Success of the Fasanella­Servat Operation Independent of Muller's Smooth Muscle Excision GILA BUCKMAN, MD, FREDERICK A. JAKOBIEC, MD, KENNETH HYDE, MD, RICHARD D. LISMAN, MD, ALBERT HORN BLASS, MD, WINSTON HARRISON, MD

Abstract: In an attempt to elucidate the mechanism whereby the Fasanella­SeNat operation corrects ptosis, the authors examined the histopathologic fea­tures of 40 consecutive surgical specimens from 37 patients. Because all spec­imens contained tarsus, this tissue was graded into two groups according to vertical height: (1) minimal (30%) and (2) moderate (70%). MOiler's smooth muscle was graded into four groups: (1) absent to negligible (42.5%); (2) minimal (45%); (3) moderate (10%); and (4) large (2.5%). Levator aponeurosis was absent, and conjunctiva was present, in all resections. Accessory lacrimal gland tissue was present in 42.5% of cases and did not cause decreased tear pro­duction. Although 87.5% of cases had absent to minimal smooth muscle re­sections, these patients had equally successful results in comparison to patients with moderate to large amounts of smooth muscle resections. Based on these data, the authors have concluded that the effectiveness of the Fasanella-SeNat operation does not depend on a MOlierectomy, but instead is probably due to a combination of other factors: (1) a vertical posterior lamellar shortening; (2) secondary contractile cicatrization of the wound; and (3) plication or advance­ment of the MUlier's smooth muscle-levator aponeurosis complex on the tarsus. Ophthalmology 96:413-418, 1989

Despite the fact that the Fasanella-Servat operation 1 is a frequently performed procedure for the correction of minimal ptosis, there has never been a systematic histo­pathologic report of a large series of excised specimens that might elucidate the mechanism(s) whereby this op-

eration corrects ptosis, In this study, 40 excised strips of tissue from 37 patients were processed and sectioned in a manner that optimally showed the micro-anatomy and constituent cell populations of the supratarsal region. The histopathologic features were correlated with the clinical results in each case.

Originally received: November 4, 1988. Revision accepted: December 28. 1988.

From the Department of Ophthalmology, and the Division of Oculoplastic Surgery, the Manhattan Eye. Ear & Throat Hospital, New York.

Presented at a meeting of the American Society of Ophthalmic Plastic and Reconstructive Surgery. October 7, 1988, Las Vegas, Nevada.

Supported in part by a grant from the Manhattan Eye, Ear & Throat Eye Foundation. New York, New York.

Reprint requests to Frederick A. Jakobiec, MD, Department of Ophthal­mology, Massachussetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114.

MATERIALS AND METHODS

The histopathologic specimens of 40 consecutive Fa­sanella-Servat operations in 37 patients were examined (3 cases were bilateral). All ofthe surgery was performed by four oculoplastic and plastic surgeons from September 1987 until January 1988. Clinical information obtained included the age, sex, amount of ptosis, levator function, preoperative Schirmer's test, preoperative response to 10% phenylephrine, and, when available, postoperative

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Schirmer's test and postoperative response to 10% phen­ylephrine. All patients had standardized pre- and post­operative plastic eye series photographs. Each chart was reviewed to determine the clinical history, the written measurement and/or sketch of preoperative ptosis, and the postoperative description. All photographs were as­sessed and compared with the surgeon's description. Pa­tients with a history of previous levator surgery were ex­cluded from the study.

The surgical technique2.3 used by all of the surgeons in this study was the same due to their common institutional background and shared training. Each surgeon used a subtle modification of the original Fasanella-Servat pro­cedure. 1 Two curved hemostats were placed tip to tip with the greatest amount of tarsus to be resected at the central portion of the eyelid. The superior 6 mm of tarsus were graded into thirds to estimate the degree of eyelid elevation to be obtained. A total of 1, 2, or 3 mm of elevation were estimated from 2, 4, or 6 mm, respectively, of tarsal re­section. A 5-0 nylon suture was run from the external eyelid crease beneath the hemostats to reappear at the opposite end of the eyelid crease; this was tied externally within the eyelid fold. The tarsal resection was performed by cutting within the crush marks of the two hemostats. Each surgeon had performed at least 500 Fasanella-Servat procedures before this study.

The specimens were processed by "breadloafing" the excised tissues and sectioning the strips parallel to their vertical axes in a superior-inferior direction (Figs 1, 2), so as to maximally show their anatomic components. Seven or eight fragments of tissue were separately embed­ded and three levels of sectioning were obtained from each in order to sample completely the tissue elements present. The sections were stained with hematoxylin­eosin, and the trichrome stain was obtained to discrimi­nate between smooth muscle and collagen. The amount of tarsus was quantitatively and qualitatively graded. The presence or absence of accessory lacrimal gland tissue, conjunctiva, levator aponeurosis, and smooth muscle re­section was assessed. An important distinction was made between Miiller's muscle and the muscularis of obliquely sectioned blood vessels based on the examination of sec­tions at various levels.

Tarsal heights were measured with a micrometer at­tached to the ocular of the microscope. Because all spec­imens contained tarsus, the tarsus was qualitatively graded into two groups: (1) minimal (grade 1) and (2) moderate (grade 2). All specimens were evaluated for the presence of smooth muscle and divided into four groups: (1) absent to negligible (group 0); (2) minimal (group 1); (3) moderate (group 2); and (4) large (group 3). These histopathologic features were correlated with clinical results; last, the re­sults were evaluated with a two-tailed t test (alpha = 0.05) for statistical significance.

RESULTS

The age range of the 37 patients was from 3 to 85 years (mean, 50 years; median, 53 years). There were 22 females

414

and 15 males; three cases were bilateral. Eight cases rep­resented congenital ptosis; 32 were acquired cases. The follow-up period was from 6 to 9 months.

Among the 40 specimens examined histopathologically, 12 (30%) were classified as having minimal tarsus (grade 1, Fig 3). These tarsal strips ranged in height from 1.6 to 2.8 mm (mean height, 2.45 mm; median length, 2.4 mm). Twenty-eight specimens (70%) were graded as moderate tarsus (grade 2, Fig 4), their actual lengths ranging from 3.0 to 4.4 mm (mean and median lengths, 3.6 mm).

In 42.5% (17 specimens), smooth muscle was absent to negligible (group 0, Fig 5); in 45% (18 cases), minimal smooth muscle (group 1, Fig 6) was found; a moderate amount of smooth muscle (Fig 7) was present in 10% (group 2, 4 cases); and a large amount of smooth muscle (group 3, Fig 8) was found in 2.5% (1 case). The average­size tarsal strip for group 0 smooth muscle was 3.31 mm and for group 1 smooth muscle was 3.15 mm. The av­erage-size tarsal strip for groups 2 and 3 smooth muscle was 3.2 mm (group 2, 3.4 mm; group 3, 2.4 mm). The average age of patients with absent to negligible smooth muscle was 53.2 years and those with minimal smooth muscle was 51.5 years. In those specimens with moderate and large amounts of smooth muscle, the average age of the patients was 29 years.

The mean preoperative ptosis was 2.7 mm and the me­dian was 2.5 mm. The mean ptosis correction (Fig 9) for specimens with minimal tarsal resection was 2.5 mm (standard deviation [SO], 0.52 mm) (median, 2.5 mm). The average ptosis correction for those with moderate tarsal resection was 2.75 mm (SO, 0.78 mm) (median, 3.0 mm) (not significant, P > 0.05). There were three undercorrections and three overcorrections in our series. Eyelid malpositions were determined relative to the con­tralateral eyelid. More than 1 mm of ptosis relative to the opposite upper eyelid was considered an undercorrection. Overcorrection was diagnosed if there was more than 1 mm of retraction relative to the contralateral upper lid. In all cases, the contralateral eyelid was determined "ac­ceptable" and fell 1 to 2 mm below the superior limbus.

The mean ptosis correction (Fig 10) for specimens with absent to negligible smooth muscle (group 0) was 2.74 mm (SO, 0.79 mm). The mean ptosis correction for those with minimal smooth muscle (group 1) was 2.83 mm (SO, 0.69 mm). There was no statistically significant difference between these two groups. In those specimens with mod­erate smooth muscle (group 2) the mean ptosis correction was 2.38 mm (SO, 0.75 mm). The patient with a large amount of smooth muscle (group 3) had 3 mm of ptosis correction. The number of cases in the last two groups was too small to permit statistical evaluation.

Fat-infiltrated tarsus (Fig 11) was present in 18 speci­mens (45%). The trichrome stain allowed the distinction between the superior pole of the tarsus, where it underwent partial fatty replacement, and the more delicate connective tissue of the conjunctival substantia propria, delineating the curvilinear interface of these two structures and en­abling accurate quantitative measurements (Fig 12). There were no treatment failures in this group with partial fatty infiltration. The average age of patients with this anatomic

BUCKMAN et al • HISTOPATHOLOGY OF FASANELLA-SERVAT

Fig 1. Top leji, typical strip of excised superior tarsal tis­sue and contiguous conjunc­tiva from the Fasanella-Ser­vat operation. Fig 2. Second row leji, "bread-loafing" to create seven separate sec­tions, each of which was embedded with an accom­panying map for sampling the topography of the speci­men. Each fragment was ad­ditionally studied through three levels of histologic sec­tioning. Fig 3. Third row leji, an excised specimen display­ing a minimal amount of tar­sus (grade I) with scant lob­ules of meibomian sebaceous glands. The reflected con­junctiva is present below (hematoxylin-eosin; original magnification, X2). Fig 4. Bottom leji, an excised spec­imen with a moderate amount of tarsus (grade 2) and abundant meibomian glands. Notice in the curve of the tissue the arterial arcade that is normally related to the superior pole of the tarsus (hematoxylin-eosin; original magnification, X2). Fig 5. Top right, a small island of red-staining MUlier's smooth muscle is present to the left of the tarsus. Such specimens were graded as zero to neg­ligible amounts of tarsus (group 0) (Masson trichrome; original magnification, X26). Fig 6. Second row right, min­imal amount of smooth muscle organized into thin fascicles (group I). Notice the lobule of associated Wolf­ring's accessory lacrimal tis­sue embedded in the superior pole of the tarsus toward the upper right (Masson tri­chrome; original magnifica­tion, X26). Fig 7. Third row right, moderate amount of excised MUlier's muscle

(group 2) (Masson trichrome; original magnification, X26). Fig 8. Bottom right, maximal amount of excised MUlier's muscle (group 3) is present from the edge of the specimen on the left all the way to the right under the superior vascular arcade (Masson trichrome; original magnification, X2).

finding was 66.3 years. In the 55% of cases without fat­infiltrated tarsus, the average age was 35.5 years. The tarsal specimens with fat infiltration, therefore, had a signifi­cantly greater age range than those without fatty changes (P < 0.05).

Accessory lacrimal gland tissue (Fig 6) was present in 42.5% of specimens. In 12 patients, pre- and postoperative Schirmer's tests were obtained. Schirmer's strip measure­ments ranged from 10 to 16 mm in both pre- and post­operative tests. Accessory lacrimal gland tissue was found

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4.0

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n = 12 n= 28

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Minimal Moderate

Tarsal Height Groups

Fig 9. Lack of correlation between amount of tarsal excision and ptosis correction.

histopathologically in 3 of these 12 cases. Conjunctiva was present and levator aponeurosis was absent, in all histopathologic sections.

The 10% phenylephrine test, performed in 25 cases preoperatively, was positive in 19 cases and negative in 6. Good surgical results were obtained in all cases which responded to 10% phenylephrine. Three cases which failed to respond to 10% phenylephrine preoperatively also had good surgical results. Two undercorrections in our series had negative 10% phenylephrine tests preoperatively. Five successful cases had 10% phenylephrine instilled post­operatively, resulting in an additional 1 to 2 mm of lid elevation.

DISCUSSION

The Fasanella-Servat operation was originally described in 1961 1 as a form of levator resection for the correction of minimal ptosis; minor modifications in the basic sur­gical procedure have been made and were followed by the surgeons who cooperated in this study.2.3 Beard4 was among the first to suggest that the levator aponeurosis plays no role in the success of the operation and proposed

416

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3.5

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Fig 10. Lack of correlation between amount of Miillerectomy and ptosis correction.

that tarsectomy alone was responsible for its success. In 1975, Putterman and Urist5 tried to prove that the Fa­sanella-Servat operation corrected ptosis by strengthening Muller's smooth muscle through its resection and ad­vancement, and, based on this theory, introduced his Muller muscle-conjunctival resection. Dortzbach,6 in a variation on the same theme, described in 1979 a tech­nique for isolating and resecting Muller's muscle.

Ptosis surgery is based on a thorough and precise knowledge ofthe anatomy of the upper eyelid. The levator palpebrae superioris striated muscle divides, at approxi­mately the level of Whitnall's ligament, into two inser­tions: an anterior tendonous one known as the levator aponeurosis, and a posterior smooth muscle one, referred to as Muller's muscle.7 Muller's muscle is sympathetically innervated; the antero-superior orbit is one of the few places in the body where an intimate arrangement exists between striated and smooth muscle types.s As they course downward, the levator aponeurosis extends anteriorly to attach to the lower third of the anterior surface of the tarsUS,9 and Muller's muscle inSerts onto the upper border of the tarsus. The posterior surface of Muller's muscle is covered with tightly adherent conjunctiva.5

Although a histopathologic . study with clinical corre­lation represents a rational approach to the mechanism

BUCKMAN et al • HISTOPATHOLOGY OF FASANELlA-SERVAT

of ptosis repair, inherent difficulties exist in the docu­mentation of ptosis. The difficulty in assessin§ and quan­tifying ptosis from photography and drawings is acknowl­edged. Achievement of bilaterally symmetrical lid position as a successful outcome may reflect drooping of the con­tralaterallid (a demonstration of Herring's law in action) rather than just ipsilateral lid elevation.

Our study histopathologically demonstrates that the absence of smooth muscle in the resected tissues is com­patible with clinically good results. Although 87.5% of cases had absent to minimal smooth muscle in the resected specimens, these patients had equally successful results in comparison to the patients with moderate to large amounts (12.5%) of smooth muscle resection. In addition, the amount of smooth muscle did not correlate with the size of the tarsal strip incorporated in the resection.

The amount of smooth muscle did, however, correlate with age. Larger amounts of smooth muscle were seen in younger patients, suggesting that Miiller's muscle migrates away from the upper edge of tarsus as one gets older. This phenomenon was originally noted by Collin et al,1O who measured the length ofMiiller's muscle and found a nor­mal lengthening and thinning of the muscle with increas­ing age. It is also possible that some of the patients with congenital ptosis had a modified procedure (an "en­hanced" Fasanella-Servat operation), wherein more than the usual amount of smooth muscle and conjunctiva was incorporated into the surgeon's clamp. This would rep­resent a subset of patients whose operation differed from the rest of the population.

No correlation was found between the amount of ptosis correction and the size of the tarsal strip. The operation could be successful in all classes of ptosis even when min­imal amounts of tarsus were excised. No relationship was found between the qualitative nature of the tarsal tissue and the success of surgery. Fat infiltration of tarsus was present in 45% of our cases, all of whom did well surgically and clinically. Fatty deposits were found only in patients older than 26 years of age, substantiating the observation of Collin et al lO of fat-infiltrated tarsus in the older pop­ulation. Lobules of accessory lacrimal gland tissue (glands of Wolf ring) are normally found within the superior bor­der of tarsus and it is not surprising that this glandular tissue was found in 42.5% of specimens; the presence of this tissue, however, did not precipitate dry eye problems. In three patients with accessory lacrimal gland resection, pre- and postoperative Schirmer's tests failed to demon­strate reduction of tear production.

There were three patients with postoperative under­corrections in our series, all of whom had moderate to severe congenital ptosis. One patient was a 4-year-old boy, with 3 mm of congenital ptosis, evidence of a partial lid crease, and 7 mm of levator function. Evaluation of the specimen showed a moderate tarsal height of 3.4 mm and the absence of smooth muscle. The second patient was a 3-year-old boy with 3.5 mm of ptosis, 6 mm of levator function, a poor lid crease, and a negative response to preoperative 10% phenylephrine. The histopathologic features showed a moderate tarsal resection of 3 mm and a moderate amount of smooth muscle. The third patient

Fig 11. Top, fatty infiltration of the superior pole of the tarsus in an elderly patient (hematoxylin-eosin; original magnification, X2). Fig 12. Bottom, the distinction between the superior pole of the tarsus, particularly when it underwent partial fatty replacement, and the connective tissue of the substantia propria is clearly shown in the Masson trichrome, owing to the intensely staining blue of the tarsal collagen. Notice that the sub­stantia propria of the conjunctiva on the left has a paler staining collagen which is more loosely textured, The fortuitous arcing in this section of the superior tarsal vascular arcade also demarcates the tarsus from the substantia propria (Masson trichrome; original magnification, x26).

was a 32-year-old man with a congenital ptosis of 3.5 mm, a levator function of 8 mm, a good lid crease, and a negative response to preoperative 10% phenylephrine. The patient underwent a Fasanella-Servat operation which partially elevated his lid by 2 mm. He subsequently un­derwent a second Fasanella-Servat which resulted in a complete correction of his ptosis. The first specimen showed a moderate tarsal resection of 3 mm and minimal smooth muscle present. The second specimen showed the absence of tarsus and large amounts of smooth muscle. We believe that these failures were due to the fact that there was a ptosis of 3 mm or greater in all three cases, and that the levator function in all three cases was less than 10 mm.

There were also three postoperative overcorrections in the current series. In two patients, the preoperative ptosis was 3.0 mm and the amount of tarsus resected was 4.0 mm. In the third case, the preoperative ptosis was 1.5 mm and the amount of tarsus resected was 3.8 mm. The levator functions were 15 to 18 mm in all three cases, and the tarsal heights were in the upper end of the moderate group of tarsal resections. It did not appear that a marked dis­parity in tarsal resection was responsible for over­correction.

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Several mechanisms for effectuating correction of ptosis by the Fasanella-Servat operation are consistent with the data presented in this study. These include: (1) a posterior lamellar shortening; (2) secondary contractile cicatrization of the wound; and (3) plication or advancement on the tarsus of the Muller's muscle-levator aponeurosis com­plex. Evidence to support the theory of posterior lamellar shortening is the fact that 87.5% of cases had absent to minimal smooth muscle resections and the levator apo­neurosis was absent in all of the specimens. The only tis­sues resected in these cases, therefore, were the conjunctiva and tarsus. However, resected specimens showed only what was removed and did not show any new anatomic relationships of structures which could have been ad­vanced on the tarsus during and after surgery. Further­more, the failures in our congenital ptosis cases, wherein equivalent amounts of tarsus were excised, suggest that posterior lamellar shortening alone may not adequately explain the mechanism. Our data also underscore that in more severe cases of congenital ptosis the Fasanella-Servat operation is suboptimal or ineffective. Finally, our findings indicate that the preoperative phenylephrine test has value only as an aid to help the prospective surgical candidate visualize a successful postoperative result. Since the cor­rection has been determined to be secondary to factors other than Muller's muscle resection, a negative phenyl­ephrine test does not in itself contraindicate the Fasanella­Servat procedure.

During the contractile phase of wound healing and cic­atrization, further vertical shortening of the lid may occur. It is unclear if this is a clinically significant factor. The excision of tarsus and conjunctiva creates a raw wound edge at the superior tarsal border. Despite its absence in the resections, smooth muscle may be reapproximated to the tarsus in the suture closure. There may also be an

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advancement of the levator aponeurosis onto the tarsus because of the intimate association of smooth muscle to the overlying levator aponeurosis. The requirement of normal levator function for this operation to succeed lends support to the possibility of advancement or plication of the levator aponeurosis playing a role. The mechanism of action in the repair of ptosis by the Fasanella-Servat operation is probably some combination of these factors. Whatever the exact mechanism, it is clear from this study that smooth muscle resection itself is not required for the procedure to be successful.

REFERENCES 1. Fasanella RM, Servat J. Levator resection for minimal ptosis: another

simplified operation. Arch Ophthalmol1961; 65:493-6. 2. Smith B, Nesi F. Practical Techniques in Ophthalmic Plastic Surgery.

St Louis: CV Mosby, 1981; 168-71. 3. Smith B, Della Rocca R, Nesi F, Lisman R. Ophthalmic Plastic and

Reconstructive Surgery. St Louis: CV Mosby, 1987; 687. 4. Beard C. Blepharoptosis repair by modified Fasanella-Servat operation.

Am J Ophthalmol1970; 69:850-7. 5. Putterman AM, Urist MJ. MUlier's muscle-conjunctival resection: tech­

nique for treatment of blepharoptosis. Arch Ophthalmol 1975; 93: 619-23.

6. Dortzbach RK. Superior tarsal muscle resection to correct blepharo­ptosis. Ophthalmology 1979; 86:1883-91.

7. Wolff E. The Anatomy of the Eye and Orbit. Philadelphia: Blakiston Co, 1933; 109.

8. Jakobiec FA, Iwamoto T. Ocular adnexa: introduction to lids, con­junctiva, and orbit. In: Jakobiec FA, ed. Ocular Anatomy, Embryology and Teratology. Philadelphia: Harper & Row, 1982; 677-731.

9. Anderson RL, Beard C. The levator aponeurosis: attachments and their clinical significance. Arch OphthalmoI1977; 95:1437-41.

10. Collin JR, Beard C, Wood I. Experimental and clinical data on the insertion of the levator palpebrae superioris muscle. Am J Ophthalmol 1978; 85:792-801.