the procedures discussed here .
we will now perform this combined procedure for all involutional entropion cases , following a half - year transitional phase . because no technique achieved a zero rate of recurrence , additional steps taken to correct the cases of recurrence are outlined . when the cilia are located too close to the eyelid margin , we perform the margin split procedure . when the lower eyelid exhibits too much laxity and requires horizontal correction to increase its strength , we add lts to the lateral orbital periosteum .
subsequent to this procedure , we perform ciliary electrolysis or the wojno ciliary removal procedure.15 it is essential to have a variety of additional techniques available to correct issues of recurrence in the treatment of entropion .
 purposeinvolutional entropion is a common condition in asian countries , including japan . 
 one cause of involutional entropion is weakening of the capsulopalpebral fascia ( cpf ) . 
 the aged , thin , membranous nature of the cpf limits the results of correction by the original jones procedure ( cpf tightening ) alone , so we added the modified hotz procedure to the entropion repair . 
 we then compared the recurrence rates and operation times in corrections performed with and without this additional procedure.casesfrom april 2010 to december 2011 , one surgeon performed lower - lid surgery using the jones procedure with the addition of the modified hotz procedure . 
 fifteen patients ( a total of 21 eyes ) underwent this combined procedure . 
 previously , the same surgeon performed the jones procedure alone for eight patients ( a total of nine eyes).resultsthe average age of the two groups was 76.4 years , with an age range of 6685 years . 
 all cases reported acceptable ciliary orientation at the end of the surgery . 
 however , patients who underwent the jones procedure alone ( nine eyes total ) reported three cases of recurrence after at least 6 months of follow - up . 
 patients who underwent the combined procedure reported two complications : one recurrence and one ectropion . 
 the recurrence rate was 5% . 
 the jones procedure using eyelid pinch required an average of 22.6 minutes to complete ; the combined method required 33.4 minutes to complete.conclusionthe combined method resulted in a significantly higher success rate than the jones procedure alone ( p < 0.05 ) . 
 the 5% failure rate of the combined method was found to be superior to the 30% recurrence rate of the jones procedure . as a result , 
 the hotz procedure enhanced the results of the entropion correction and required only 10 additional minutes of surgery . 
 we now perform this combined procedure for all cases . 
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