Harman’s operation. The aim of this operation is to insert a fine metal chain between the occipito-frontalis and the lid, the chain being left permanently in position. The operation has not yet been performed sufficiently often to allow any definite statement about the final results to be made.
The results have not been very satisfactory in three cases in which the author has performed this operation.
Instruments. A 4-inch straight surgical needle, to which is attached the fine wire chain such as is used by spectacle makers to attach glasses to the dress. It measures about O.75 millimetre in diameter. It is attached to the needle by a soldered ring or by means of a piece of silk doubly looped through the needle without a knot.
Operation. Under a general anæsthetic. ‘The method of implanting the chain will be followed readily by reference to Fig. 140. The chain-needle is inserted above the external angular process at A, is passed inwards, and with a slightly upward inclination deeply beneath the tissues of the forehead, to be withdrawn at B; as much of the chain is drawn through as desired. The needle is reinserted at B, passed beneath the brow close to the orbital margin and through the tissues of the lid to C, where it is withdrawn and the chain after it. In like manner it is passed from C to D through the substance of the tarsus and withdrawn. It is now returned from D to E above the brow and withdrawn, and a final length embedded above the brow from E to F, which is just above the internal angular process. The chain should be buried completely and stretched evenly between the points A, B, C, D, E and F; and by traction the loop BCDE should be adjusted at B and E; when the lid is at the desired height the slack at B and E is taken up by traction on A and F.
Fig. 140. Harman’s Operation for Ptosis.
‘The position of the points E and B is of importance; they must be situated in the region of the most effective elevation of the brow by contraction of the frontalis muscle, as determined by experiment before the commencement of the operation (and they should be placed well above the eyebrow).
‘The lengths of chain lying buried above the brows from A to B and E to F, and the angles A B C and D E F, are arranged so that there is sufficient holding power to prevent the subsequent drop of the lid, but will not prevent adjustment to forcible traction on the lid until the links of the chain have become interwoven and surrounded by the growth of connective tissue. This growth should be sufficiently vigorous by the end of a week to securely fix the chain against all the force of traction of the orbicularis muscle. (In one case in which the author removed the chain after two weeks there was no connective tissue in the links and it was easily withdrawn.) Until this time the free ends of the chain should be turned towards each other over the skin of the brow and cemented in position by a cotton-wool and collodion dressing, after which time the free ends, A and F, are cut off and the free extremities pushed beneath the skin.’
Panas’ operation. In this operation a direct adhesion of the skin of the lid to the occipito-frontalis muscle is aimed at.