The clamp is removed, and the “corners” are once again grasped (Fig. 21.7). The tarsus with attached conjunctiva is resected (Figs. 21.8 and 21.9). The suture is tested to ensure that it has not been accidentally cut (Fig. 21.10). The lateral arm of the suture is passed from the conjunctival side through to the skin side of the eyelid where it is tied (Figs. 21.11 and 21.12). The medial end is handled likewise (Fig. 21.13). The eye is dressed in the usual fashion.

Complications

Complications of the Fasanella–Servat procedure include under or overcorrection, contour abnormalities, contralateral ptosis secondary to Hering’s law (which is a “risk” with any type of unilateral ptosis procedure), duplicate eyelid creases, suture allergies, corneal abrasions, dry eye syndrome, hematomas, wound dehiscence, pyogenic granulomas, and bleeding [7, 16].

202

Fig. 21.8  The tarsus and reflected conjunctiva/Müller’s muscle are removed

Fig. 21.9  Here is shown the removed fragment of tarsus with reflected conjunctiva. Bleeding is minimal from the cut edge due to the hemostatic effect of the clamp

Fig. 21.10  The suture is pulled taut to ensure that it has not been inadvertently cut

K. Jebodhsingh et al.

Fig. 21.13  Both the medial and lateral ends of the suture have been knotted on the skin surface

Undercorrection can be avoided by selecting patients with minimal ptosis and sufficient levator function. Eyelid peaking can be prevented by careful placement of the hemostat or the Putterman clamp and precise suture placement. The insertion of a bandage contact lens can help avoid postoperative keratopathy. There is the potential for postoperative dermatochalasis and double eyelid crease [17]. To prevent bleeding and hematoma formation, it may be necessary to preoperatively stop anticoagulants.

There are a few recommendations for postoperative adjustments for contour and height abnormalities. Beard [18] described using local anesthesia and without suture removal, “stretching” the eyelid. For overcorrection, eyelid massage

can also be effective [19, 20]. In 2009, Rosenburg et al. [21] described an office procedure without anesthetic that causes minimal discomfort to the patient. Six days postoperatively (when much of the edema has resolved but tissues have not yet densely fibrosed), gentle downward tugging is performed in the desired area of adjustment from the lashes or eyelid margin.

Discussion

This procedure has the advantage of high reliability with appropriate preoperative criteria and is minimally invasive. The success rate of the Fasanella–Servat procedure has been reported to range from 28 [22] to 95% [14] for most types of ptosis.

In 2007, Pang et al. [7] found a success rate of 89.5% of cases (137/153). The authors retrospectively reviewed 169 charts of two surgeons (JTH and JHO) from 1988 to 1996. Among subgroups, success was highest at 100% in Horner’s syndrome (8/8) and postlevator surgery (11/11) and lowest in congenital ptosis at 76.4% (13/18). Seventy-five percent of failures were undercorrections. These results are summarized in Table 21.1.

The procedure is generally quick so that it can be done in frail patients relatively safely with local anesthetic in a treatment room. It is less likely to cause overcorrection or contour abnormalities than levator advancement surgery.

The operation is very useful for small degrees of ptosis, and the likelihood of overcorrection is low. In cases where there is scarring in the eyelid skin crease from trauma or previous surgery, it can bypass the scar by working posteriorly.

Like any operation, proper patient selection is the key, and in the average oculoplastic practice, up to 75% of ptosis repairs can be done using this method. It can be combined with blepharoplasty, but this creates two wounds unnecessarily. So, we prefer levator advancement in the setting of blepharoplasty surgery.

Contour abnormalities can be addressed by skewing the clamp to one side. In other words, if the medial portion of the eyelid is low, but the lateral side has good height, then the clamp can be placed on the medial ½ of the eyelid to elevate only one side of the eyelid. This is especially valuable in a reoperation situation.

In summary, this operation is one of the great creations of oculoplastic surgery. Many people have used their ingenuity to enhance and perfect this technique.

References

1.Fasanella RM, Shields MB. Obituaries – Javier Servat, MD. Arch Ophthalmol. 2002;120:104.

2.Fasanella RM, Servat J. Levator resection for minimal ptosis: another simplified operation. Arch Ophthalmol. 1961;65:493–6.

3.Beard C. Ptosis. 3rd ed. St. Louis: The C.V. Mosby Company; 1981. p. 232–66.

4.Putterman AM, Urist MJ. Müller’s muscle-conjunctival resection ptosis procedure. Ophthalmic Surg. 1978;9(3):27–32.

5.Putterman AM. A clamp for strengthening Müller’s muscle in the treatment of ptosis. Modification, theory, and clamp for the Fasanella-Servat ptosis operation. Arch Ophthalmol. 1972;87(6):665–7.

6.Buckman G, Jakobiec FA, Hyde K, et al. Success of the Fasanella-Servat operation independent of Müller’s smooth muscle excision. Ophthalmology. 1989;96:413–8.

7.Pang NK, Newsom RW, Oestreicher JH, Chung HT, Harvey JT. Fasanella-Servat procedure: indications, efficacy, and complications. Can J Ophthalmol. 2008;43(1):84–8.

8.Georgescu D, Cole E, Epstein G, Fountain T, Migliori M, Nguyen Q, et al. Müller muscle-conjunctiva resection for blepharoptosis in patients with glaucoma filtering blebs. Ophthal Plast Reconstr Surg. 2007;23(4):285.

9.Skibell BC, Harvey JH, Oestreicher JH, Howarth D, Gibbs A, Wegrynowski T, et al. Adrenergic receptors in the ptotic human eyelid: correlation with phenylephrine testing and surgical success in ptosis repair. Ophthal Plast Reconstr Surg. 2007;23(5):367–71.

10.Crawford JS. Repair of blepharoptosis with a modification of the Fasanella-Servat operation. Can J Ophthalmol. 1973;8(1):19–23.

11.Bodian M. A revised Fasanella-Servat ptosis operation. Ann Ophthalmol. 1975;7(4):603–5.

12.Fox SA. A modified Fasanella-Servat procedure for ptosis. Arch Ophthalmol. 1975;93(8):639–40.

13.Lauring L. Blepharoptosis correction with the sutureless Fasanella-Servat operation. Arch Ophthalmol. 1977;95:671–4.

14.Gupta VP, Aggarwal R, Mathur SP. Blepharoptosis repair by modified sutureless Fasanella-Servat Operation (F.S.O.) – a large series of 50 cases. Indian J Ophthalmol. 1992;40:86–9.

15.Betharia SM. Transconjunctival levator resection: a modified simple technique. Ann Ophthalmol. 1988;20(6):234–8.

16.Carroll RP. Preventable problems following the FasanellaServat procedure. Ophthalmic Surg. 1980;11:44–51.

17.Personal Communication, Dr. J. Oestreicher.

18.Beard C. Blepharoptosis repair by modified FasanellaServat operation. Am J Ophthalmol. 1970;69(5):850–7.

19.Dortzbach RK, Kronish JW. Early revision in the office for adults after unsatisfactory blepharoptosis correction. Am J Ophthalmol. 1993;115:68–75.

20.Jordan DR, Anderson RL. A simple procedure for adjusting eyelid position after aponeurotic ptosis surgery. Arch Ophthalmol. 1987;105:1288–91.

21.Rosenberg C, Lelli Jr GJ, Lisman RD. Early postoperative adjustment of the Fasanella-Servat procedure: review of 102 consecutive cases. Ophthal Plast Reconstr Surg. 2009;25(1):19–22.

22.Sampath R, Saunders DC, Leatherbarrow B. The Fasanella-Servat procedure: a retrospective study. Eye. 1995;9(Pt 1):124–5.

Abstract  Full-thickness eyelid resection offers predictable correction of blepharoptosis in scarred, multioperated eyelids. Two surgical techniques, the lamellar and en bloc techniques, are described in detail. Both techniques rely on removal of tarsus, and/or scar tissue replacing tarsus, in a millimeter-for-millimeter fashion to achieve the desired amount of correction. Results are highly predictable because the scarred, multioperated eyelid loses distensibility and fluidity between tissue planes such that the amount of tissue resection corresponds exactly to the amount of eyelid elevation. Ways to address asymmetric tarsal platform show and contour deformity are also presented.

The concept of full-thickness eyelid resection was first introduced by Hervouet and Tessier in 1956 [1], then popularized in the 1970s [2]. In 1975, McCord described an external approach tarsoaponeurectomy for initial blepharoptosis surgery in which pretarsal orbicularis muscle is excised and a formula is then used to determine the extent of removal of underlying levator muscle aponeurosis, tarsus, Müller’s muscle, and conjunctiva [3]. Mustarde developed the splitlevel full-thickness eyelid resection, in which the

N. Shorr (*)

Division of Oculoplastic Surgery,

Jules Stein eye Institute, UCLA School of Medicine, Los Angeles, CA, USA

e-mail: drshorr@pacbell.net

anterior skin–orbicularis resection is performed at a level superior to the tarsoconjunctival resection, with the goal of tissue preservation by tucking the levator aponeurosis-Müller’s muscle complex [4]. While Mustarde reported satisfactory results on patients with mild-to- moderate blepharoptosis, Karesh expanded this technique for use on patients with severe blepharoptosis with poor levator function [5].

We define full-thickness eyelid resection for blepharoptosis correction as the external approach removal of all or some tissue layers from both the anterior and posterior eyelid lamellae but always with tarsus (and/or scar tissue replacing tarsus) resection in a millimeter-for- millimeter ratio to achieve the desired amount of correction. This approach is recommended for secondary correction of residual blepharoptosis in “multioperated” eyelids, i.e., eyelids that have undergone one or more prior surgical procedures, with scarred tissue planes. In a normal eyelid, levator aponeurosis and Müller’s muscle are distensible, and the anatomic tissue layers slide upon themselves. In reoperation cases, tarsus and the full-thickness eyelid tissue encompassing scar along the superior tarsal margin are nondistensible. When this nonfluid tissue is resected in full-thickness fashion, a predictable millimeter-for-millimeter blepharoptosis correction is achieved.

Let us employ an analogy. If one purchases a pair of trousers and later realizes that the trouser legs are 3 in. too long, how is this problem fixed? An expert tailor would measure the excess length and cut 3 in. off the bottom of each