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Palpebral ptosis
PALPEBRAL PTOSIS Correction by Transplant of Fascia Lata By ROBERTO FARINA and PLINIO DE TOLEDO PIZA
From the Department of Plastic Surgery and the Ophthalmological Clinic, Hospital das Clinicas, Brazil Definition.--By ptosis is understood the drooping of the upper eyelid so that it falls below its normal level. )Etiology.--Ptosis may arise from lesions or processes affecting either the muscular or the nervous systems, or both simultaneously. In the former case the levator muscle is affected ; in the latter case ptosis may arise from lesions of the sympathetic nervous system (innervating Miiller's muscle) or the cranial nerves (third nerve), innervating the levator muscle of the upper eyelid. There are two types of ptosis, the false and the true. The false, or pseudoptosis, occurs as the result of specific processes situated in one of the anatomical component parts of the eyelid, and may therefore be of cutaneous, muscular, tarsal, or conjunctival origin. On the other hand, enucleation and microophthalmia itself may be responsible for May's pseudo-ptosis or mechanical ptosis (May, 1941). These cases are not usually operated on unless, after curing the process responsible for the pseudo-ptosis, a true ptosis follows as the resuk. True ptosis may be congenital or hereditary and acquired. The hereditary type is generally bilateral and is due to the absence or incomplete development of the levator muscle of the upper eyelid or to agenesis of the third nucleus. Acquired ptosis is generally unilateral and due to third nerve motor paralysis. Symptornatology.--According to Parsons and Duke Elder (I948), in total paralysis of the third nucleus there is a palpebral ptosis that masks the appearance of the diplopia ; there is also paralysis of the entire external ocular muscles with the exception of the superior oblique (fourth nerve) and the external rectus muscle (sixth nerve). When the upper eyelid is raised the eyeball appears deviated outwards and slightly downwards owing to the action of the two unaffected muscles. There are immobility and semi-dilatation of the pupil (mydriasis) added to which there is absence of accommodation. Owing to loss of tonus of the paralysed muscles there is a slight degree of proptosis (exophthalmos). Restriction of ~ movement upwards and, to a slight extent, downwards of the eyeball is observed. A crossed diplopia appears when the eyelid is raised, the false image being higher. An incomplete paralysis of the third nerve often occurs, isolated muscles then being occasionally affected. Obviously, from the physio-pathological point of view, all these facts interfere with the sight. The eyelid droops and covers the pupil ; the palpebral rim is greatly reduced so that the patient, in order to see, not only contracts the frontal muscle, thereby knitting his brow and raising the superciliary region, but also x4~
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inclines his head backwards, assuming a peculiar and characteristic position. In a unilateral ptosis, therefore, the eyebrow of the affected side remains at a higher level than that of the sound one. TREATMENT
The choice of method depends upon the type of ptosis. On this point we agree with the majority of writers on the subject (Arruga, I946 ; Malbran and Nocito, I947; Vanrell, I948). On the other hand, we must also agree wkh Valerio (I939) when he declares that there is perhaps no other question in ophthalmology which is open to such a wide divergence of opinion. Smith (I95O) reported t h e existence of some fifty-seven different methods of treatment for ptosis. Such a high figure clearly shows that with none of these methods are the results entirely satisfactory. When the ptosis is complete and the levator muscle of the upper eyelid partly retains its function, Blaskovics' (Blaskovics and Kreiker, I947) operation is indicated (musculo-tarsal reduction). When a paralysis of the levator muscle is total, but the rectus muscle retains its function, an operation is indicated which aims at combining the action of these two muscles (Motais, Nida). When the superior rectus muscle and the levator of the upper eyelid are paralysed, we have to resort to the adjuvant action of the occipito-frontal muscle (Lexer and Wiener, quoted by Kirschner, 194o). Generally speaking, however, we find that the Wiener-Lexer technique is satisfactory for correcting all ptosis, independently of the site of the lesion and of whether they are complete or incomplete, unilateral or bilateral, congenital or acquired. After plastic treatment, of course, there remains the actual ocular problem kself (strabismus), which must undergo either purely orthoptic or surgical treatment, or both simukaneously. Operation.--A Iocal anmsthetic is employed and cleansing carried out with iodine-alcohol. The following steps are carried out :-I. Horizontal incision AB right in the centre of the super,~X.~'~) ciliary region, 2 cm. in length (Fig. I). 2. Incision parallel to the ciliar border CD, separated from the border itself by 2 mm. and length varying from _~l I to I'5 cm. ~----z~ ] 3. Make two channels AC and BD by divulsion, joining /~", ~ ( together the two lateral extremes, also medially. We also make two more channels by divulsion, one pretarsal CD and the other retrofrontal (frontal muscle) XX 1. 4. Incision of about IO cm. on the anterior lateral surface of the thigh up to the aponeurosis (fascia lata). Removal of strip of fascia lata of Io cm. by 3 mm. 5. Introduction of the graft into the channels previously made so as to form an irregular quadrilateral XCDX 1. Suture Fro. ~ of the graft (fascia lata) with fine cotton at the tarsus (two Scheme of stitches, one at each angle C and D) and at the frontal muscle operation. (also one at each angle X and X 1) respectively. 6. Closure of the operative wounds with fine cotton. Vaseline dressing for ten days : penicillin post-operatively.
\
PALPEBRAL PTOSIS
I43
CASE REPORTS
Case i (Fig. 2) (M. J. B., aged 20 years).--Ophthalmological Clinic. Operation, 7th January x949. Right eye : total traumatic ptosis since I947 (evisceration performed 29th September i948). Left eye :normaI. Case z (Fig. 3) (U. M. S., aged 23 years).--Ophthalmological Clinic. 9th July i948. Both eyes : partial congenital palpebral ptosis.
Operation,
Case 3 (Fig. 4) (G. P. S., aged 22 years).--Ophthalmological Clinic. I3th February i95 o. Both eyes : partial congenital palpebral ptosis.
Operation,
Case 4 (Fig. 5) (G. L., aged Ix years).--Ophthalmological Clinic. Operation, x2th March 1948. Right eye : total traumatic palpebral ptosis, I944. Left eye : the left eye goes up (sursum vergens) when the right one is fixed ; when the left eye is fixed the right one moves downward (deorsum vergens). Case 5 (Fig. 6) (L. G.A., aged 22 years).--Ophthalmological Clinic. Operation, 19th May I95 o. Left eye: partial congenital palpebral ptosis. Normal extrinsic muscles. Right eye : normal. Case 6 (Fig. 7) (M. F. J., aged I8 years).--Ophthalmological Clinic. Operation, I6th July I948. Right eye: total congenital palpebral ptosis ; paralytical divergent strabismus ; internal, superior, and inferior rectus muscles palsied. Case 7 (Fig. 8) (P. L., aged 5 years).--Private Clinic. total congenital palpebral ptosis. Right eye : normal.
Operation, 1949. Left eye :
Case 8 (Fig. 9) (M. A. Z., aged 5 years).--Operation, i7th June 1949. Left eye : congenital palpebral ptosis. Discrete functional convergent strabismus. Right eye : normal. Case 9 (Fig. IO) (A. D. M., aged 7 years).--Ophthalmological Clinic. Operation, 9th May I95I. Both eyes : partial congenital palpebral ptosis ; normal function of the superior rectus muscle. Left eye : functional convergent strabismus. Case io (Fig. II) (F. S., aged 56 years).~Ophthalmological Clinic. Operation/' 2oth December I95o. Left eye: post-surgical palpebral ptosis since I949 ; normal function of the superior rectus muscle. Right eye : normal. Case i i (Fig. I2) (W. L. A., aged 2I years).~Ophthalmological Clinic. Operation, I3th July I95 I. Both eyes: congenital palpebral ptosis ; integrity of the extrinsic musculature. Case x2 (Fig. x3) (D. D. M., aged23 years).~Ophthalmological Clinic. Operation, Ixth July 195 I. Both eyes: congenital palpebral ptosis ; integrity of the extrinsic musculature. Case 13 (Fig. I4) (M. L. A., aged 3° years).--Ophthalmological Clinic. Operation, x5th January I951. Right eye: paralytic palpebral ptosis five years ago. Left eye : normal. Case x4 (Fig. 15) (R. N., aged 14 years).--Ophthalmological Clinic. Operation, 1st October I95o. Right eye : congenital palpebral ptosis. Left eye : normal.
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FIG. 3
2
FIG. 4
FIG. 5
FIG. 6
FIG. 7
FIG. 8
FIG. 9 Cases 2 to 9.
Before and after operation.
PALPEBRAL
PTOSIS
145
FIG. IO
FIG. I I
FIG. 13
FIG. I2
FIG. 15
FIG. 14 Cases io to 15.
Before and after o p e r ~ i o n .
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REMARKS It is a conditio sine qua non for carrying out the method we are studying that there should be functional integrity of the occipitofrontal muscle. Some writers (Malbran and Nocito, I947) find that the processes which utilise the action of the frontal muscle altogether constitute an antiphysiological resource and are of relative efficiency. We do not agree with this opinion : first, because the good results obtained by us are here to attest the efficiency of the method ; secondly, because we think "antiphysiological" is a very strong term to use. On what grounds should we consider the action of the frontal muscle as being antiphysiological in cases of ptosis if that muscle is natural, spontaneous, and unconsciously solicited, coming into play, although not correct, it at least reduces the functional deficiency of the affected eyelid ? It being an accessory muscle of thg elevating function of the superior eyelid, that we should have recourse to it whe~ that function weakens or disappears, is just and physiological. Moreover, the suppletory action of the frontal muscle when solicited, besides the good results and advantages it gives, does not present any of the inconveniences arising from other methods. Thus Lindner (quoted by Valerio, I939) finds that Blaskovics' technique with tarsectomy may be dangerous not only by opening a communication with the retro-orbital region but also because, if the incision of the tarso-orbital is a generous one, a very disagreeable fatty hernia may appear. Moreover its use is confined to cases of incomplete ptosis and with part preservation of the elevating function. Motais, in turn, provokes a kind of virtual symblepharon between the eyelid and the eyeball, once the movements of the former become the function of the latter. One is compelled to admit, in addition to all this, that there must be a weakening of the superior rectus muscle besides its being overloaded with the weight of the eyelid. Hence one infers that important modifications are established in the static and dynamic balance of the eyeball. According to valerio (I939), there would be unilateral hypophoria (axes of vision not of the same plane) or e v e n appearance of an actual strabismus " deorsum vergens " with diplopia through predominance of the antagonic muscles. Motais as well as Nida have their supporters (Bourguet, I93O; Di Marzio, quoted by Caramazza, I942; Valerio, I939). Both demand as a premise that the superior rectus be entire, which does not always happen because the third nerve is the one common to the superior rectus and to the levator of the eyelid. The utilisation of the function of the occipito-frontal muscle is defended by many writers (Blair et al., I932 ; Figi, I95 o ; Pickerill, I949 ; Zeno, I944). As happens with other methods it also has its little drawbacks. Thus in some cases we note a slight effacement of the orbito-palpebral sulcus ; a withdrawal of the eyelid from the eyeball when the eye is forced open : in using a fascia lata transplant we are obliged to make a fresh scar on the donating area (the thigh). But to compensate for these slight drawbacks the method has the advantage that it may be used for any type of ptosis besides being propitious to very satisfactory results. SUMMARY The authors consider palpebral ptosis an a~sthetico-functional defect of serious consequence. They show the physiological mechanism of the method
PALPEBRAL
PTOSIS
147
which, in spite of being indirect, may be applied to all types of blepharoptosis ; they make a few comments as to the occasion of and precautions necessary during the intervention, and stress the slight inconveniences. REFERENCES ARRUGA, H. (1946). " Cirurgia Ocular." Buenos Aires : Ed. Salvat. BLAIR, V. P., BROWN, J. H., and HAMM, W. G. (I932). Arch. Ophthal., 7, 83I. BLaSKOVrCS, L., and KRmKER, A. (I947). " Cirurgia de los ojos." Buenos Aires : Ed. Salvat. BOURGUET (I930). " Reflexions sur le traitement chirurgical du ptosis congenital. Congr6s. Comptes rendus des s6ances. Soci6t6 Scientifique Fran~aise de Chirurgie r6paratrice plastique et esthetique," p. 57. Paris : Ed. Maloine. CARAMAZZA, F. (I942). " Sulla blefaroplastica. Atti del congresso Europeo de chirurgia plasfica di guerra." La chirurgia Plastica, 229. DI MARZlO. Quoted by Caramazza (1942). FIGI, F. A. (195o). Plast. reconstr. Surg., 5, 4o3 • KIRSCHNER, M. (194o). " Tratado de tecnica operatoria general y especial," vol. ii. Rio de Janeiro : Ed, Labor S.A. LEXER and WIENER. Quoted by Kirschner (194o). LINDNER. Quoted by Valerio (1939). MALBRAN, J. L., and GARClA NOCITO, P. F. (I947). " Plasticas palpebrales y conjuntivales." Buenos Aires : Ed. E1 Ateneo. MAY, C. H. (1941). " M a n u a l de doenqas dos olhos." Rio de Janeiro : Ed. Scientifica. PARSONS, Sir JOHN, and DUKE-ELDER, Sir STEWART (1948). " Diseases of the Eye." New York : Macmillan. PICKERILL, C. (1949). Brit. J. plast. Surg., 2, 116. SMITH, F. (195o). " Plastic and Reconstructive Surgery." Philadelphia and L o n d o n : W. B. Saunders Co. VALERIO, M. (1939). " Contributo allo studio del trattamento chirurgico della ptosi palpebrale con particulare riguardo all'introduzione della tecnica di Nida." La chirurgia Plastica, 3, 107VANRELL, F. G. (I948). " Enfermedades de los pfirpados." Buenos Aires : Ed. Salvat. ZENO, L. (1944). " Ptosis palpebral congenita," vol. i, p. 425 . 3 ° Congr. Lat. Amer. Cir. Plastica~ Santiago do Chile : Artes y Letras Ltda.
From the Department of Plastic Surgery and the Ophthalmological Clinic, Hospital das Clinicas, Brazil Definition.--By ptosis is understood the drooping of the upper eyelid so that it falls below its normal level. )Etiology.--Ptosis may arise from lesions or processes affecting either the muscular or the nervous systems, or both simultaneously. In the former case the levator muscle is affected ; in the latter case ptosis may arise from lesions of the sympathetic nervous system (innervating Miiller's muscle) or the cranial nerves (third nerve), innervating the levator muscle of the upper eyelid. There are two types of ptosis, the false and the true. The false, or pseudoptosis, occurs as the result of specific processes situated in one of the anatomical component parts of the eyelid, and may therefore be of cutaneous, muscular, tarsal, or conjunctival origin. On the other hand, enucleation and microophthalmia itself may be responsible for May's pseudo-ptosis or mechanical ptosis (May, 1941). These cases are not usually operated on unless, after curing the process responsible for the pseudo-ptosis, a true ptosis follows as the resuk. True ptosis may be congenital or hereditary and acquired. The hereditary type is generally bilateral and is due to the absence or incomplete development of the levator muscle of the upper eyelid or to agenesis of the third nucleus. Acquired ptosis is generally unilateral and due to third nerve motor paralysis. Symptornatology.--According to Parsons and Duke Elder (I948), in total paralysis of the third nucleus there is a palpebral ptosis that masks the appearance of the diplopia ; there is also paralysis of the entire external ocular muscles with the exception of the superior oblique (fourth nerve) and the external rectus muscle (sixth nerve). When the upper eyelid is raised the eyeball appears deviated outwards and slightly downwards owing to the action of the two unaffected muscles. There are immobility and semi-dilatation of the pupil (mydriasis) added to which there is absence of accommodation. Owing to loss of tonus of the paralysed muscles there is a slight degree of proptosis (exophthalmos). Restriction of ~ movement upwards and, to a slight extent, downwards of the eyeball is observed. A crossed diplopia appears when the eyelid is raised, the false image being higher. An incomplete paralysis of the third nerve often occurs, isolated muscles then being occasionally affected. Obviously, from the physio-pathological point of view, all these facts interfere with the sight. The eyelid droops and covers the pupil ; the palpebral rim is greatly reduced so that the patient, in order to see, not only contracts the frontal muscle, thereby knitting his brow and raising the superciliary region, but also x4~
142
BRITISH
JOURNAL
OF PLASTIC
SURGERY
inclines his head backwards, assuming a peculiar and characteristic position. In a unilateral ptosis, therefore, the eyebrow of the affected side remains at a higher level than that of the sound one. TREATMENT
The choice of method depends upon the type of ptosis. On this point we agree with the majority of writers on the subject (Arruga, I946 ; Malbran and Nocito, I947; Vanrell, I948). On the other hand, we must also agree wkh Valerio (I939) when he declares that there is perhaps no other question in ophthalmology which is open to such a wide divergence of opinion. Smith (I95O) reported t h e existence of some fifty-seven different methods of treatment for ptosis. Such a high figure clearly shows that with none of these methods are the results entirely satisfactory. When the ptosis is complete and the levator muscle of the upper eyelid partly retains its function, Blaskovics' (Blaskovics and Kreiker, I947) operation is indicated (musculo-tarsal reduction). When a paralysis of the levator muscle is total, but the rectus muscle retains its function, an operation is indicated which aims at combining the action of these two muscles (Motais, Nida). When the superior rectus muscle and the levator of the upper eyelid are paralysed, we have to resort to the adjuvant action of the occipito-frontal muscle (Lexer and Wiener, quoted by Kirschner, 194o). Generally speaking, however, we find that the Wiener-Lexer technique is satisfactory for correcting all ptosis, independently of the site of the lesion and of whether they are complete or incomplete, unilateral or bilateral, congenital or acquired. After plastic treatment, of course, there remains the actual ocular problem kself (strabismus), which must undergo either purely orthoptic or surgical treatment, or both simukaneously. Operation.--A Iocal anmsthetic is employed and cleansing carried out with iodine-alcohol. The following steps are carried out :-I. Horizontal incision AB right in the centre of the super,~X.~'~) ciliary region, 2 cm. in length (Fig. I). 2. Incision parallel to the ciliar border CD, separated from the border itself by 2 mm. and length varying from _~l I to I'5 cm. ~----z~ ] 3. Make two channels AC and BD by divulsion, joining /~", ~ ( together the two lateral extremes, also medially. We also make two more channels by divulsion, one pretarsal CD and the other retrofrontal (frontal muscle) XX 1. 4. Incision of about IO cm. on the anterior lateral surface of the thigh up to the aponeurosis (fascia lata). Removal of strip of fascia lata of Io cm. by 3 mm. 5. Introduction of the graft into the channels previously made so as to form an irregular quadrilateral XCDX 1. Suture Fro. ~ of the graft (fascia lata) with fine cotton at the tarsus (two Scheme of stitches, one at each angle C and D) and at the frontal muscle operation. (also one at each angle X and X 1) respectively. 6. Closure of the operative wounds with fine cotton. Vaseline dressing for ten days : penicillin post-operatively.
\
PALPEBRAL PTOSIS
I43
CASE REPORTS
Case i (Fig. 2) (M. J. B., aged 20 years).--Ophthalmological Clinic. Operation, 7th January x949. Right eye : total traumatic ptosis since I947 (evisceration performed 29th September i948). Left eye :normaI. Case z (Fig. 3) (U. M. S., aged 23 years).--Ophthalmological Clinic. 9th July i948. Both eyes : partial congenital palpebral ptosis.
Operation,
Case 3 (Fig. 4) (G. P. S., aged 22 years).--Ophthalmological Clinic. I3th February i95 o. Both eyes : partial congenital palpebral ptosis.
Operation,
Case 4 (Fig. 5) (G. L., aged Ix years).--Ophthalmological Clinic. Operation, x2th March 1948. Right eye : total traumatic palpebral ptosis, I944. Left eye : the left eye goes up (sursum vergens) when the right one is fixed ; when the left eye is fixed the right one moves downward (deorsum vergens). Case 5 (Fig. 6) (L. G.A., aged 22 years).--Ophthalmological Clinic. Operation, 19th May I95 o. Left eye: partial congenital palpebral ptosis. Normal extrinsic muscles. Right eye : normal. Case 6 (Fig. 7) (M. F. J., aged I8 years).--Ophthalmological Clinic. Operation, I6th July I948. Right eye: total congenital palpebral ptosis ; paralytical divergent strabismus ; internal, superior, and inferior rectus muscles palsied. Case 7 (Fig. 8) (P. L., aged 5 years).--Private Clinic. total congenital palpebral ptosis. Right eye : normal.
Operation, 1949. Left eye :
Case 8 (Fig. 9) (M. A. Z., aged 5 years).--Operation, i7th June 1949. Left eye : congenital palpebral ptosis. Discrete functional convergent strabismus. Right eye : normal. Case 9 (Fig. IO) (A. D. M., aged 7 years).--Ophthalmological Clinic. Operation, 9th May I95I. Both eyes : partial congenital palpebral ptosis ; normal function of the superior rectus muscle. Left eye : functional convergent strabismus. Case io (Fig. II) (F. S., aged 56 years).~Ophthalmological Clinic. Operation/' 2oth December I95o. Left eye: post-surgical palpebral ptosis since I949 ; normal function of the superior rectus muscle. Right eye : normal. Case i i (Fig. I2) (W. L. A., aged 2I years).~Ophthalmological Clinic. Operation, I3th July I95 I. Both eyes: congenital palpebral ptosis ; integrity of the extrinsic musculature. Case x2 (Fig. x3) (D. D. M., aged23 years).~Ophthalmological Clinic. Operation, Ixth July 195 I. Both eyes: congenital palpebral ptosis ; integrity of the extrinsic musculature. Case 13 (Fig. I4) (M. L. A., aged 3° years).--Ophthalmological Clinic. Operation, x5th January I951. Right eye: paralytic palpebral ptosis five years ago. Left eye : normal. Case x4 (Fig. 15) (R. N., aged 14 years).--Ophthalmological Clinic. Operation, 1st October I95o. Right eye : congenital palpebral ptosis. Left eye : normal.
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FIG. 3
2
FIG. 4
FIG. 5
FIG. 6
FIG. 7
FIG. 8
FIG. 9 Cases 2 to 9.
Before and after operation.
PALPEBRAL
PTOSIS
145
FIG. IO
FIG. I I
FIG. 13
FIG. I2
FIG. 15
FIG. 14 Cases io to 15.
Before and after o p e r ~ i o n .
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REMARKS It is a conditio sine qua non for carrying out the method we are studying that there should be functional integrity of the occipitofrontal muscle. Some writers (Malbran and Nocito, I947) find that the processes which utilise the action of the frontal muscle altogether constitute an antiphysiological resource and are of relative efficiency. We do not agree with this opinion : first, because the good results obtained by us are here to attest the efficiency of the method ; secondly, because we think "antiphysiological" is a very strong term to use. On what grounds should we consider the action of the frontal muscle as being antiphysiological in cases of ptosis if that muscle is natural, spontaneous, and unconsciously solicited, coming into play, although not correct, it at least reduces the functional deficiency of the affected eyelid ? It being an accessory muscle of thg elevating function of the superior eyelid, that we should have recourse to it whe~ that function weakens or disappears, is just and physiological. Moreover, the suppletory action of the frontal muscle when solicited, besides the good results and advantages it gives, does not present any of the inconveniences arising from other methods. Thus Lindner (quoted by Valerio, I939) finds that Blaskovics' technique with tarsectomy may be dangerous not only by opening a communication with the retro-orbital region but also because, if the incision of the tarso-orbital is a generous one, a very disagreeable fatty hernia may appear. Moreover its use is confined to cases of incomplete ptosis and with part preservation of the elevating function. Motais, in turn, provokes a kind of virtual symblepharon between the eyelid and the eyeball, once the movements of the former become the function of the latter. One is compelled to admit, in addition to all this, that there must be a weakening of the superior rectus muscle besides its being overloaded with the weight of the eyelid. Hence one infers that important modifications are established in the static and dynamic balance of the eyeball. According to valerio (I939), there would be unilateral hypophoria (axes of vision not of the same plane) or e v e n appearance of an actual strabismus " deorsum vergens " with diplopia through predominance of the antagonic muscles. Motais as well as Nida have their supporters (Bourguet, I93O; Di Marzio, quoted by Caramazza, I942; Valerio, I939). Both demand as a premise that the superior rectus be entire, which does not always happen because the third nerve is the one common to the superior rectus and to the levator of the eyelid. The utilisation of the function of the occipito-frontal muscle is defended by many writers (Blair et al., I932 ; Figi, I95 o ; Pickerill, I949 ; Zeno, I944). As happens with other methods it also has its little drawbacks. Thus in some cases we note a slight effacement of the orbito-palpebral sulcus ; a withdrawal of the eyelid from the eyeball when the eye is forced open : in using a fascia lata transplant we are obliged to make a fresh scar on the donating area (the thigh). But to compensate for these slight drawbacks the method has the advantage that it may be used for any type of ptosis besides being propitious to very satisfactory results. SUMMARY The authors consider palpebral ptosis an a~sthetico-functional defect of serious consequence. They show the physiological mechanism of the method
PALPEBRAL
PTOSIS
147
which, in spite of being indirect, may be applied to all types of blepharoptosis ; they make a few comments as to the occasion of and precautions necessary during the intervention, and stress the slight inconveniences. REFERENCES ARRUGA, H. (1946). " Cirurgia Ocular." Buenos Aires : Ed. Salvat. BLAIR, V. P., BROWN, J. H., and HAMM, W. G. (I932). Arch. Ophthal., 7, 83I. BLaSKOVrCS, L., and KRmKER, A. (I947). " Cirurgia de los ojos." Buenos Aires : Ed. Salvat. BOURGUET (I930). " Reflexions sur le traitement chirurgical du ptosis congenital. Congr6s. Comptes rendus des s6ances. Soci6t6 Scientifique Fran~aise de Chirurgie r6paratrice plastique et esthetique," p. 57. Paris : Ed. Maloine. CARAMAZZA, F. (I942). " Sulla blefaroplastica. Atti del congresso Europeo de chirurgia plasfica di guerra." La chirurgia Plastica, 229. DI MARZlO. Quoted by Caramazza (1942). FIGI, F. A. (195o). Plast. reconstr. Surg., 5, 4o3 • KIRSCHNER, M. (194o). " Tratado de tecnica operatoria general y especial," vol. ii. Rio de Janeiro : Ed, Labor S.A. LEXER and WIENER. Quoted by Kirschner (194o). LINDNER. Quoted by Valerio (1939). MALBRAN, J. L., and GARClA NOCITO, P. F. (I947). " Plasticas palpebrales y conjuntivales." Buenos Aires : Ed. E1 Ateneo. MAY, C. H. (1941). " M a n u a l de doenqas dos olhos." Rio de Janeiro : Ed. Scientifica. PARSONS, Sir JOHN, and DUKE-ELDER, Sir STEWART (1948). " Diseases of the Eye." New York : Macmillan. PICKERILL, C. (1949). Brit. J. plast. Surg., 2, 116. SMITH, F. (195o). " Plastic and Reconstructive Surgery." Philadelphia and L o n d o n : W. B. Saunders Co. VALERIO, M. (1939). " Contributo allo studio del trattamento chirurgico della ptosi palpebrale con particulare riguardo all'introduzione della tecnica di Nida." La chirurgia Plastica, 3, 107VANRELL, F. G. (I948). " Enfermedades de los pfirpados." Buenos Aires : Ed. Salvat. ZENO, L. (1944). " Ptosis palpebral congenita," vol. i, p. 425 . 3 ° Congr. Lat. Amer. Cir. Plastica~ Santiago do Chile : Artes y Letras Ltda.