Abstract  The Fasanella–Servat procedure is useful in correcting ptosis of the upper eyelid. It does so by removing conjunctiva, Müller’s muscle, and tarsus using a posterior eyelid approach. A graded algorithm provides a high success rate in patients who have ptosis with good levator muscle function. The surgery is quick and atraumatic and can be used in frail and elderly patients. The surgery can be used to correct upper eyelid contour abnormalities.

into the subconjunctival space above the tarsal plate, placing two curved hemostats no more than 3 mm from the upper border of the tarsus, then placing 5-0 chromic sutures in a horizontal mattress fashion above the two curved hemostats. The tissue in the hemostats was excised, and two Frost sutures were placed to prevent corneal abrasion. The procedure was described as the removal of tarsus, conjunctiva, Müller’s muscle, and levator palpebrae superioris.

History

Dr. Fasanella and Dr. Servat met in 1959 when the young Peruvian, Dr. Servat, went to New Haven, Connecticut, for his ophthalmology residency at Yale University under the mentoring of Dr. Rocko M. Fasanella, the Chief of the Eye Service. It was here, on a busy surgical day in 1960, where they operated on a child with ptosis who had Cooley anemia requiring multiple transfusions. Speed was essential, and on that day, the Fasanella–Servat procedure was created [1]. In 1961, Fasanella and Servat [2] described their procedure for correcting small amounts of ptosis in patients with normal levator function. The procedure, as they described it, involved everting the upper eyelid and infiltration of local anesthetic

J.T. Harvey (*)

Department of Ophthalmology, McMaster University Medical Centre, Hamilton, ON, Canada

e-mail: jtharvey@mcmaster.ca

Mechanism of Action

Over the years, there have been a number of suggestions as to the mechanism by which this procedure works. Fasanella and Servat proposed that it was the shortening of the levator, Müller’s muscle, tarsus, and conjunctiva that caused the eyelid elevation [2]. However, Beard proposed that it was the shortening of the tarsus [3], and he showed in pathologic studies that excised tissues consisted of only conjunctiva, Müller’s muscle, and tarsus and without levator muscle present [3]. Beard correctly noted that retraction of the aponeurosis prevented its inclusion in hemostats, and this was later confirmed by Putterman. Putterman concluded that resection and advancement of Müller’s muscle was the basis for success in the Fasanella–Servat procedure [4]. He found that when an external levator resection was performed with a Putterman clamp in place, the levator aponeurosis was easily accessible and not found to be trapped by the clamp [5]. Furthermore, Putterman pointed out that there is

no eyelid elevation in tarsoconjunctival grafts taken from the upper eyelid. In 1989, Buckman et al. [6] performed a histopathology study that showed that 87.5% of specimens displayed minimal or no smooth muscle, and they concluded that Müller’s muscle resection had little, if any, effect. However, it was further stated that no correlation was found between the amount of tarsus excised and the degree of eyelid elevation achieved. The mechanism of action of the Fasanella–Servat procedure has remained inconclusive.

Indications

The Fasanella–Servat procedure is suited for no more than 3 mm of ptosis with levator function greater than 10 mm [2, 4, 7]. Ideally, it is used for 1.5–2 mm of ptosis with levator function of 13–15 mm. The procedure has been used for congenital, neurogenic, myogenic, traumatic, bilateral ptosis as well as correction of eyelid contour abnormality from previous surgery or trauma. It is contraindicated in patients with significant posterior lamellar scarring or shortened tarsus (congenital, surgical, or traumatic). It is generally recommended that this procedure should not be repeated if unsuccessful on the first attempt as this could cause shortening of the tarsus and eyelid instability. To our knowledge, there have not been any studies that look specifically at complications after a Fasanella–Servat procedure in patients with corneal disease or following corneal surgery. However, it has been shown that in highrisk patients with glaucoma filtering blebs, Müller muscle–conjunctiva resection can provide an effective and safe means for ptosis repair [8].

It has been suggested that the absence of eyelid elevation following instillation of phenylephrine indicates poor response of Müller’s muscle to adrenergic stimulation, indicating that a tarso- conjunctiva-Müllerectomy (Fasanella procedure) or an anterior approach (levator advancement surgery) may prove more beneficial than a pure conjunctivo-Müllerectomy [5]. However, in 2007, Skibell et al. showed that the Fasanella– Servat and Putterman procedures have equal outcomes, independent of adrenergic receptors [9].

Procedure

There have been multiple variations of the original procedure described by Dr. Fasanella and Dr. Servat. Beard modified the technique in 1969 using a running suture of catgut and externalizing the knot in the temporal crease [3]. In 1972, Putterman developed a clamp to supplant the use of curved hemostats for the Fasanella–Servat procedure [5]. The clamp was placed over the superior 3 mm of tarsus and Müller’s muscle, and a double-armed 6-0 plain gut suture is placed in a running fashion above the clamp. This clamp is best known today for its use in the Müller’s muscle conjunctival resection procedure. In 1973, Crawford used a Demarres retractor to evert the eyelid [10]. Bodian [11] used a 5-0 running nylon suture that he exteriorized with bolsters to the eyelid. In an effort to end the cut-and-sew technique, Fox [12] excised all eyelid tissue above the hemostats and placed a running 5-0 plain gut suture across the inner eyelid. Lauring, [13] in 1977, described a sutureless method, in which two curved hemostats were placed on the everted eyelid for 1 min. Iris scissors were used to cut down the broad groove left by the clamps after the hemostats were then removed. There have also been others that have described a sutureless technique [14]. In 1983, Betharia et al. [15] used sutures instead of curved hemostats to isolate the eyelid tissue to be excised.

Since its inception in 1961, the Fasanella– Servat procedure has become more refined. Beard and Putterman were responsible for two major advances in technique. Beard advocated a simplified suturing approach, and the Putterman clamp increased efficiency.

Description of the Procedure

The patient is positioned in the usual fashion, topical anesthesia is placed into the conjunctival sac, and the upper eyelid is infiltrated with local anesthetic in the usual way.

The patient is instructed to “look down.” This aids in everting the eyelid over the Desmarres

retractor (Fig. 21.1). With toothed forceps the tarsus is grasped at the medial and lateral “corners” (Fig. 21.2). The “corners” are an arbitrary location where the horizontal and vertical portions of the tarsus meet. (If one thinks of the tarsus as a rectangle, then the superior border is the horizontal edge and the medial and lateral borders of the tarsus are the vertical edges. Where these meet is the “corner.”) Grasping too narrow a portion of tarsus will give a peaked eyelid contour. The Putterman clamp is applied

(Fig. 21.3). The placement of the clamp determines the amount of eyelid elevation that will occur. Small (1 mm), medium (2 mm), and large resections (3 mm) correspond to one clamp width, two clamp widths, or three clamp widths of resection, respectively. The original description of the procedure called for two curved hemostats, and this can be used instead of the Putterman clamp (Fig. 21.4). A double-armed absorbable suture is placed full thickness “back and forth” superior to the clamp (Figs. 21.5 and 21.6).

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Fig. 21.3  The Putterman clamp is placed. The amount of tarsus included in the clamp will determine the amount of lid elevation

Fig. 21.4  As an alternative, curved hemostats can be used to clamp the tarsus. This is how the surgery was originally described by Fasanella and Servat

Fig. 21.5  A 5-0 chromic suture is passed “back and forth” superior to the clamp

K. Jebodhsingh et al.