Hi, I like silicone but Prolene also used with success. Not sure it matters too much. Both are adjustable, reversible, removable and repeatable. There is an argument for autologous fascia lata, but in my opinion, the morbidity in the harvest and the difficulty adjusting, reversing, removing or repeating bias me to the easy materials. Best wishes. Ric

Let's also not forget the direct application of the frontalis muscle. This is great in children. Ric

Yup. Knot, under the skin, knot :). 8.0 vicryl will vanish either way, but looks nice. Best wishes. Ric

Hi Zomorrorod, great question. Distichiasis is very difficult to treat. In the upper lid a full tarsal rotation can be effective, but often regresses even when done dramatically. In the lower lid I've excised and advanced the posterior lamella but again with regression. Electrolysis is an ongoing game but has a place. Bandage contact lens and skilled self epilation with a magnifying mirror can be useful but is lifelong and dull for the patient. The problem is that when you have metaplastic change in the meibomian glands such that they produce lashes removing or destroying the glands still results in severe oil deficiency. I don't have any universal solution but try to take into account where the patient is willing to compromise. If you find a brilliant technique please let me know! Best wishes Ric

@@riccaesar Thanks so much Dr Ric Caeser, What about excision of a strip of the marginal tarsus to remove the distichiatic lashes then suture mucous membrane graft? Will postoperative entropion or lid deformity be an issue? The other option is splitting the anterior and posterior lamellae with applying cryotherapy? I have a case with lid margin keratinization and metaplastic lashes, very large number of distichiatic lashes.

@@zomorrorod7 Hi. Both techniques are worth trying but both can be associated with subsequent cicatricial entropion. Lid split and cryo is probably the safer option to try first. Best wishes Ric

Hi Matt. Canthal suspension alone is indeed limited it its power. It's usually used as an adjunct to lower lid blepharoplasty or to support the lid after other procedures that may generate an ectropic pull. It has a place in functional epiphora, with patent lacrimal drainage but mild lid laxity, but even then can lack adequate power. Best wishes Ric

Hi, my patients' favourites are the hyaluronic acid based tears such as Hyloforte and Thealoz Duo. I've little experience with serum tears. Apologies. Ric

Hi Lucas. It is mandatory to stretch the punctum large enough to hold the posterior ampulla with the forceps. How you stretch it is up to you :). Sometimes I don't have a dilator so then use the vannas scissors to carefully stretch it open. If really closed I sometimes use a green needle. So long as the end result is a removed posterior ampulla and revealed canaliculus you have a 90% chance of success. Best wishes Ric

Hi, I place the sutures adjacent to the canalicular wall in the soft tissue. Mini Monaka easy and painless to remove in clinic. I would have answered that I've never seen one stuck in the canaliculus, but then last week, investigating a patient with epiphora, I found one half way down the canaliculus, causing a blockage. Never say never. Best wishes. Ric

Hi - yes. Sometimes it gets infected and has to be removed, and sometimes it needs to be replaced if it becomes less effective with time, but it is made out of silicone and doesn't dissolve. Best wishes Ric