Reply re: "Frontalis Muscle Flap Versus Maximum Anterior Levator Resection as the First Option for Patients With Severe Congenital Ptosis".

To the Editor: I thank Dr. Putterman for his comments on our recent publication. For me it is a pride that he has read our work and took the time to make suggestions, which I appreciate and respect. As he commented, we have a relatively large percentage of reoperations, about 50% of 24 patients treated with super maximum resection/Whitnall sling. Keep in mind that this reoperation result is after a follow up of 10 years, and as we understand Dr. Putterman’s fantastic work, of 8 patients in the group of super maximum resection associating a Tarsectomy (T) (Table 4, group I), only 1 patient required reoperation according his criteria. But based on our criteria, 4 patients would have required reoperation (2.5, 2.5, 3, 2 mm of postoperative ptosis), which means half of the patients of the entire group (just like our 50% of revision surgery in our work). Nevertheless, we could not see the evolution in time of the patients in Dr. Putterman’s study, and to have a good comparison of both techniques/groups, it would be interesting to have similar follow-up times. Another difference in our study is that all 71 cases were operated on with an age younger than 2 years old. In Dr. Putterman’s work, we only can find 2 cases younger than 2 years old and these were included in the non-Tarsectomy group (Table 4, group II). I want to thank Dr. Putterman for the recommendation to perform a Tarsectomy associated with super maximum resection. This is a valuable contribution to the ptosis surgeon community. The aim of our study was just to evaluate the reoperation rate of a new technique (frontalis muscle flap) with a wellknown technique (super maximum resection) under the same conditions (same surgeon, same reoperation criteria) and in a homogenous age group of patients. I believe the technique we developed for frontalis muscle flap, in appropriate hands, is safer with less morbidity, less complications, and less reoperation rates than any other technique for patients with severe congenital ptosis having very poor levator muscle function. I appreciate again the cordial suggestion and wish to thank Dr. Putterman for his invaluable contributions to ptosis surgery. I am willing to respond to any new concerns regarding this issue. Ramón Medel, MD. Luz María Vasquez, M.D. Juan Carlos Sánchez España, M.D., Ph.D.