| Abstract|| |
Purpose: The purpose of this study is to assess the outcomes of frontalis sling using fascia lata and silicone aurosling for congenital unilateral ptosis patients with poor levator function. Material and Methods: Retrospective study of archival cases from 22 patients from author's center. All the patients with unilateral ptosis with poor levator function were included excluding those having poor Bell's phenomenon and associated pathology like jaw winking, 3rd nerve misdirection, squint, impaired corneal sensitivity, and neoplastic lesions. Patients were diagnosed based on the history and clinical examination including measurements. Corrections were performed by single surgeon. Marginal reflex distance-1 (MRD1) values observed preoperatively, immediate postoperatively, and late postoperatively in both groups. Results: Of the 22 cases, 12 were treated with fascia while the remaining 10 were treated with silicone aurosling material. The mean age of the fascia group was 11.42 ± 3.55 years while it was 14 ± 4.2 years for the silicone group. There were 10 males and 12 females in the study group. The mean follow-up in the study group was 20.14 ± 2.05 months, and the difference between the groups was not statistically significant. The difference between the two groups at the preoperative and immediate postoperative did not vary with statistical significance (P = 0.926 and P = 0.242, respectively). The late postoperative MRD1 did vary significantly between the two groups. The mean late postoperative MRD1 for fascia group was 3.67 ± 0.32 with a range of 3.1–4.15 while for the silicone group was 3.2 ± 0.46 with a range of 2.5–4. The difference was statistically significant (P = 0.023). Discussion and Conclusion: The stability of the change in silicone aurosling group was relatively less as compared to the fascia lata. The recent material aspect study of such silicone aurosling material indicates that they are susceptible to damage and that cause the loss of stability. More studies with larger sample size and longer follow-up are needed.
Keywords: Frontalis sling, ptosis, silicone aurosling
|How to cite this article:|
Balaji S M. Efficacy of autogenous fascia lata and silicone aurosling in correction of congenital blepharoptosis by frontalis suspension. Indian J Dent Res 2018;29:166-70
|How to cite this URL:|
Balaji S M. Efficacy of autogenous fascia lata and silicone aurosling in correction of congenital blepharoptosis by frontalis suspension. Indian J Dent Res [serial online] 2018 [cited 2021 Aug 1];29:166-70. Available from: https://www.ijdr.in/text.asp?2018/29/2/166/229606
| Introduction|| |
Congenital ptosis or drooping or falling of the upper eyelid from birth has immense negative effects, including psychological development of child and when not treated, would proceed to adulthood. It may cause abnormal head posturing in bilateral cases and could lead to deprivation amblyopia in unilateral cases. Levator muscle dystrophy is the most common etiopathogenesis of congenital ptosis. Due to this dystrophy, the muscle and aponeurotic tissues are often infiltrated and/or replaced by fat/fibrous tissue. The most common form of congenital ptosis is myogenic ptosis. It is defined as a condition where there is no or <4 mm of levator muscle function. The patients affected by this form of ptosis cannot bring down their upper eyelid to lower limbus, and it remains in its upper position when looking down.
The treatment protocol algorithm demands the proper estimation of the levator muscle function and severity of ptosis.
There are several methods for surgical correction of ptosis. They include the levator muscle resection, the Fasanella–Servat procedure, Muller muscle–conjunctival resection, supramaximal levator resection, and frontalis sling surgery. Harris and Dortzbach described transcutaneous levator tucking for the correction of blepharoptosis. Blaskovicz first described the posterior approach to shorten the levator muscle which demanded extensive dissection. Later, tarsectomy was combined with this procedure too. For milder ptosis, Muller's muscle–conjunctival resection, Fasanella and Servat approach were preferred. In the frontalis sling procedure that is reserved for severe ptosis, the eyelid is suspended with frontalis muscle and facilitation of eyelid movement achieved when the brow is raised. It creates a linkage between frontalis muscle and tarsus of upper lid, allowing better primary gaze.,,,
For a congenital myogenic ptosis, autogenous fascia lata is considered to be the best suspension material. The method was postulated by Payr in 1909 and demonstrated by Wright in 1922. Later, several modifications were performed for this procedure. Notable ones include Crawford, use of banked fascia lata, Palmaris longus tendon, polytetrafluoroethylene, silicone band, 4-0 nylon, mersilene mesh, and even dura mater. Autogenous fascia lata is still the preferred one as it has one of the lowest complication rates while synthetic materials have their own complication rates. Development of fascia lata is nearly complete by the 1st year of life and about 20 cm in its linear dimension can suitably be chosen as a donor site for frontal suspension.,,,,
There are several studies that have attempted to study the efficiency of the surgical procedures, but very little from India. Given the documented difference in orbital anatomy, among Asian-Indians as compared to Western populations,,, this outcome study was performed to estimate the outcome of the congenital unilateral ptosis correction surgery in Indians using frontalis sling using fascia lata and allograft materials.
| Materials and Methods|| |
This is a retrospective study from archival records of author's center. Patients of either gender, with adequate records (≥18 months follow-up), between January 2007 and December 2016 were included for this study. All patients presenting with primary unilateral congenital ptosis with poor levator function (≤4 mm) only were included for this study. Exclusion criteria were those with other ocular malformations, trauma, poor bell's phenomenon and Marcus Gunn jaw winking, oculomotor nerve misdirection, squints, impaired corneal sensitivity, and associated ocular neoplastic lesions. Patients with incomplete records, poor follow-up were not included in this study. Patients with unilateral congenital ptosis were diagnosed clinically on the basis of oral history, old photographs if available and detailed clinical examination including defective levator function and absence of lid creases. All surgeries were performed by a single, well-experienced surgeon during the study period. From the records, demographic details, details of ocular examinations (pre, immediate, and postoperative follow-up)-marginal reflex distance in primary gaze (MRD-1) were collected. MRD1 was previously determined by the examiner and patient aligning at the same level. Light was directed at the patient's eyes. Measurement (in mm) from the light reflex on the patient's cornea to the level of the center of the upper eyelid margin, with the patient gazing in the primary position, is the MRD-1. Postoperative complications, if any were also noted.
After adequate preparation and induction of general anesthesia, a pentagon shape surgical mark was made over the upper eyelid skin. Two incisions were placed, above the eyelash line, with each being 3 mm long. The incisions were placed in the center – about 6 mm nasally (toward medial) and temporally (lateral side) to the center of cornea over the upper lid. After this, 3 eyebrow incisions were given. A 2 mm long central stab incision was placed 5 mm above the eyebrow. Subsequently, the medial and lateral brow incisions were placed to these central lid incisions. Carefully, from these incisions, tunneling of the frontalis muscle was performed to interconnect.
Fascia lata procedure
Fascia lata from thigh muscle was harvested before these ocular incisions. Through the lateral eyelid incision, the fascia lata was introduced and appropriately guided to pass through the medial lid incision in such a position to create a sling. One end of the fascia was then passed through the lateral supra-eyebrow stab incision. The other end of the tendon passed into the medial supra-eyebrow stab incision. The free ends were carefully positioned into the muscle plane through the central supra-eyebrow stab incision. Diligent care was taken to maintain the muscle plane and not to damage the muscles during the entire procedure. The lid margin height was adjusted according to the predetermined amount of correction required. After adequate and repeated checking, the free ends of the fascia were secured together and then with the frontalis muscle using 6-0 ethilon [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d.
|Figure 1: (a and b) Preoperative and postoperative frontal view showing increased palpebral fissure width (c) Harvesting fascia lata graft from the patient's thigh (d) Insertion of fascia lata graft through eyebrow incision|
Click here to view
Allograft procedure – silicone aurosling
Commercially available sterile silicone frontal suspension set (consisting of a long silicone tube with stainless hollow rods on both ends measuring 40 cm and the rod measuring 6.3 cm) was used. Through the lateral eyelid, the needle was passed, towards the medial lid incision, creating a sling in the process. One free end of the tube was advanced through the lateral supra-eyebrow stab incision in the muscle plane. The other end of the tube was advanced similarly into the medial supra-eyebrow stab incision. Both the free ends were guided along the muscle plane into the central supra-eyebrow stab incision. Care was taken to maintain the muscle plane and not to damage the muscle – all throughout the procedure. Both the free ends were secured together using a silicone sleeve 7 mm in dimension. The lid margin height was adjusted according to the amount of correction. With eyelid in the desired position the sleeve was tightened and the excess tube was trimmed. The sleeve and tube were sutured to the frontalis muscle and buried in the subcutaneous pocket [Figure 2], [Figure 3], [Figure 4].,,
|Figure 2: (a) Preoperative frontal view showing blepharoptosis (3 mm) on the right side. (b) Incision markings on the right side forming a pentagon|
Click here to view
|Figure 3: (a) Silicone aurosling – A long silicone tube with a stainless hollow tube at both ends.(b) Silicone tube (aurosling) introduced into the upper eyelid through temporal and nasal incisions using a stainless steel needle. (c) An awl is introduces along the intramuscular tunnel connecting lateral eyebrow and temporal eyelid incision. (d) The two free ends of the aurosling are introduced along the intramuscular tunnel, exit through the central eyebrow incision. (e) With the right upper eyelid in desired position, the sleeve is tightened around the silicone tubes|
Click here to view
In both procedures, the primary closure of all the stab wounds on the skin was done using 6-0 Ethilon. Frost suspension of the right eye was done and maintained for 3 days. Lubricating eye drops and ointment, as required were prescribed during the immediate postoperative period.
Data collected were entered and analysis was performed using Statistical Package for Social Services SPSS version 16, (IBM, Somers, NY, USA) software. Descriptive statistics are presented. Paired t-test was used to detect the difference between pre- and post-operative data in the study groups, and the independent samples test was used to calculate the difference between both groups in numerical variables. Pearson Chi-square tests were used to calculate the difference between groups in categorical variables. P ≤ 0.05 was taken as statistically significant.
| Results|| |
There were 22 cases that fulfilled the inclusion and exclusion criteria. Of them, 12 were treated with fascia while the remaining 10 were treated with silicone sling material. The mean age of the fascia group was 11.42 ± 3.55 years for the fascia group while it was 14 ± 4.2 years for the silicone group. The age difference was statistically significant.
There were 10 males and 12 females in the study groups and the gender difference between the two groups was not statistically significant. The mean follow-up in the study group was 20.14 ± 2.05 months, and the difference between the groups was not statistically significant.
The preoperative, immediate postoperative, and late postoperative MRD-1 measurements for the two groups are shown in [Table 1] and [Figure 5]. The difference between the two groups at the preoperative and immediate postoperative did not vary with statistical significance (P = 0.926 and P = 0.242, respectively). The late postoperative MRD1 did vary significantly between the two groups. The mean late postoperative MRD1 for fascia group was 3.67 ± 0.32 with a range of 3.1–4.15 while for the silicone group was 3.2 ± 0.46 with a range of 2.5–4. The difference was statistically significant (P = 0.023).
|Table 1: Demographics and surgical outcomes in the fascia and silicone graft materials for congenital ptosis correction|
Click here to view
|Figure 5: Graph showing the mean ± standard deviation of the marginal reflex distance-1 in the three phases of the study. Blue– Fascia Lata group; Green – Silicone aurosling group|
Click here to view
The most common complication at late postoperative stage was noted to be undercorrection in 3 (30%) of the silicone and 1 (16.67%) of the fascia case. There were no other complications such as lid lags, overcorrection, knot failure, granuloma formation, infection of sling, exposure, donor site infection, scar, or late failure.
| Discussion|| |
The anatomy and anthropometry of Indian, Asian, and Western eyelids are different. The typical Indian eyes have distinct morphological and anthropometrical values than rest.,, While planning corrective eye surgeries that concerns esthetics, the differences in morphology and measurements have to be accounted. In addition, the perception of Indian eye and its cultural significance, especially have to be accounted for while planning corrective surgeries in children. Congenital ptosis corrections require significant planning, especially if the MRD1 values are significantly low.
The present study was a retrospective in design, with archival records details being used for the purpose of this study. Within the constraints of the study design, inclusion and exclusion criteria, a study population of 22 cases were identified. From the [Table 1], it was identified that gender was neither a significant factor nor the preoperative and immediate postoperative MRD1 were statistically different between silicone aurosling and fascia lata group. This indicated that, regarding MRD1 preoperatively or immediate postoperatively, the study groups did not have a difference. However, the late postoperative period MRD1 values were significantly different between the study groups.
Although there were no cases that can be deemed as complete relapse, in both the situation, there was loss of stability. On an average, the loss of stability in fascia group was 0.21 mm while in silico ne group, it was 0.5 mm. This indicates that relapse tendency is higher with silicone auroslings.
Regarding material, in spite of much advancement in oculoplastic material sciences, autologous fascia lata continues to remain the material of choice for ptosis correction with frontalis sling and is often considered as the gold standard procedure. The next preferred material is the preserved fascia lata., The single most drawback of fascia lata is the stability of the results. If improperly performed, the eyelid height, contour, and creasing would deteriorate with time. They often are reported to be satisfactory in the early postoperative period but start to change with time. On the other hand, silicone material generally believed to have good esthetical acceptance, but their capacity to exhibit varying rates of extrusion, infection, and granuloma formation prevents them to be used as material of choice. Till date, there are no reports indicating the effect of muscle pull.
In addition, the recurrence of ptosis in silico ne material, as observed in our study also, is reported to vary between 7% and 44%. These were attributed to the different follow-up periods, different configurations of sling, and heterogeneity of diseases. The results of the present study indicate that autogenous fascia has more reliable long-term results than silicone auroslings, as reflected by the reduced MRD-1. In the present study, the stability of silicone auroslings is lesser than that of fascia lata group.
Gradual reduction of MRD1 progressively with silicone auroslings was observed by Nucci et al. and several other studies reported the same phenomenon. Reasons such as inadequate bond formation between the synthetic material and the surrounding tissue, cheese-wiring effect of the suspension material (silicone auroslings slid upward from the fixation sites at the tarsal plate) were suggested. The reduction of MRD1or ptosis recurrence, after surgery on a longer follow-up, was noticed and investigated by newer studies. The silicone auroslings in such patients were retrieved and subjected to physical and micromorphological analysis. They observed that the silicone auroslings migrated from their implanted/secured positions, with the migration distances being larger with late recurrence contributing to cheese-wiring effects. The silicone aurosling is subjected to continuous, lasting stress due to gravity, and tension of the orbicularis oculi muscle. This stress eventually may cause deformation as evidenced by their destructive pull test and breaking strength. This indicates that the material undergoes structural deformation,in vivo degradation such as multiple cracks, surface debris, and loss of regular homogenous structure. These findings support our observation of relative higher decrease in MRD1 with silicone auroslings at long follow-up than the fascia lata.
The study has limitations with retrospective nature of study design, limited study sample, and nonconsideration of other auxiliary ocular measurements. However, such factors have not been reported to influence the outcome differences. Further, large-scale studies with longer follow-up are essential to confirm the findings of this study.
| Conclusion|| |
A single surgeon's experience of congenital myogenic ptosis correction with frontalis sling is presented with the focus on comparison of MRD1 correction and its stability over a period of about 20 months. The results indicate that fascia lata is well-tolerated and when performed has best stable result. Silicone auroslings suffer from cumulative stress development and resultantly the MRD1 dimension decreases with time. Large-scale studies with more parameters need to be performed to confirm the present findings.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bilgin LK, Yeniad B. The long-term results of frontalis suspension using autogenous fascia lata in children with congenital ptosis under 3 years old. Plast Surg Int 2010;2010:609462.
Matayoshi S, Pereira IC, Rossalo LA. Surgical treatment of congenital blepharoptosis. Rev Bras Oftalmol 2014;73:202-9.
Allard FD, Durairaj VD. Current techniques in surgical correction of congenital ptosis. Middle East Afr J Ophthalmol 2010;17:129-33.
] [Full text]
Ben Simon GJ, Macedo AA, Schwarcz RM, Wang DY, McCann JD, Goldberg RA, et al.
Frontalis suspension for upper eyelid ptosis: Evaluation of different surgical designs and suture material. Am J Ophthalmol 2005;140:877-85.
Ahmad SM, Della Rocca RC. Blepharoptosis: Evaluation, techniques, and complications. Facial Plast Surg 2007;23:203-15.
Carraway JH, Denk MJ. Refinements in ptosis surgery using frontalis sling technique. Oper Tech Plast Reconstr Surg 1994;1:113-9.
Othman Abdelkader MF, Abdelrahman Abdallah RM. Evaluation of transconjunctival levator tucking for congenital ptosis. J Egypt Ophthalmol Soc 2017;110:41-5. [Full text]
Kiranantawat K, Suhk JH, Nguyen AH. The Asian eyelid: Relevant anatomy. Semin Plast Surg 2015;29:158-64.
Patil SB, Kale SM, Math M, Khare N, Sumeet J. Anthropometry of the eyelid and palpebral fissure in an Indian population. Aesthet Surg J 2011;31:290-4.
Wang C, Pu LL. Commentary on: Visual, physiological, and aesthetic factors and pitfalls in Asian blepharoplasty. Aesthet Surg J 2016;36:284-6.
Putterman AM. Margin reflex distance (MRD) 1, 2, and 3. Ophthal Plast Reconstr Surg 2012;28:308-11.
Mand SS, Marey HM, Rajab GZ. Frontalis suspension using autogenous fascia lata versus gore-tex sheet for treatment of congenital ptosis with poor levator function. J Clin Exp Ophthalmol 2015;6:1.
Feijo ED, Nery AC, Limongi RM. Frontalis sling surgery: Do we really need the wright needle? Rev Bras Oftalmol 2016;75:89-93.
Wheatcroft SM, Vardy SJ, Tyers AG. Complications of fascia lata harvesting for ptosis surgery. Br J Ophthalmol 1997;81:581-3.
Bansal RK, Sharma S. Results and complications of silicone frontalis sling surgery for ptosis. J Pediatr Ophthalmol Strabismus 2015;52:93-7.
Nucci P, Lembo A, Santangelo E, Fogagnolo P, Serafino M. Five-year follow-up of a 30-month trial of stability of silicone band frontalis suspension for the treatment of severe unilateral upper eyelid ptosis in infants. Semin Ophthalmol 2016;31:215-8.
Kim CY, Son BJ, Son J, Hong J, Lee SY. Analysis of the causes of recurrence after frontalis suspension using silicone rods for congenital ptosis. PLoS One 2017;12:e0171769.
Dr. S M Balaji
Dental and Craniofacial Hospital, 30, KB Dasan Road, Teynampet, Chennai - 600 018, Tamil Nadu
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]