Fasanella-Servat Procedure

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Article initiated by:

Ji Kwan Park

All contributors:

Jennifer Hui, Jewel Sandy, Ji Kwan Park, Gangadhara Sundar, MD, Michael T Yen, MD, Cat Nguyen Burkat, MD FACS

Assigned editor:

Gangadhara Sundar, MD

Review:

Assigned status Update Pending

 by Gangadhara Sundar, MD on May 9, 2024.

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Contributing Editors:	add

Introduction

Posterior approach ptosis corrections have been controversial and evolving over the years. Several approaches have been introduced, refined, abandoned and reinvented. Some of these include the tarsoconjunctival resection (Fasanella-Servat procedure), the Muller's muscle - Conjunctival resection (MMCR , Putterman procedure), and the more recently repopularized White Line advancement procedures.

In 1961 Fasanella and Servat first introduced an excision of the tarsoconjunctival tissue, Müller’s muscle, and levator palpebrae superioris to correct small amounts of ptosis in patients with good levator function. Since its inception, more than 30 modifications have been proposed to improve safety and allow ease of use without compromising surgical results. The procedure addresses all types of ptosis, including congenital, myogenic, neurogenic, traumatic, ptosis from Horner’s syndrome, and ptosis following enucleation. This procedure is indicated for correction of mild to moderate ptosis, with at least 10 mm of levator function and no more than 3 mm of ptosis, preferably with a negative phenylephrine test.

History

Fasanella and Servat described the use of two curved hemostat forceps to secure the superior 3 mm of the tarsus and 3 mm of conjunctiva and Muller’s muscle on the everted upper lid. 5-0 double arm chromic sutures were placed through the conjunctiva, tarsus, levator, and Muller’s muscle starting on the temporal side. While pulling up on the temporal edge, the tissues were excised in small bites (4 to 5 mm). Interrupted mattress sutures were then placed to firmly hold the tissues before the cut was extended. A total of 4 to 5 interrupted sutures were placed. Two 4-0 black silk (Frost) sutures with protective pieces of rubber tubing or bands were used to prevent corneal damage.

Beard popularized the procedure in 1966 with his modification of the procedure which incorporated a running serpentine suture of plain catgut and externalization of the knot. In 1972, the Putterman clamp was developed to provide more facile manipulation of the tarsus. The technique involved the use of a double armed 6-0 plain gut suture placed in a running fashion across the base of clamp. In 1973, Crawford introduced Demarres retractor to improve exposure of the levator-Muller’s complex on lid eversion. Fox suggested resection of 3 mm portions of doubled up tissues (tarsus and conjunctiva) at the attached tarsal border. Closure was made with a running 5-0 plain gut sutures across the inner eyelid. Bodian used 5-0 nylon sutures in a running mattress over external bolsters. In 1977, Lauring introduced a sutureless technique in which the curved hemostats were used on the everted eyelid for 1 minute followed by excision of a broad groove of tissue with iris scissors. Betharia et al., later introduced the use of sutures to isolate the lid tissues in place of the hemostat forceps. More recently, graded approaches on Müller’s muscle excision have also been described.

Mechanism of Action

The mechanism of action remains unclear.  Fasanella and Servat initially surmised that the procedure worked by shortening the levator, Müller’s muscle, tarsus and conjunctiva.However, further pathologic studies by Beard showed only conjunctiva, Müller’s muscle, and tarsus, without the levator aponeurosis. Putterman suggested that the resection and advancement of the Müller’s muscle was the basis for success in this procedure. However, Buckman et al., found that 87.5% of excised specimens had minimal or no smooth muscles. It was concluded that the success of the procedure is due to a combination of vertical posterior lamellar shortening (tarsal plate), secondary contractile cicatrization of the wound, and advancement of the Müller’s muscle complex on the tarsus. Samimi et al., also believe the success of the procedure is independent from its effects on the Müller’s muscle.

Surgical Steps

The preoperative assessment includes measurements of the palpebral fissure height, levator function, and margin-to-reflex distance-1 (MRD1). Measurements may also be performed both before and 10 minutes after the installation of 2.5% phenylephrine. Samimi et al., advocated for Müller’s muscle conjunctival resection (MMCR) in patients with a positive phenylephrine test. MMCR usually offers excellent predictability in these patients. Nonetheless, high functional and cosmetic success can still be achieved in patients with a positive phenylephrine test.

1. Local Anesthesia infiltration subconjunctivally above the superior border of the tarsal plate while the eyelid is everted over a Desmarres retractor.  
2. Traction sutures may be placed at the nasal and temporal ends of the superior border of tarsus.
3. A caliper or ruler is used to mark the amount of superior tarsus and immediately adjacent to Muller’s  muscle and conjunctiva while the traction sutures are held with moderate tension. The amount of tarsus and Müller’s muscle-conjunctiva complex to be excised is debatable but no more than 3 mm of the tarsus should be marked.
4. Two curved hemostats are placed just above the marked line to grasp the tarsoconjunctival Müller’s complex. Skin and oribicularis should not be clamped. The tip of the clamps should meet at the highest point of eyelid arch desired, which is approximately above the pupils. A Putterman clamp may also be used for easy, single hand manipulation.
5. A double armed 6-0 plain gut suture, or a 6-0 prolene suture in some cases, is placed in the medial lid below the hemostat. One arm is then run laterally full thickness through the tissue to be plicated approximately 1.5 mm beneath the hemostat.
6. The hemostats are released after 60 seconds, leaving an ischemic bed. The crushed tissues are excised using a #15 blade or scissors while sparing the sutures. 
7. The other arm closes the wound towards the lateral edge where the knot may be buried. 
8. An alternative to steps #5-7 is to pass the sutures in a running horizontal mattress fashion across the lid then reversed to complete the closure. A #15 blade may be used to excise the tissues by making metal on metal contact with the curved hemostats or the Putterman clamp. 
9. The knot may also be externalized by passing both needles through full thickness of the lid to the skin near the lateral aspect of superior eyelid crease. Traction sutures are removed if used.
10. A bandage contact lens is used when knots are buried inside the eyelid to avoid corneal abrasion. 
11. Antibiotic ointment or eye drops are then applied. The sutures are removed after 5–7 days.

Complications

The most common complication is faulty placement of the clamps which may lead to a peaked eyelid contour. Difficulties in placing the nasal hemostat in the setting of a temporal tarsus shift in the elderly may result in residual nasal ptosis. Dermatochalasis may become more prominent after the procedure, and patients who may benefit from blepharoplasty may be better served with the external approach. Nonetheless, the Fasanella Servat procedure may be combined with a blepharoplasty. Overcorrection may be managed with internal (Berke) or full-thickness blepharotomy (Elner),early removal of sutures, and digital massage. Undercorrection may require external levator aponeurotic advancement surgeries.

Post operative keratitis may be a self limiting problem with use of softer sutures and is avoided with use of a bandage contact lens. As the accessory aqueous glands are excised, the procedure may exacerbate keratitis sicca. Suture granuloma and postoperative hemorrhage are also rare complications.

Contraindications

The procedure should be avoided in patients with cicatricial diseases such as pemphigoid, conjunctival scarring, amyloidosis, lymphoma, trachoma, and conjunctival granuloma. Keratitis sicca, filtering blebs, and other significant corneal diseases are also contraindications.

Efficacy

Although the success rate may vary between 28%-100% in all types of ptosis repair, a large retrospective study showed 87.7% success in patients with involutional ptosis. An additional study showed no statistical significance in efficacy when the Fasanella Servat procedure was performed as the primary surgery versus when done following a Müller’s muscle conjunctival resection. The procedure remains an invaluable tool in correcting small amounts of asymmetry that arise after primary internal approach ptosis repairs. Surgical outcomes were no different when compared to small incision techniques for involutional ptosis corrections. Although more patients reported post-operative pain, the Fasanella Servat procedures required approximately half the operative time when compared to small incision approaches.

Nonetheless, the need for removing normal tarsus in addition to conjunctiva and Müller’s muscle has been debated. A large excision of the tarsus more than 3 mm can result in lid instability and irregular eyelid contour. However, some authors suggest that removing only a small amount of tarsus does not alter lid stability and the procedure allows for easy entry into the avascular plane between Müller’s muscle and levator aponeurosis without severing the tissues.Perry et al., had excellent results with additional tarsus resections following a 9 mm excision of the Müller’s muscle to address the amount of undercorrection after phenylephrine testing.

In contrast to the Müller’s muscle conjunctival resection, a standardized nomogram for the Fasanella Servat procedure has not been established despite several attempts. Buckman et al., found no correlation between amount of tarsus excised and the degree of lid elevation. A ratio of removing 2 mm tarsus for every 1 mm of eyelid elevation has been suggested. Other surgeons have had success with 2 mm of conjunctiva-Müller’s complex and 1 mm of tarsus resection for every 1 mm of eyelid elevation.

Summary

Since its inception in 1961, the Fasanella Servat procedure has been proven to be a valuable internal approach to correct mild to moderate amounts of ptosis. Modifications to the technique have allowed for ease of use and minimization of complications. With careful patient selection and surgical mastery, the Fasanella Servat procedure is a quick, efficient, and successful technique to treat patients with upper lid ptosis of various etiologies. While other posterior approach procedures have surpassed the numbers of Fasanella-Servat procedure it remains a milestone in the evolution of posterior approach ptosis surgeries.