Reply re: “Conjunctiva-Sparing Posterior Ptosis Surgery

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We would like to thank Drs. Kikkawa and Lucarelli for calling our attention to a very important article written by Dr. Dortzbach.1 Dr. Dortzbach described a technique for poster ptosis repair that preserves the conjunctiva, and in this way is similar in spirit to the technique that we described. There are however critical differences between the operation published by Dr. Dortzbach and our conjunctiva-sparing technique. In particular, Dr. Dortzbach describes a dissection plane between the Mueller’s muscle and the levator prior to initiating a dissection plane between the Muller’s muscle and the conjunctiva. With the Muller’s muscle completely isolated from the conjunctiva and levator muscle, Dr. Dortzbach described excising the distal 10 mm to 12 mm of Muller’s muscle. The proximal Muller’s muscle and conjunctiva would then be sutured to the superior border of the tarsus.1
A critical difference between Dr. Dortzbach’s technique and ours is the dissection plane between the Mueller’s muscle and the levator. In our technique, we do not initiate a dissection plane between the Mueller’s muscle and the levator; instead, we describe a window pane conjunctival dissection, leaving the attachments between the Muller’s muscle and the levator intact. We believe that it is possible that the attachments between the Muller’s muscle and levator are important for the efficacy of the posterior approach to ptosis repair. In addition, rather than excising the distal portion of the Muller’s muscle, we use a Putterman-style clamp and sutures to plicate and advance the Muller’s muscle prior to excising the intervening muscle in the clamp. This effectively shortens the Muller’s muscle without disrupting the attachments of the distal Muller’s muscle to the tarsus.2
Finally, Dr. Dortzbach describes a sutured closure of the conjunctiva at the completion of his procedure.1 In our technique, we replace the conjunctival flap in the normal anatomical position without sutured closure. Avoiding sutures in this location minimizes the risk of suture-related complications postoperatively, such as corneal abrasion or irritation, and is we believe one of the major advantages of our technique.2
We would like to sincerely thank Drs. Kikkawa and Lucarelli for calling attention to this seminal article by Dr. Dortzbach and agree it deserves citation in any article concerning posterior approach ptosis surgery techniques.
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