Frontalis suspension with supramid suture: longevity results in very young patients with congenital ptosis

Evolution of the «frontal flap advancement» in congenital ptosis

The treatment of congenital ptosis with poor levator activity is often based upon the union of the superior eyelid to the frontalis muscle by using different materials as potential grafts. Nevertheless, theses grafts may lead some complications. In order to avoid them, a new technic has been described using an advancement flap of the frontalis muscle, that is tided to the upper tarsus, eliminating the need of a graft. Although, it is not yet a standard procedure, reason why many variants has been recently described with the objective of improve the aesthetical and functional results. The goal of this systematic review is to conscientiously evaluate these variants with the propose of determine which one gives the best results in terms of safety, functional and aesthetical outcomes. From the review of the published procedures, we conclude that the best technique in terms of functional and aesthetical results is: sub-orbicularis dissection via lid crease incision reaching the orbital margin, followed by blunt dissection of the frontalis muscle and creation of a "U" shaped flap (that might be associated to a levator advancement in severe cases), finally, the frontalis flap is stitched to the upper end of the tarsus taking care to maintain a symmetrical contour when compared to the contralateral eye. The final eyelid margin height should be 1.5 mm above the sclero-corneal limbus.

Silicone sling frontalis suspension for congenital ptosis: Outcome of 174 consecutive cases

BACKGROUND

Frontalis suspension (FS) is the treatment of choice in congenital ptosis with poor levator function. We report the surgical outcome of FS using a double triangle configuration of silicone slings in children.

METHODS

A retrospective cohort study of all paediatric patients with simple myogenic congenital ptosis repaired with FS over a 12-year period (2009-2020). Each silicone sling was secured by simple knots. Pre- and post-operative margin reflex distance (MRD₁ ) measurements were determined from clinical photographs using ImageJ Software. Main outcome measures were improvement in eyelid height, eyelid asymmetry, reoperation rate and timing.

RESULTS

One hundred and thirty nine patients (174 eyes) were included, with 35 (25%) having bilateral surgery. Mean (±SD) age was 1.4 ± 1.9 years. Mean follow up time was 32 ± 20.5 months. Sixteen patients (11%) had a history of previous ptosis repair surgery. Mean MRD₁ improved by an average of 1.5 mm. The final MRD₁ in the group of patients who did not have a second procedure was a mean of 2.1 mm. The MRD₁ difference between both eyes in all unilateral cases improved from 2.5 mm preoperatively to 1.2 mm at final visit (p < 0.001). In the 123 cases without a history of previous ptosis surgery, repeat ptosis repair was performed in 37 (30%) patients, 34.9 ± 19.9 months after the initial procedure. Overall, repeat repair was performed in 47 patients (34%).

CONCLUSIONS

Double triangle silicone sling frontalis suspension has a favourable outcome in two-thirds of paediatric patients with simple myogenic congenital ptosis. Failed cases can be addressed with a second repair, using either autogenous fascia lata or a second silicone sling.

Minimal Dissection Direct Frontalis Muscle Advancement Flap for Congenital Ptosis Repair

BACKGROUND

Frontalis flap advancement is an alternative means of congenital ptosis repair from frontalis suspension utilizing autologous fascia or allogenic implants. Variations in technique, including flap division, location and number of skin incisions, and dissection planes, are described in the literature.

MATERIALS AND METHODS

A retrospective case series of patients with congenital myogenic ptosis treated with simplified, minimal dissection frontalis flap advancement involving a single upper eyelid crease incision with dissection in the preseptal and subcutaneous planes without division to mobilize the frontalis flap. Inclusion criteria: pediatric patients age < 18 years with either primary or recurrent congenital ptosis following previous surgical repair. Exclusion criteria: ptosis of neurogenic etiology or postoperative follow-up < 3 months. Primary outcome measures were postoperative margin-reflex distance 1 (MRD1), the difference in MRD1 between surgical and nonsurgical eyelids in unilateral ptosis, and lagophthalmos. Secondary outcome measures included recurrence and complications.

RESULTS

Twenty-six patients met inclusion criteria, 24 males and 2 females. Mean postoperative MRD1 at last follow-up was 2.9 ± 1.2 mm and the mean difference in MRD1 between surgical and nonsurgical eyelids at last follow-up was 1.1 ± 1.0 mm. Average lagophthalmos at postoperative month 2 to 5 was 0.6 ± 0.7 mm. One patient demonstrated postoperative lid retraction that required re-operation. Four of 31 eyelids (12.9%) demonstrated ptosis recurrence at 5, 12, or 24 months.

CONCLUSIONS

In this retrospective series, the authors report clinically and statistically significant surgical eyelid height improvement and symmetry between nonsurgical and surgical eyelids in congenital ptosis patients treated with minimal dissection direct frontalis flap advancement.

Surgical treatment of unilateral severe simple congenital ptosis

Unilateral congenital ptosis with poor levator function of ≤4 mm continues to be a difficult challenge for the oculoplastic surgeon. Surgical correction can be accomplished with unilateral frontalis suspension, maximal levator resection, or bilateral frontalis suspension with or without levator muscle excision of the normal eyelid. Bilateral frontalis suspension was proposed by Beard and Callahan to overcome the challenge of postoperative asymmetry, allowing symmetrical lagophthalmos on downgaze, postoperatively. However, most surgeons and patients prefer unilateral correction on the abnormal eyelid either with a frontalis suspension or maximal levator resection. Frontalis suspension may be performed through the various surgical techniques using different autogenous or exogenous materials. Autogenous fascia lata is considered the material of choice with low recurrence rates but carries the drawbacks of the difficulty of harvesting and postoperative morbidity from the second surgical site. Recent reports have suggested that maximal levator resection provides improved cosmesis, a more natural contour, and avoids brow scars. Although both treatments have shown to have similar success rates, there is much debate about what the most favorable method for treating severe unilateral ptosis. We review the literature on the various surgical treatments for unilateral severe congenital ptosis, including the rationale, advantages and disadvantages of each technique.

Double Rhomboid Suture Technique for Congenital Ptosis

PURPOSE

Congenital ptosis is a troubling eye condition for pediatric ophthalmologists. There are many considerations to contemplate when deciding when to operate and which technique to use.

METHODS

A retrospective chart review of 69 pediatric patients treated for congenital ptosis using a double rhomboid frontalis sling with a nylon suture at a single tertiary care center.

RESULTS

For patients with more than 6 months of follow-up, there were 38 patients with 46 primary surgeries (22 [58%] males and 16 [42%] females). The average age at the first surgery was 39.34 ± 33.18 months. There was a mean follow-up time of 51.87 ± 53.79 months. There were 7 children who needed one revision and 1 child who needed a second revision, equaling a 23.9% rate of revision. Patients who had surgery before the age of 3 years had a statistically significant likelihood of needing a second surgery (chi-square test = 7.246, P = .007, 95% confidence interval = 0.027 to 0.687). It was also statistically significant (P < .05) that, throughout childhood, older patients were less likely to need a revision.

CONCLUSIONS

A double rhomboid frontalis sling using a nylon suture is an effective technique to treat congenital ptosis. This technique is easy to master and has a low cost compared to techniques involving autografts and allografts. It is also important to advise the family of the likelihood of a second surgery if there is a need to operate at a young age. [J Pediatr Ophthalmol Strabismus. 2018;55(2):117-121.].

The Value of the Frontalis Suspension Procedure as a Repeat Intervention in Congenital Blepharoptosis

PURPOSE

To evaluate the therapeutic benefits of frontalis suspension as a repeat intervention in congenital blepharoptosis.

METHODS

Pediatric patients diagnosed as having congenital ptosis who had at least 2 years of postoperative follow-up were included in this retrospective study. A successful outcome was defined as a postoperative margin-reflex distance of 3 mm or greater. The chi-square, Student's t, and Mann-Whitney U tests were used in comparisons.

RESULTS

Eighty-four eyes of 77 patients with a follow-up period of 8.4 ± 0.7 years were included. The initial surgery was levator resection in 29 (34.5%) eyes and frontalis suspension in 55 (65.5%) eyes. Frontalis suspension was performed for all repeat interventions (n = 20). Surgical success was achieved in 61.9% of patients with single surgery (75.9% for levator resection vs 54.5% for frontalis suspension; P = .06) and in 77.4% of patients following repeated surgeries (93.1% vs 69.1% for patients who initially underwent levator resection vs frontalis suspension, respectively; P = .012). A higher success rate was associated with better preoperative levator function (P = .01) and a higher margin-reflex distance (P = .004), and was inversely proportional to ptosis severity (P = .04).

CONCLUSIONS

Frontalis suspension as a repeat intervention for congenital blepharoptosis is associated with a further increase in long-term anatomic success rates and should be considered when initial procedures fail or remain inadequate. [J Pediatr Ophthalmol Strabismus. 2017;54(5):320-323.].

Clinical Results of Modified Frontalis Suspension Technique Using Preserved Fascia Lata for Congenital Ptosis

PURPOSE

The purpose of this study was to evaluate the clinical results of modified frontalis suspension technique with preserved fascia lata and to analyze the results according to age and preoperative ptosis degree.

METHODS

This study involved a retrospective review of the electronic medical records of congenital ptosis patients who underwent unilateral or bilateral frontalis sling surgery using preserved fascia lata between March 1, 2004 and December 31, 2012.

RESULTS

Seventy-seven patients (99 eyes) were included in the study. The mean age of the patients at the time of surgery was 6.2 ± 6.7 years. Mean follow-up time was 5.4 ± 3.2 years. Among 77 patients, 22 patients (28.5%) had a mild degree of ptosis, 39 (50.6%) had moderate, and 16 (20.7%) had a severe degree of ptosis. A satisfactory result (good and fair) was achieved in 65 of the 77 patients (84.4%) and a poor result was recorded in 12 patients (15.5%). Preoperative ptosis degree had no effect on the surgical success rate (19/22 [86.3%] in the mild group versus 34/39 [87.1%] in the moderate group versus 12/16 [75%] in the severe group, P = 0.243). There was no significant difference in surgical success rate between the unilateral and bilateral ptosis groups (45/55 [81.8%] versus 20/22 [90.9%], P = 0.479 respectively), between sexes (41/46 [89.1%] in male versus 24/31 [77.4%] in female, P = 0.271), or age groups (52/60 [86.6%] in younger group versus 13/17 [76.4%] in elder group, P = 0.526). Recurrence of ptosis did not differ according to the preoperative ptosis degree (3/22 [13.6%] in the mild group, 5/39 [12.8%] in the moderate group, and 2/16 [12.5%] in the severe group, P = 0.994). Age also had no influence on the ptosis recurrence. The preoperative marginal reflex distance 1 of 0.41 ± 1.06 mm increased to 1.67 ± 0.80 mm postoperatively (P = 0.000).

CONCLUSIONS

The authors identified the long-term efficacy of preserved fascia lata in frontalis sling surgery with a modified frontalis suspension method for all age groups of patients. There was a small rate of recurrence (12.9%) over a maximum of 9 years of follow-up, which was corrected with additional surgery.

Surgical Sutures with Porous Sheaths for the Sustained Release of Growth Factors

Surgical sutures with highly porous sheaths are developed using a swelling and freeze-drying procedure without compromising their mechanical properties. The modified sutures show a high capacity for loading biofactors and are able to release the loaded biofactors in a sustained manner.