TY - JOUR
AU - MD, Ju-Wen Yang,
AB - Abstract Background The traditional technique for levator muscle resection includes a time-consuming dissection procedure that causes tissue trauma and swelling. The Putterman ptosis clamp has been popularly used in recent years for conjunctival müllerectomy. In this paper, we describe a modified surgical technique for ptosis treatment using the Putterman ptosis clamp. The modified technique improves the surgical results of levator muscle resection. Objectives We performed a retrospective case-series study to determine the outcomes and complications associated with the use of the Putterman ptosis clamp in levator muscle resection. Methods Adults aged ≥18 years with moderate-to-severe ptosis underwent the modified technique for levator muscle resection. We first performed dissection to expose the aponeurosis and tarsus. Then, we placed the Putterman ptosis clamp to measure redundant aponeurotic and septal tissues and to perform the resection. Following the adjustment of the eyelid fissure, we refixed the levator muscle to the tarsus with 4-0 vicryl stitches. Results Seventeen patients (34 eyes) were included in the study. Of the 34 eyes, 31 (91.2%) experienced the complete resolution of ptosis after the surgery. One patient (2 eyes, 5.9%) had mild bilateral dermatochalasis and received revision surgery 6 months postoperative. One patient (1 eye, 2.9%) lost the crease of the left eye and received revision surgeries 2 and 6 months after the first surgery. No residual ptosis or severe adverse events were noted in the patients. Conclusions Modified levator muscle resection using the Putterman ptosis clamp is an effective procedure for ptosis treatment. Level of Evidence: 4 Ptosis is a common problem encountered in the practice of oculoplastic surgery. A multifaceted and individualized approach is required for the treatment of upper eyelid ptosis. Given that periocular laxity will affect surgical prognosis, the preoperative evaluation of the associated laxity of the surrounding tissue is important. Other factors that may influence the operation include eyebrow position, supratarsal depression, skin laxity, orbital fat herniation, ptosis degree, and associated trichiasis. The normal vertical palpebral fissure height is 7 to 10 mm in male patients and 8 to 12 mm in female patients.1 The degree of ptosis can be classified on the basis of palpebral fissure height into the following: mild ptosis ≤2 mm, moderate ptosis 3 mm, and severe ptosis ≥4 mm (margin reflex distance 1 [MRD-1]: mild ≥2 mm, moderate 1 to 2 mm, severe ≤0 mm).2 In this study, we treated involutional ptosis, which is defined as the disinsertion of the aponeurosis. Levator muscle resection is the recommended surgical treatment for patients with moderate ptosis and levator function greater than 6 mm.3 In this paper, we describe a modified technique for levator muscle resection using the Putterman Müller’s muscle-conjunctival resection-ptosis clamp (Bausch & Lomb Storz Co., Manchester, MO).4-8 The modified surgical procedure allowed the objective design of levator muscle resection. METHODS We conducted the retrospective review of the case histories for 24 months. The review was performed with the approval of the Institutional Review Board of the Ethics Committee of Chang Gung Memorial Hospital, Taiwan. Patients who underwent levator muscle resection with the assistance of the Putterman ptosis clamp during the period of June to September 2014 were included in the study. Relevant data, including age, sex, ptosis degree, eyelid fissure height during dissection, MRD-1, and levator muscle function, were recorded.6,9,10 We conducted retrospective review to determine postoperative outcomes, including eyelid position, complications, and revision surgery. We excluded patients with a history of myasthenia graves, facial nerve palsy, and weakness of the frontalis muscle; those who underwent lower eyelid surgery or brow fixation surgery simultaneously with levator muscle resection; or those who underwent traditional levator muscle resection without the use of the Putterman ptosis clamp. During preoperative consultation, the patients were informed of the surgical side effects and risks associated with levator muscle resection. Side effects include eyelid hematoma, asymmetry, lagophthalmos, and dry eye. The procedure was performed by surgeon Dr. Yang, as follows:11 Preoperative contour drawing was followed by the administration of local anesthesia (1% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine) without sedation. Redundant skin and orbicularis muscle were removed through assisted electrocautery. Dissection was performed to expose the aponeurosis, and the herniated eyelid fat pad was then removed. The dissection was performed at a low wound margin to expose the tarsus. Loose septal and aponeurotic tissues were then clamped using the Putterman ptosis clamp. Loose tissue was removed by electrocautery (Figure 1). The aponeurosis was sutured to the tarsus with three stitches of 4-0 vicryl to adjust the height of the eyelid fissure. The orbicularis muscle was fixed to the aponeurosis with three stitches of 4-0 vicryl suture. The skin wound was continuously closed with 7-0 ethilone. The surgical steps are shown in Figure 2. The skin sutures were removed after 1 week. Postoperative care included the application of gentamicin eye ointment to the wound and ice packing twice per day. Figure 1. View largeDownload slide Application of the Putterman clamp demonstrated on an 87-year-old woman (case 3) at the loose levator aponeurosis and tissue removal with electrocautery. Figure 1. View largeDownload slide Application of the Putterman clamp demonstrated on an 87-year-old woman (case 3) at the loose levator aponeurosis and tissue removal with electrocautery. Figure 2. View large Download slide View large Download slide Diagram of the surgical technique. (A) Draw the surgical lines and remove the skin and orbicularis muscle with electrocautery. (B) Incise the septum with electrocautery. (C) Remove the excess eyelid fat pad. (D) Disinsert the levator aponeurosis and expose the tarsus. (E) Hold the loose septal and aponeurotic tissues with the Putterman ptosis clamp. (F) Cut the loose septal and aponeurotic tissues with electrocautery. (G) Fix the levator aponeurosis to the tarsus with 4-0 vicryl stitches. (H) Adjust the 4-0 vicryl stitches. (I) Fix the orbicularis muscle to the aponeurosis with 4-0 vicryl stitches. (J) Close the skin wound with 7-0 ethilone continuously. Figure 2. View large Download slide View large Download slide Diagram of the surgical technique. (A) Draw the surgical lines and remove the skin and orbicularis muscle with electrocautery. (B) Incise the septum with electrocautery. (C) Remove the excess eyelid fat pad. (D) Disinsert the levator aponeurosis and expose the tarsus. (E) Hold the loose septal and aponeurotic tissues with the Putterman ptosis clamp. (F) Cut the loose septal and aponeurotic tissues with electrocautery. (G) Fix the levator aponeurosis to the tarsus with 4-0 vicryl stitches. (H) Adjust the 4-0 vicryl stitches. (I) Fix the orbicularis muscle to the aponeurosis with 4-0 vicryl stitches. (J) Close the skin wound with 7-0 ethilone continuously. The patients were followed up after surgery in the outpatient department. Postoperative eyelid fissure height, MRD-1, periocular condition, and complications were recorded. Photographs were taken for documentation at each follow up. Any complaint or dissatisfaction that the patient had about the surgery was also recorded. Successful surgical outcome was defined as the decrease in bilateral eyelid fissure asymmetry to less than 1 mm and stable surgical effects at the end of the follow-up period without the need for revision surgery. RESULTS Over the period of June to September 2014, 17 patients were diagnosed with aponeurotic ptosis in both eyes (34 eyes). The patients then underwent levator muscle resection using the Putterman ptosis clamp. Seventeen patients (three men and 14 women) participated in the study. The average age of the patients was 71.9 years (range, 60-87 years). The demographic data of the patients are provided in Table 1. At the end of the study, all of the patients (34 eyes, 100%) experienced the complete resolution of ptosis and symptomatic improvement. Thirty-one eyes (91.2%) underwent surgery once and three eyes (8.8%) of two patients were reevaluated: one for bilateral dermatochalasis and another for the loss of the crease in the left eye. Photographs of the pre- and postoperative appearances of cases 2 and 16 are illustrated in Figures 3 and 4. No serious adverse side effects or responses were observed. Mean follow-up duration was 5.8 months (range, 1-24 months). The mean levator muscle unction of the patients was 10.9 mm (range, 5-15 mm). All patients had documented preoperative ptosis. The postoperative height of the eyelid fissure of the patients improved by an average of 2.4 mm (range, 0.5-4.5 mm). Table 1. Clinical Data of the Participants Case No.  Age (years)  Sex  Eye  Preoperative eyelid fissure (mm)  Postoperative eyelid fissure (mm)  Amount of improvement of eyelid fissure (mm)  Preoperative MRD-1 (mm)  Postoperative MRD-1 (mm)  Preoperative LMF (mm)  Complications  Follow-up duration (months)  1  72  M  OD  3  7  4  0  2  8  N/A  1  OS  4  6  2  0  1  8  N/A  2  79  F  OD  5  8.5  3.5  0  3.5  8  N/A  24  OS  3  9  6  0  4  5  Vicryl stitches exposed  3  87  F  OD  5  7  2  0  2  10  N/A  6  OS  6  7  1  0  2  10  N/A  4  61  F  OD  6.5  7.5  1  1.5  2  13  Vicryl stitches exposed  3  OS  5.5  7.5  2  1  2  13  N/A  5  78  F  OD  3  7.5  4.5  0  2  10  N/A  7  OS  4  8  4  0  2.5  10  N/A  6  76  F  OD  6  6.5  0.5  0  1  11  N/A  3  OS  5  7  2  0  2  9  N/A  7  73  F  OD  6  8  2  1  3  10  N/A  6  OS  5  8  3  0  3  10  N/A  8  76  F  OD  3  7  4  0  2  10  N/A  3  OS  3  7  4  0  2  10  N/A  9  60  M  OD  6  7.5  1.5  0.5  2.5  15  N/A  5  OS  5  8  3  0  3  13  N/A  10  71  F  OD  6  7.5  1.5  0  2  13  N/A  1  OS  6  7  1  0  1.5  13  N/A  11  61  M  OD  4  7  3  0  2  10  N/A  4  OS  5  7  2  0  2  10  N/A  12  72  F  OD  6  7.5  1.5  0.5  2.5  13  N/A  4  OS  7  7.5  0.5  0  2.5  13  N/A  13  81  F  OD  5  9  4  0  4  12  N/A  6  OS  5  9  4  0  4  12  N/A  14  78  F  OD  6  6  0  1  1  9  N/A  1  OS  5  6  1  0  1  8  N/A  15  75  F  OD  7  8  1  1.5  3  12  N/A  4  OS  6  8.5  2.5  1  3.5  10  N/A  16  63  F  OD  6.5  8.5  2  1  3  15  Dermatochalasis  9  OS  6.5  8.5  2  1  3  15  Dermatochalasis  17  60  F  OD  6  8  2  0.5  3  12  N/A  11  OS  6  8  2  0.5  3  12  Lost crease  Mean  71.9      5.2  7.6  2.4  0.3  2.4  10.9    5.8  Case No.  Age (years)  Sex  Eye  Preoperative eyelid fissure (mm)  Postoperative eyelid fissure (mm)  Amount of improvement of eyelid fissure (mm)  Preoperative MRD-1 (mm)  Postoperative MRD-1 (mm)  Preoperative LMF (mm)  Complications  Follow-up duration (months)  1  72  M  OD  3  7  4  0  2  8  N/A  1  OS  4  6  2  0  1  8  N/A  2  79  F  OD  5  8.5  3.5  0  3.5  8  N/A  24  OS  3  9  6  0  4  5  Vicryl stitches exposed  3  87  F  OD  5  7  2  0  2  10  N/A  6  OS  6  7  1  0  2  10  N/A  4  61  F  OD  6.5  7.5  1  1.5  2  13  Vicryl stitches exposed  3  OS  5.5  7.5  2  1  2  13  N/A  5  78  F  OD  3  7.5  4.5  0  2  10  N/A  7  OS  4  8  4  0  2.5  10  N/A  6  76  F  OD  6  6.5  0.5  0  1  11  N/A  3  OS  5  7  2  0  2  9  N/A  7  73  F  OD  6  8  2  1  3  10  N/A  6  OS  5  8  3  0  3  10  N/A  8  76  F  OD  3  7  4  0  2  10  N/A  3  OS  3  7  4  0  2  10  N/A  9  60  M  OD  6  7.5  1.5  0.5  2.5  15  N/A  5  OS  5  8  3  0  3  13  N/A  10  71  F  OD  6  7.5  1.5  0  2  13  N/A  1  OS  6  7  1  0  1.5  13  N/A  11  61  M  OD  4  7  3  0  2  10  N/A  4  OS  5  7  2  0  2  10  N/A  12  72  F  OD  6  7.5  1.5  0.5  2.5  13  N/A  4  OS  7  7.5  0.5  0  2.5  13  N/A  13  81  F  OD  5  9  4  0  4  12  N/A  6  OS  5  9  4  0  4  12  N/A  14  78  F  OD  6  6  0  1  1  9  N/A  1  OS  5  6  1  0  1  8  N/A  15  75  F  OD  7  8  1  1.5  3  12  N/A  4  OS  6  8.5  2.5  1  3.5  10  N/A  16  63  F  OD  6.5  8.5  2  1  3  15  Dermatochalasis  9  OS  6.5  8.5  2  1  3  15  Dermatochalasis  17  60  F  OD  6  8  2  0.5  3  12  N/A  11  OS  6  8  2  0.5  3  12  Lost crease  Mean  71.9      5.2  7.6  2.4  0.3  2.4  10.9    5.8  F, female; LMF, levator muscle function; M, male; MRD, margin reflex distance 1; OD, right eye; OS, left eye. View Large Table 1. Clinical Data of the Participants Case No.  Age (years)  Sex  Eye  Preoperative eyelid fissure (mm)  Postoperative eyelid fissure (mm)  Amount of improvement of eyelid fissure (mm)  Preoperative MRD-1 (mm)  Postoperative MRD-1 (mm)  Preoperative LMF (mm)  Complications  Follow-up duration (months)  1  72  M  OD  3  7  4  0  2  8  N/A  1  OS  4  6  2  0  1  8  N/A  2  79  F  OD  5  8.5  3.5  0  3.5  8  N/A  24  OS  3  9  6  0  4  5  Vicryl stitches exposed  3  87  F  OD  5  7  2  0  2  10  N/A  6  OS  6  7  1  0  2  10  N/A  4  61  F  OD  6.5  7.5  1  1.5  2  13  Vicryl stitches exposed  3  OS  5.5  7.5  2  1  2  13  N/A  5  78  F  OD  3  7.5  4.5  0  2  10  N/A  7  OS  4  8  4  0  2.5  10  N/A  6  76  F  OD  6  6.5  0.5  0  1  11  N/A  3  OS  5  7  2  0  2  9  N/A  7  73  F  OD  6  8  2  1  3  10  N/A  6  OS  5  8  3  0  3  10  N/A  8  76  F  OD  3  7  4  0  2  10  N/A  3  OS  3  7  4  0  2  10  N/A  9  60  M  OD  6  7.5  1.5  0.5  2.5  15  N/A  5  OS  5  8  3  0  3  13  N/A  10  71  F  OD  6  7.5  1.5  0  2  13  N/A  1  OS  6  7  1  0  1.5  13  N/A  11  61  M  OD  4  7  3  0  2  10  N/A  4  OS  5  7  2  0  2  10  N/A  12  72  F  OD  6  7.5  1.5  0.5  2.5  13  N/A  4  OS  7  7.5  0.5  0  2.5  13  N/A  13  81  F  OD  5  9  4  0  4  12  N/A  6  OS  5  9  4  0  4  12  N/A  14  78  F  OD  6  6  0  1  1  9  N/A  1  OS  5  6  1  0  1  8  N/A  15  75  F  OD  7  8  1  1.5  3  12  N/A  4  OS  6  8.5  2.5  1  3.5  10  N/A  16  63  F  OD  6.5  8.5  2  1  3  15  Dermatochalasis  9  OS  6.5  8.5  2  1  3  15  Dermatochalasis  17  60  F  OD  6  8  2  0.5  3  12  N/A  11  OS  6  8  2  0.5  3  12  Lost crease  Mean  71.9      5.2  7.6  2.4  0.3  2.4  10.9    5.8  Case No.  Age (years)  Sex  Eye  Preoperative eyelid fissure (mm)  Postoperative eyelid fissure (mm)  Amount of improvement of eyelid fissure (mm)  Preoperative MRD-1 (mm)  Postoperative MRD-1 (mm)  Preoperative LMF (mm)  Complications  Follow-up duration (months)  1  72  M  OD  3  7  4  0  2  8  N/A  1  OS  4  6  2  0  1  8  N/A  2  79  F  OD  5  8.5  3.5  0  3.5  8  N/A  24  OS  3  9  6  0  4  5  Vicryl stitches exposed  3  87  F  OD  5  7  2  0  2  10  N/A  6  OS  6  7  1  0  2  10  N/A  4  61  F  OD  6.5  7.5  1  1.5  2  13  Vicryl stitches exposed  3  OS  5.5  7.5  2  1  2  13  N/A  5  78  F  OD  3  7.5  4.5  0  2  10  N/A  7  OS  4  8  4  0  2.5  10  N/A  6  76  F  OD  6  6.5  0.5  0  1  11  N/A  3  OS  5  7  2  0  2  9  N/A  7  73  F  OD  6  8  2  1  3  10  N/A  6  OS  5  8  3  0  3  10  N/A  8  76  F  OD  3  7  4  0  2  10  N/A  3  OS  3  7  4  0  2  10  N/A  9  60  M  OD  6  7.5  1.5  0.5  2.5  15  N/A  5  OS  5  8  3  0  3  13  N/A  10  71  F  OD  6  7.5  1.5  0  2  13  N/A  1  OS  6  7  1  0  1.5  13  N/A  11  61  M  OD  4  7  3  0  2  10  N/A  4  OS  5  7  2  0  2  10  N/A  12  72  F  OD  6  7.5  1.5  0.5  2.5  13  N/A  4  OS  7  7.5  0.5  0  2.5  13  N/A  13  81  F  OD  5  9  4  0  4  12  N/A  6  OS  5  9  4  0  4  12  N/A  14  78  F  OD  6  6  0  1  1  9  N/A  1  OS  5  6  1  0  1  8  N/A  15  75  F  OD  7  8  1  1.5  3  12  N/A  4  OS  6  8.5  2.5  1  3.5  10  N/A  16  63  F  OD  6.5  8.5  2  1  3  15  Dermatochalasis  9  OS  6.5  8.5  2  1  3  15  Dermatochalasis  17  60  F  OD  6  8  2  0.5  3  12  N/A  11  OS  6  8  2  0.5  3  12  Lost crease  Mean  71.9      5.2  7.6  2.4  0.3  2.4  10.9    5.8  F, female; LMF, levator muscle function; M, male; MRD, margin reflex distance 1; OD, right eye; OS, left eye. View Large Figure 3. View largeDownload slide (A) Preoperative appearance of a 79-year-old woman (case 2) with bilateral ptosis, more severe ptosis in the left eye. (B) One week after the surgery, showing limited eyelid ecchymosis and swelling. (C) One month after the surgery, showing good recovery and symmetry. (D) Two years after the surgery, showing stable surgical effects. Figure 3. View largeDownload slide (A) Preoperative appearance of a 79-year-old woman (case 2) with bilateral ptosis, more severe ptosis in the left eye. (B) One week after the surgery, showing limited eyelid ecchymosis and swelling. (C) One month after the surgery, showing good recovery and symmetry. (D) Two years after the surgery, showing stable surgical effects. Figure 4. View largeDownload slide (A) Preoperative appearance of a 63-year-old woman (case 16) with bilateral ptosis. (B) One week after the surgery, showing limited eyelid ecchymosis and swelling. (C) Three months after the surgery, showing bilateral dermatochalasis. (D) Three months after revision surgery for dermatochalasis, showing good recovery and symmetry. Figure 4. View largeDownload slide (A) Preoperative appearance of a 63-year-old woman (case 16) with bilateral ptosis. (B) One week after the surgery, showing limited eyelid ecchymosis and swelling. (C) Three months after the surgery, showing bilateral dermatochalasis. (D) Three months after revision surgery for dermatochalasis, showing good recovery and symmetry. Seven patients (41%) had minor complaints 1 week after the surgery. One month after surgery, six patients (35%) had minor complaints. Three months after surgery, only one patient (0.6%) complained about losing the crease of the left eye. At the end of the follow-up period, none of the patients (0%) had complaints about the surgical results. Results indicated that the patients were satisfied with the outcome of the modified technique for levator muscle resection. DISCUSSION Several options exist for the treatment of involutional ptosis, a common problem faced by the elderly. Severe cases of ptosis, however, necessitate the removal of excess tissue. The traditional surgical method for levator muscle resection includes a time-consuming dissection that may cause tissue trauma and swelling. Moreover, its success depends on the experience of the surgeon. The results of dissection or tissue removal may be related to the occurrence of lagophthalmos or dry eye, and inadequate tissue removal will impair the surgical effect of levator muscle resection. The use of the Putterman ptosis clamp provides an objective method for the surgical design and removal of the appropriate tissue volume during the operation. The Putterman ptosis clamp aids levator muscle resection without massive bleeding and tissue hematoma. In addition, the use of the Putterman ptosis clamp shortens the duration of surgery and postoperative recovery, as observed by the surgeon. Dr. Yang published a preliminary three-case report in June 2016.11 Compared with the preliminary reports in 2016, this study included more participants and longer follow-up time for evaluating the surgical effects and complications of the modified technique for levator muscle resection. We will perform comparative studies in the future. The use of a clamp to hold the levator muscle during the resection of the levator palpebrae is not a new method. In 1952, Berke reported the use of a ptosis clamp for holding the levator muscle during resection.12 Keyhani used a ptosis clamp for the surgical correction of congenital ptosis through anterior levator resection in 2007.13 The Putterman ptosis clamp was first devised in 1972 to replace the two curved hemostats used in the Fasanella-Servat ptosis operation.4 It relieves ptosis by strengthening the Müller muscle through resection and advancement. In 1974, Putterman first reported the use of the clamp in the transconjunctivally isolated resection of levator palpebrae superioris (LPS).5 Without removing the clamp, he transferred the LPS aponeurosis from the internal transconjunctival to the external transcutaneous position. In recent years, the Putterman Müller’s muscle-conjunctival resection-ptosis clamp has been popularly used for conjunctival müllerectomy.7,8 We noticed that its application in levator muscle resection as a muscular clamp is as good as that in müllerectomy. The case series we described illustrates that the modified method for levator muscle resection is a facile and safe procedure that can be used with good success for patients with moderate-to-severe ptosis. In this series, we did not observe any severe complications, and all patients had noticeable symptomatic improvement. The success rate showed that approximately 91.2% of the included ptosis cases were resolved without the need for revisions. Eyelid fissure height and MRD-1 had a mean improvement of 2.4 and 2.1 mm, respectively. These results indicated that elderly patients tolerated the procedure well. In addition, the surgery included resecting excess redundant skin, eyelid fat pad, septal tissue, and levator muscle. Appropriate tissue removal is the key for the satisfactory reconstruction of the appearance of elderly patients. The upper eyelid elevators consist of a levator muscle and Müller muscle. Putterman-Müller’s clamp was designed for müllerectomy via the conjunctival side. We observed that Müller muscle-conjunctival resection and our modified levator muscle resection using the Putterman ptosis clamp provided better contours than the traditional levator muscle resection. Although the Müller muscle-conjunctival resection ptosis procedure has a shorter operative time, levator muscle resection achieves better corrective result through the removal of the redundant eyelid fat pad, septal tissue, and skin. In contrast to the upper eyelid anatomy of Caucasians, that of Asians exhibits the fusion of the orbital septum to the levator aponeurosis at variable distances below the superior tarsal border and the presence of a preaponeurotic fat pad protrusion and a thick subcutaneous fat layer.14 Thus, the redundant fat pad, septal tissue, and skin should be removed to create the ideal appearance for Asian patients. Supratarsal depression, including enophthalmos, and decreased orbital fat and eyelid fat pad are associated with ptosis. We can preserve more eyelid fat pad for patients with supratarsal depression during the surgery. In Asian patients with ptosis, however, redundant eyelid fat pads should be removed. The amount of levator muscle resected in this procedure was based on the intraoperative objective assessment of the laxity using the clamp. A novice oculoplastic surgeon must be careful to not remove excessive aponeurotic tissue. We suggest leaving 1 mm of redundant central aponeurotic tissue for further adjustment during the surgery. For an experienced surgeon, we suggest leaving approximately 1 mm tissue as measured through visual inspection; otherwise, an ophthalmic scale placed between the superior border of the tarsus and the Putterman ptosis clamp is helpful for measuring the height of excess tissue. The redundant tissue could be preserved or resected later on the basis of the appearance of the palpebral fissure after the first levator tarsal connection with the 4-0 vicryl stitch. Surgeons should make this decision during the surgery. We found, however, that most of the palpebral fissures had an ideal height after the first central fixation. We also found that the small amount of tissue allowance helped prevent lagophthalmos and improve the postoperative contour of the eyelid. A recent prospective study reported by Zigiotti et al15 showed that the resection of the anterior levator muscle with the assistance of the Putterman ptosis clamp has a 92% success rate. A continuous suture was placed at the base of the clamp before muscle removal. The amount of resectioned tissue was decided preoperatively. Our method is different from Zigiotti’s method because in our method, we left 1 mm of redundant central aponeurotic tissue to control the height of the eyelid fissure. The degree of excision was determined by objectively placing the clamp during the operation. The 1 mm tissue allowance enabled us to adjust eyelid height during the fixation of the levator muscle to the tarsus to achieve an ideal postoperative appearance. We applied the Putterman ptosis clamp to modify the method for levator muscle resection. Similar to the traditional method for levator muscle resection, the aponeurosis was cut free at its insertion site at the anterior surface of the tarsus to expose the superior tarsal border. In our modified technique, we removed the loose levator aponeurosis with the assistance of the clamp and did not dissect the levator muscle. Although most parts of the resected tissue were aponeurotic, the surgical effect was good. Unlike in the surgical method for levator aponeurosis advancement, we resected parts of the levator aponeurosis during surgery.16 We found that tissue bleeding and swelling remarkably decreased during the modified method for levator muscle resection compared with that during the traditional method for levator muscle resection. These beneficial effects may be related to the shortened duration of tissue dissection. An experienced surgeon may find that adjusting eyelid height during the modified technique is easier because tissue swelling during the modified technique is lower than during the traditional method. Accidental injury to the lacrimal gland is a concern during the use of the Putterman ptosis clamp. However, no problems with the patients’ eyes were recorded at the end of the follow-up series. The lateral upper area was spared from the clamp during use. Therefore, the chance of injury to the lacrimal gland was low. This case series describes a novel technique for the treatment of ptosis and its initial surgical results. The limitations of this study include its retrospective design, limited follow-up period, and small patient population. A large series or comparative studies would be useful in the future. CONCLUSIONS The modified levator muscle resection enabled the objective design of tissue removal. It decreases tissue trauma and has a high success rate. This technique is a useful adjunct to the current treatment options for ptosis. Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Kanski JJ, ed. Clinical Ophthalmology: A Systematic Approach: 5th Edition . India: Butterworth Heinemann Publishing; 2003: 32- 39. 2. Garg A, Alió JL, ed. Surgical Techniques in Ophthalmology (Oculoplasty and Reconstructive Surgery) . India: Jaypee Brothers Medical Publishing; 2010: 33. 3. Garg A, Alió JL, ed. Surgical Techniques in Ophthalmology (Oculoplasty and Reconstructive Surgery) . India: Jaypee Brothers Medical Publishing; 2010: 67. 4. 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- 667. Google Scholar CrossRef Search ADS PubMed  5. Putterman AM. A clamp for the transconjunctival isolation and transcutaneous resection of the levator palpebrae superioris muscle operation. Am J Ophthalmol . 1974; 78( 3): 533- 534. Google Scholar CrossRef Search ADS PubMed  6. Putterman AM, Urist MJ. Müller muscle-conjunctiva resection. Technique for treatment of blepharoptosis. Arch Ophthalmol . 1975; 93( 8): 619- 623. Google Scholar CrossRef Search ADS PubMed  7. Putterman AM, Fett DR. Müller’s muscle in the treatment of upper eyelid ptosis: a ten-year study. Ophthalmic Surg . 1986; 17( 6): 354- 360. Google Scholar PubMed  8. Putterman AM. Müllers muscle-conjunctival resection ptosis procedure. Aust N Z J Ophthalmol . 1985; 13( 2): 179- 183. Google Scholar CrossRef Search ADS PubMed  9. Nerad JA, ed. Techniques in Ophthalmic Plastic Surgery: A Personal Tutorial . China: Elsevier Health Sciences Publishing; 2010: 211. 10. Nema HV, Nema N, ed. Recent Advances in Ophthalmology-10 . India: Jaypee Brothers Medical Publishing; 2011: 310- 311. 11. Yang JW. Management of senile ptosis with levator muscle resection using the putterman clamp. Plast Reconstr Surg Glob Open . 2016; 4( 6): e726. Google Scholar CrossRef Search ADS PubMed  12. Berke RN. A ptosis clamp for holding the levator muscle during resection of the levator palpebrae muscle. Trans Am Acad Ophthalmol Otolaryngol . 1952; 56( 5): 736. Google Scholar PubMed  13. Keyhani K, Ashenhurst ME. Modified technique and ptosis clamp for surgical correction of congenital pediatric ptosis by anterior levator resection. Facial Plast Surg . 2007; 23( 3): 156- 161. Google Scholar CrossRef Search ADS PubMed  14. Jeong S, Lemke BN, Dortzbach RK, Park YG, Kang HK. The Asian upper eyelid: an anatomical study with comparison to the Caucasian eyelid. Arch Ophthalmol . 1999; 117( 7): 907- 912. Google Scholar CrossRef Search ADS PubMed  15. Zigiotti GL, Delia G, Grenga Pet al.   Elevator Muscle Anterior Resection: A New Technique for Blepharoptosis. J Craniofac Surg . 2016; 27( 1): 201- 203. Google Scholar CrossRef Search ADS PubMed  16. Waqar S, McMurray C, Madge SN. Transcutaneous blepharoptosis surgery - advancement of levator aponeurosis. Open Ophthalmol J . 2010; 4: 76- 80. Google Scholar CrossRef Search ADS PubMed  © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
TI - Modified Levator Muscle Resection Using Putterman Muller's Muscle-Conjunctival Resection-Ptosis Clamp
JO - Aesthetic Surgery Journal
DO - 10.1093/asj/sjx187
DA - 2018-05-01
UR - https://www.deepdyve.com/lp/oxford-university-press/modified-levator-muscle-resection-using-putterman-muller-s-muscle-Ld0alWtobN
SP - 480
EP - 487
VL - 38
IS - 5
DP - DeepDyve
ER -