I would like to thank Dr Mehta and his colleagues for their article ‘Management of Mersilene mesh chronic eyelid complications: a systematic approach’ published in the June 2004 issue.1

I have been using Mersilene mesh in eyelid surgery since 1993 and I would like to make two comments:

First: The authors mentioned some ‘steps to minimize Mersilene mesh complications’. These included cutting the mesh 5 mm wide or less, eyelid skin crease stab incision closure, burying the mesh knot well beneath the frontalis muscle, and a postoperative course of systemic antibiotics.

Based on our experience, I would like to add one more step that is very important. The mesh should not touch the eyelid and/or brow skin while being inserted, I believe that the main cause of infection or granuloma formation is the introduction of organisms with the mesh while its being dragged and threaded inside the lid tissues. To avoid that, I first cover the whole area of the lid and brow with ‘steri- drape’ (3 M Health Care, MN, USA). Through the sterile drape, I make the stab wounds in the lids and brow. I insert the mesh in a double triangle fashion leaving the ends protruding from the brow wounds. Only then did I remove the sterile drape, close the eyelid stab wounds, adjust the level of the lid by pulling the two ends of the mesh, and complete the procedure as usual.

Using this technique, the mesh does not come in contact with the skin and the risk of any organism getting trapped in the mesh spaces is practically eliminated. Consequently, the incidence of infection and/or granuloma formation is markedly reduced.2

Second: The authors proposed a systematic approach for the management of chronic granuloma and Mersilene mesh extrusion. In cases of forehead granuloma or mesh extrusion without eyelid crease infection, the authors proposed to administer systemic antibiotics±excision of the granuloma without excising the mesh. I disagree with this. Based on my experience of over few hundred cases, I believe that this approach will not cure the problem, but will just quieten it temporarily and will only result in more infection and more fibrosis around the mesh. Even in the three cases reported by the authors, the condition only resolved when the whole mesh was dissected and excised as much as possible. I believe there is no place for a ‘conservative’ approach even with a single granuloma that appears innocent and amenable to simple excision under antibiotic cover.