Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material

Functional indications for upper eyelid ptosis and blepharoplasty surgery: a report by the American Academy of Ophthalmology

OBJECTIVE

To evaluate the functional indications and outcomes for blepharoplasty and blepharoptosis repair by assessing functional preoperative impairment and surgical results.

METHODS

Literature searches of the PubMed and Cochrane Library databases were conducted on July 24, 2008, with no age or date restrictions, and they were limited to articles published in English. These searches retrieved 1147 citations; 87 studies were reviewed in full text, and 13 studies met inclusion criteria and were included in the evidence analysis.

RESULTS

The 13 studies reported the functional effects or treatment results of simulated ptosis; several types of blepharoptosis repair, including conjunctiva-Müller's muscle resection, frontalis suspension, and external levator resection; and upper eyelid blepharoplasty.

CONCLUSIONS

Repair of blepharoptosis and upper eyelid dermatochalasis provides significant improvement in vision, peripheral vision, and quality of life activities. Preoperative indicators of improvement include margin reflex distance 1 (MRD(1)) of 2 mm or less, superior visual field loss of at least 12 degrees or 24%, down-gaze ptosis impairing reading and other close-work activities, a chin-up backward head tilt due to visual axis obscuration, symptoms of discomfort or eye strain due to droopy lids, central visual interference due to upper eyelid position, and patient self-reported functional impairment.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Current ptosis management: a national survey of ASOPRS members

PURPOSE

To assess current practice patterns for management of ptosis by current ASOPRS members.

METHODS

An invitation to participate in a web-based, anonymous survey was sent to current members of the American Society of Ophthalmic Plastic and Reconstructive Surgeons (ASOPRS) via e-mail. The survey consisted of 4 sections: preoperative testing of ptosis patients, surgical preferences, dry eye evaluation in ptosis patients, and length of postfellowship practice. Responses were analyzed using standard statistical methods.

RESULTS

Fifty percent of ASOPRS members performed more than 100 ptosis procedures in the past year. Most ASOPRS members performed preoperative photography, automated perimetry testing, and phenylephrine testing in evaluation of ptosis patients. A slight majority of ASOPRS members did not use preoperative Schirmer testing as the primary screening tool for dry eye disease. Most ASOPRS members performed internal levator aponeurosis advancement surgery, although most surgeons performing concurrent ptosis repair and blepharoplasty preferred an external approach. Frontalis sling surgery was performed using a wide variety of materials for suspension.

CONCLUSION

Current trends in the management and preoperative evaluation of blepharoptosis by ASOPRS members revealed a number of interesting common practices that are of value to current practitioners.

Modified frontalis suspension technique with review of large series

PURPOSE

To describe and report results of a modified frontalis suspension technique utilizing direct fixation to tarsus, lash margin rotation, eyelid crease fixation, conservative blepharoplasty, and rhomboidal configuration.

METHODS

A retrospective chart review of frontalis suspension patients over a 28-year period was performed.

RESULTS

Data from 171 eyelids in 93 patients were reviewed. Ages ranged from 1 to 84 years with a median age of 16. The indications for surgery included the following: congenital ptosis in 107 eyelids (62.6%), chronic progressive external ophthalmoplegia in 17 (9.9%), jaw winking ptosis in 14 (8.2%), blepharophimosis in 12 (7.0%), cranial nerve III palsy in 10 (5.8%), traumatic ptosis in 9 (5.3%), and myasthenia in 2 (1.2%). Autogenous fascia lata was utilized in 156 lids (91.3%), while silicone rods or banked fascia was used in 11 (6.4%) and 4 (2.3%) lids, respectively.Average follow up was 11.7 months (range 2 to 108 months). An excellent result was defined as ≤1 mm asymmetry in primary gaze and an eyelid position of 2.5 mm or less below the superior limbus. Eighty-nine of 93 patients (95.7%) achieved excellent results. Six lids in 4 patients (3.5%) were undercorrected. No patients were overcorrected. Only 2 patients with autogenous fascia lata (3.4%) required a secondary bilateral frontalis suspension at the 2- and 3-year time intervals.

CONCLUSIONS

The authors believe that technique modifications including direct eyelid crease incision and tarsal fixation, conservative fat removal blepharoplasty even in children, lash margin rotation, and rhomboidal configuration with single midline brow incision give improved results of frontalis suspension when compared with conventional techniques.

Current techniques in surgical correction of congenital ptosis

Ptosis refers to vertical narrowing of the palpebral fissure secondary to drooping of the upper eyelid to a lower than normal position. Ptosis is considered congenital if present at birth or if it is diagnosed within the first year of life. Correction of congenital ptosis is one of the most difficult challenges ophthalmologists face. Multiple surgical procedures are available including, frontalis sling, levator advancement, Whitnall sling, frontalis muscle flap, and Mullerectomy. Selection of one technique over another depends on the consideration of several factors including the surgeon experience, the degree of ptosis in the patient, as well as the degree of levator muscle function. Current recommendations for the correction of congential ptosis vary based on clinical presentation. Advantages and disadvantages of each of these procedures are presented with recommendations to avoid complications.

Prolene frontalis suspension in paediatric ptosis

AIM

The aim of this study was to assess the efficacy of frontalis suspension using 4-0 prolene sutures for paediatric ptosis with poor levator function.

PATIENTS AND METHODS

A retrospective chart review was performed on children who underwent 4-0 prolene frontalis suspension from 2000 to 2008 with a minimum of 6 months' follow-up. Functional success was defined when three criteria were met: (a) satisfactory lid height (defined as margin-to-reflex distance ≥3 mm with minimal frontalis muscle tone); (b) satisfactory lid symmetry (≤2 mm asymmetry in margin-to-reflex distance); and (c) satisfactory cosmesis. Recurrence was defined by a drop in lid height of ≥3 mm from the initial post-operative level.

RESULTS

A total of 23 patients (30 eyelids) were included. The mean follow-up duration was 28.7 months (range 6.3 to 100 months). The functional success rate was 74% (17/23 patients). Ptosis recurred in 22% (5/23) of patients. Only one patient (4%) developed a complication: a case of minor wound infection.

CONCLUSIONS

In paediatric ptosis with poor levator function, prolene frontalis suspension has good efficacy and an excellent safety profile. The results of prolene frontalis suspension are comparable to those of other non-autogenous materials.

Frontalis suspension surgery in upper eyelid blepharoptosis

Frontalis suspension is a commonly used surgery that is indicated in patients with blepharoptosis and poor levator muscle function. The surgery is based on connecting the tarsal plate to the eyebrow with various sling materials. Although fascia lata is most commonly used due to its long-lasting effect and low rate of complications, it has several limitations such as difficulty of harvesting, insufficient amounts in small children, and postoperative donor-site complications. Other sling materials have overcome these limitations, but on the other hand, have been reported to be associated with other complications. In this review we focus on the different techniques and materials which are used in frontalis suspension surgeries, as well as the advantage and disadvantage of these techniques.

An alternative frontalis suspension technique: triband suspension--a modified Garcia's procedure

Blepharoptosis surgery is one of the most common oculoplastic procedures, and the aim is to clear the visual axis. Many surgical techniques for the correction of ptosis have been described and performed, but the operative approach is based on the extent of eyelid excursion, the amount of levator function, and the degree of ptosis.In this study, the frontalis sling procedure with triband suspension was performed on 32 eyelids of 23 patients. All the patients had visual loss because of blepharoptosis with only 0 to 3 mm of measurable levator function. Postoperatively, the palpebral fissure was increased in all the patients. The purpose of this study was to report the use of a modified frontalis sling procedure for congenital ptosis patients with minimal to no levator function. In conclusion, this modified frontalis sling technique if used maximizes the frontalis muscle, creating sufficient eyelid elevation, with stable effect over time.

Frontalis suspension using expanded polytetrafluoroethylene: results of different surgical designs

BACKGROUND/PURPOSE

Several surgical designs and materials have been proposed for frontalis suspension for treating congenital ptosis and ptosis with poor levator muscle function. This study evaluated the surgical results of frontalis suspension using expanded polytetrafluoroethylene (ePTFE) with two different surgical designs (open-type and closed-type).

METHODS

We reviewed the medical records of 96 patients (68 children and 28 adults) who underwent frontalis suspension surgery using ePTFE. Postoperative eyelid position, ptosis recurrence, and complications were recorded.

RESULTS

Twenty-eight out of 68 children and all 28 adults underwent closed-type frontalis suspension surgery, and 40 children underwent open-type surgery. The recurrence rate was 20% (8 of 40 eyelids) for children with closed-type surgery, and 2% (1 of 50 eyelids) for those with open-type surgery. There was a statistically significant difference in the recurrence rate between the two surgical methods in children (p = 0.011). The recurrence rate was 5% (2 of 40 eyelids) in adults who underwent the closed-type method. The recurrence rate after closed-type surgery was significantly different between the child and adult groups (p = 0.04).

CONCLUSION

Open-type frontalis suspension surgery using ePTFE is preferable to closed-type surgery for children with upper eyelid ptosis. Closed-type surgery provides more favorable results in adults than in children.

Outcomes in silicone rod frontalis suspension surgery for high-risk noncongenital blepharoptosis

PURPOSE

To evaluate the outcomes of silicone rod frontalis suspension for complicated cases of ptosis with poor levator function.

METHODS

A retrospective interventional case series of consecutive patients undergoing silicone rod frontalis suspension by 2 surgeons over 20 years generated records of 51 eyelids (33 patients) with ptosis secondary to cranial nerve III palsy, myasthenia gravis, chronic progressive external ophthalmoplegia, or oculopharyngeal dystrophy. Outcome measures included postoperative change in eyelid height, lagophthalmos, and corneal fluorescein staining; need for reoperation; patient and physician satisfaction; grading of postoperative photographs; and interobserver agreement.

RESULTS

Forty-five percent of patients had preoperative corneal staining. Surgery resulted in a significant increase in eyelid height (+2.8 mm; p < 0.0001), lagophthalmos (+0.4 mm, p < 0.0001), and corneal staining grade (+0.3 units; p = 0.02). Most patients achieved a subjectively acceptable result. Patient and physician agreement with outcome assessment was good (kappa = 0.65, p < 0.0001). Twenty eyelids (39%) required revision of the silicone sling, most often for adjustment of eyelid height. Survival analysis differed by diagnosis (p = 0.0154) and was most favorable for patients with myasthenia gravis. Interobserver agreement on postoperative photographs was marginal.

CONCLUSIONS

Silicone rod frontalis suspension surgery increases the eyelid height in complicated blepharoptosis patients with minimal eyelid excursion. Patients and physicians concur closely regarding satisfaction; masked assessment of photographic outcome parameters by observers yields marginal agreement. Because most patients undergoing this procedure have a narrow window for appropriate postoperative eyelid height, a relatively high proportion of patients required revision. Silicone rod frontalis suspension surgery is chosen in these challenging cases for the ease of adjustment.

Browlifting as an alternative procedure for apraxia of eyelid opening

Essential blepharospasm is an idiopathic disorder that consists of spontaneous, spasmodic, and involuntary eyelid closure in the absence of ocular disease. Some patients develop an inability to open their eyelids in the absence of orbicularis spasms. These patients have essential blepharospasm combined with apraxia of eyelid opening. Botulinum toxin injections are the treatment of choice for blepharospasm but results may be insufficient, especially in cases associated with apraxia. Apraxia can be treated surgically by levator aponeurosis advancement, frontalis suspension, and upper myectomy. The authors report the first browlift using polypropylene suture to manage eyelid apraxia associated with blepharospasm as an alternative and minimally invasive procedure.

A new trend for the treatment of blepharoptosis: frontalis-orbicularis oculi muscle flap shortening technique

Operation techniques for blepharoptosis have been a great challenge for plastic surgeons. Complications and recurrence in conventional operations of eyelid ptosis cannot be neglected. The finding of the close linkage between the longitudinal-oriented frontalis muscle (FM) and the horizontal-orientated orbicularis oculi (OOM) muscle convinced us of the efficacy to develop the dynamic and powerful Frontalis-Orbicularis Oculi Muscle (FOOM) flap-shortening technique which corrects blepharoptosis with good biomechanics in place of the traditional frontalis muscle sling. From January 2003 to September 2007, the FOOM flap shortening technique was applied on 35 ptotic eyelids of 31 patients, age ranging from 18 year to 77 years. All FOOM flaps were harvested and adjusted depending on the severity of the blepharoptosis. The follow up period ranged from 5 to 55 months. Thirty eyelids had good results, with the degree of ptosis less than 2mm. There were only five recurrent ptotic eyelids due to technical undercorrection. The estimation of resected length is measured when the FOOM flap is fully stretched and the length is approximately 22.0-23.0 mm for mild cases, 23.0-24.0 mm for moderate cases, and 25.0-26.0 mm for severe blepharoptosis. The FOOM flap-shortening technique was developed and corrected blepharoptosis with good results compared to conventional operation techniques. It achieves antagonistic equilibrium with ideal biomechanics by debilitating eye-closing power and enhancing eye-opening power.

Correction of congenital severe ptosis by suspension of a frontal muscle flap overlapped with an inferiorly based orbital septum flap

BACKGROUND

This report introduces a new method for correction of congenital severe upper eyelid ptosis.

METHODS

The poor levator-function upper eyelid ptosis of 22 patients was corrected using suspension of the frontal muscle flap overlapped with an inferiorly based orbital septum flap as a motor unit, which substituted for the function of the levator muscle. The frontal muscle flap and orbital septum flap were formed in the frontal part and upper eyelid, respectively. Two flaps were overlapped and sutured to suspend the upper eyelid and to correct the congenital severe upper eyelid ptosis. This technique avoids the need for the linking structure necessary with the standard frontalis sling approach and improves the direction of pull to mimic that of a normal levator more closely than that of frontalis muscle advancement.

RESULTS

The follow-up period ranged from 6 to 20 months (mean, 12 months). A total of 4 patients had bilateral surgery, whereas 18 patients underwent unilateral surgery (26 eyelids). In 22 cases (26 eyes), congenital severe upper eyelid ptosis was treated using suspension of the frontal muscle flap overlapped with an inferiorly based orbital septum flap. After the operation, 17 cases (19 eyes) were followed up and analyzed retrospectively. The average follow-up period was about 12 months (range, 6-20 months). The 17 corrected eyes had a symmetric redundant fold of preseptal skin according to the marginal reflex distance-1 (MRD-1) measurement used to judge efficacy. Two eyes in this series required reoperation for undercorrection. Complications such as ectropion and corneal exposure were avoided.

CONCLUSION

Use of a frontalis muscle lap overlapped with an inferior based orbital septum flap to manage severe congenital upper eyelid ptosis is a useful procedure that results in substantial cosmetic and functional improvement with few complications.

Diagnosis and management of third nerve palsy

PURPOSE OF REVIEW

To provide clinically relevant information regarding the diagnosis, etiology, work-up and treatment of third cranial nerve palsies, while incorporating information from current publications and providing our opinions on these studies.

RECENT FINDINGS

In the past year, an important study focused on the confirmation of current neuro-imaging guidelines for third cranial nerve palsies. Recent case reports have highlighted etiologies such as giant cell arteritis, trauma, neuro-syphilis and demyelination secondary to infliximab and multiple sclerosis. Surgically, newer studies have focused on globe-tethering procedures for correcting strabismus and the use of frontalis suspension for correcting ptosis. Improved imaging technology with high-resolution magnetic resonance imaging (hr-MRI) allows for direct visualization of the entire nerve path and the affected muscles.

SUMMARY

Management of a third nerve palsy depends upon localization of the causative lesion and determination of the underlying etiology. Once these issues are addressed, strabismus surgery can be both challenging and rewarding in these complex patients.

Broad fascia fixation enhances frontalis suspension

PURPOSE

To report the use of a modified frontalis suspension procedure for congenital ptosis patients with minimal to no levator function.

METHODS

Retrospective, non-comparative case series of frontalis suspension by 2 surgeons over a 21-year period.

RESULTS

Frontalis suspension with broad fascia fixation was performed on 48 eyelids of 25 patients. All patients had visual obscuration due to blepharoptosis with only 0 mm to 2 mm of measurable levator function. Age ranged from 3 to 13 years. Minimum length of follow-up was 6 months (range, 6-174 months). The palpebral fissure was increased in all patients, improving their head position and unmasking their visual axis in primary gaze. Postoperatively, all patients developed transient exposure symptoms. There were no migrations, extrusions, infections, or granulomas. All patients achieved a satisfactory postoperative result based on eyelid position, function, and contour.

CONCLUSIONS

This modified frontalis suspension procedure maximizes frontalis muscle recruitment, creating powerful eyelid elevation with stable effect over time. The technique minimizes other procedures' pitfalls and advances in cosmesis are achieved with enhanced eyelid crease formation and adjustable eyelid contour.