A Modified Fasanella-Servat Procedure for Ptosis Sidney
A. Fox, MD
This procedure was first suggested for "minimal ptosis of 3-4 mm." However, since the amount of ptosis varies widely with the etiological factors, the true indication in any given case is not the amount of ptosis but the amount of levator action. Hence, unless there is at least 10 mm of levator action, this operation is contraindicated. Since the levator (except that part of the aponeurosis that is adherent to the tarsus) is not involved, the procedure has been simplified accord-
ingly.
Fasanella and Servat1 re¬ a levator resection oper¬ ation for minimal ptosis. It was stated that the operation consisted "essentially of a resection of Muller's muscle, levator, tarsus and conjunc¬ tiva." The technique suggested was quite simple: The ptotic lid is everted and doubled over, both layers are clamped at the attached tarsal border, and 3 mm of conjunctiva and 3 mm of tar¬ sus are resected. In order to avoid presumed levator retraction, the re¬ section is done a little at a time and sutured after each short cut. After some time of using this pro¬ cedure, I decided to move the clamp further back toward the ciliary mar¬ gin of the lid in order to avoid the la¬ borious cut-and-sew technique.2 This gave a surprising result: In adults with wide tarsi (8 to 11 mm), there was no problem. However, in the young, whose tarsi measured 7 mm or less in width, very little space was left for getting a good "bite" with the suture, no matter how small the clamps. As a result, the clamps had to be removed frequently to attain good wound closure. It was soon noted that
1962, In ported
Submitted for publication May 7, 1974. From New York University School of Medicine. Reprint requests to 11 E 90th St, New York, NY 10028.
Downloaded From: http://archopht.jamanetwork.com/ by a Oakland University User on 06/12/2015
this caused no change in result, and this gave rise to the suspicion that ei¬ ther the levator did not retract or that it was not resected at all. The tissue resected in the next six cases, in both adults and children, was then sent for histological study. The reports were uniform: the specimens consisted of a tarsoconjunctival layer, some strands of Müller muscle, and a narrow strip of palpebrai conjunctiva; there was no levator. This has been confirmed by Beard.' In other words, the Fasanella-Servat procedure as published is not a tarso-levator resec¬ tion, but a tarsus-Müller muscle-con¬ junctiva resection. In view of this, and since levator retraction does not occur, I now use the following tech¬
nique.
TECHNIQUE The lid is everted and the doubled-up tis¬ (tarsus and palpebrai conjunctiva) are fastened together with two small clamps at the attached tarsal border (Fig 1). The folded-over tissues in the clamps are re¬ sected about 3 mm behind the upper tarsal border and behind the clamps. Closure is then made with a single running 5-0 plain catgut suture, which is locked at every other stitch (Fig 2). Thus, a "simple" oper¬ ation is further simplified. The 5-0 plain catgut suture softens read¬ ily and absorbs in several days. The knots at either end are well beyond the cornea and cause no trouble. Rarely, patients have complained of a foreign-body feeling, sues
Fig
1.—Lid is everted and
doubled-up
tissues
two small clamps, and 3-mm portions of both resected at attached tarsal border.
healing is rapid and if the eye is patched for two or three days, the com¬ plaints have never been of long duration. but
COMMENT
This is an intriguing little oper¬ ation and quite effective, but it has definite indications. A mild (2- to 3mm) ptosis is not an indication; but a ptosis that has 10 mm or more of levator action is. This difference is impor¬ tant. It must be emphasized that the expressions "small amount of ptosis" or "advanced ptosis" are simply de¬ scriptive phrases that are valueless in
are grasped in layers of tissues are
Fig 2.—Closure is made with 5-0 locked every other stitch.
surgical decision. Men doing this kind of surgery know that there are kinds of ptosis, such as the traumat¬ ic and familial and that occurring in Horner syndrome, in which almost the whole cornea is covered but levator action may be 11 or 12 mm. On the other hand, a congenital ptosis may measure 3 mm and have only 4 to 5 mm of levator action. In general, then, this procedure has its greatest sphere of usefulness in acquired ptosis with good levator ac¬ tion, and is least useful in congenital ptosis. The criterion is the amount of a
Downloaded From: http://archopht.jamanetwork.com/ by a Oakland University User on 06/12/2015
plain catgut running suture,
action, and not the amount of ptosis, regardless of the cause. To put levator
it another way, unless there is at least 10 mm of levator action, the result will be disappointing.
References 1. Fasanella R, Servat J: Levator resection for minimal ptosis: Another simplified operation. Arch Ophthalmol 65:493-496, 1962. 2. Fox SA: Surgery of Ptosis. New York, Grune & Stratton Inc, 1968, p 99. 3. Beard C: Blepharoptosis repair by modified Fasanella-Servat operation. Am J Ophthalmol 69:850-857, 1970.
A. Fox, MD
This procedure was first suggested for "minimal ptosis of 3-4 mm." However, since the amount of ptosis varies widely with the etiological factors, the true indication in any given case is not the amount of ptosis but the amount of levator action. Hence, unless there is at least 10 mm of levator action, this operation is contraindicated. Since the levator (except that part of the aponeurosis that is adherent to the tarsus) is not involved, the procedure has been simplified accord-
ingly.
Fasanella and Servat1 re¬ a levator resection oper¬ ation for minimal ptosis. It was stated that the operation consisted "essentially of a resection of Muller's muscle, levator, tarsus and conjunc¬ tiva." The technique suggested was quite simple: The ptotic lid is everted and doubled over, both layers are clamped at the attached tarsal border, and 3 mm of conjunctiva and 3 mm of tar¬ sus are resected. In order to avoid presumed levator retraction, the re¬ section is done a little at a time and sutured after each short cut. After some time of using this pro¬ cedure, I decided to move the clamp further back toward the ciliary mar¬ gin of the lid in order to avoid the la¬ borious cut-and-sew technique.2 This gave a surprising result: In adults with wide tarsi (8 to 11 mm), there was no problem. However, in the young, whose tarsi measured 7 mm or less in width, very little space was left for getting a good "bite" with the suture, no matter how small the clamps. As a result, the clamps had to be removed frequently to attain good wound closure. It was soon noted that
1962, In ported
Submitted for publication May 7, 1974. From New York University School of Medicine. Reprint requests to 11 E 90th St, New York, NY 10028.
Downloaded From: http://archopht.jamanetwork.com/ by a Oakland University User on 06/12/2015
this caused no change in result, and this gave rise to the suspicion that ei¬ ther the levator did not retract or that it was not resected at all. The tissue resected in the next six cases, in both adults and children, was then sent for histological study. The reports were uniform: the specimens consisted of a tarsoconjunctival layer, some strands of Müller muscle, and a narrow strip of palpebrai conjunctiva; there was no levator. This has been confirmed by Beard.' In other words, the Fasanella-Servat procedure as published is not a tarso-levator resec¬ tion, but a tarsus-Müller muscle-con¬ junctiva resection. In view of this, and since levator retraction does not occur, I now use the following tech¬
nique.
TECHNIQUE The lid is everted and the doubled-up tis¬ (tarsus and palpebrai conjunctiva) are fastened together with two small clamps at the attached tarsal border (Fig 1). The folded-over tissues in the clamps are re¬ sected about 3 mm behind the upper tarsal border and behind the clamps. Closure is then made with a single running 5-0 plain catgut suture, which is locked at every other stitch (Fig 2). Thus, a "simple" oper¬ ation is further simplified. The 5-0 plain catgut suture softens read¬ ily and absorbs in several days. The knots at either end are well beyond the cornea and cause no trouble. Rarely, patients have complained of a foreign-body feeling, sues
Fig
1.—Lid is everted and
doubled-up
tissues
two small clamps, and 3-mm portions of both resected at attached tarsal border.
healing is rapid and if the eye is patched for two or three days, the com¬ plaints have never been of long duration. but
COMMENT
This is an intriguing little oper¬ ation and quite effective, but it has definite indications. A mild (2- to 3mm) ptosis is not an indication; but a ptosis that has 10 mm or more of levator action is. This difference is impor¬ tant. It must be emphasized that the expressions "small amount of ptosis" or "advanced ptosis" are simply de¬ scriptive phrases that are valueless in
are grasped in layers of tissues are
Fig 2.—Closure is made with 5-0 locked every other stitch.
surgical decision. Men doing this kind of surgery know that there are kinds of ptosis, such as the traumat¬ ic and familial and that occurring in Horner syndrome, in which almost the whole cornea is covered but levator action may be 11 or 12 mm. On the other hand, a congenital ptosis may measure 3 mm and have only 4 to 5 mm of levator action. In general, then, this procedure has its greatest sphere of usefulness in acquired ptosis with good levator ac¬ tion, and is least useful in congenital ptosis. The criterion is the amount of a
Downloaded From: http://archopht.jamanetwork.com/ by a Oakland University User on 06/12/2015
plain catgut running suture,
action, and not the amount of ptosis, regardless of the cause. To put levator
it another way, unless there is at least 10 mm of levator action, the result will be disappointing.
References 1. Fasanella R, Servat J: Levator resection for minimal ptosis: Another simplified operation. Arch Ophthalmol 65:493-496, 1962. 2. Fox SA: Surgery of Ptosis. New York, Grune & Stratton Inc, 1968, p 99. 3. Beard C: Blepharoptosis repair by modified Fasanella-Servat operation. Am J Ophthalmol 69:850-857, 1970.
