Frontalis muscle flap suspension for the correction of congenital blepharoptosis in early age children

Outcomes for expanded polytetrafluoroethylene strip in frontalis suspension surgery

PURPOSE

This study evaluates surgical outcomes and complication rates of frontalis suspension with expanded polytetrafluoroethylene (ePTFE).

METHODS

This retrospective cohort study reviewed all patients undergoing frontalis suspension surgery using ePTFE as the sling material from January 1 2012 to March 3 2020 by a single surgeon at a single academic center. Two different surgical techniques were evaluated in the placement of the sling material. Demographic, clinical, and operative data were extracted. Outcome data including postoperative lid height, reoperation, and complication rate were extracted for the cohort and compared between the two surgical techniques. Descriptive statistics were utilized.

RESULTS

Sixty-four eyes from 49 unique patients were included in this study. Forty-three (67.2%) patients had isolated congenital blepharoptosis; 14 (21.9%) had blepharophimosis, ptosis, and epicanthus inversus syndrome (BPES); and 2 (3.1%) had cranial nerve III palsy. Fifty-one (79.7%) patients had no prior blepharoptosis surgery. Lid crease incision and stab incision techniques were utilized for 24 (37.5%) and 40 (62.5%) eyes, respectively. Overall, 21 (32.8%) eyes required reoperation with ePTFE to achieve appropriate eyelid height or contour. Only one patient experienced implant infection, requiring removal of ePTFE sling after a second reoperation. There were no cases of implant exposure or granuloma formation noted during the study period.

CONCLUSION

An ePTFE strip soaked in cefazolin prior to utilization in surgery is a viable material for frontalis suspension surgery, with a lower infectious or inflammatory complication rate than previously reported. However, reoperation rate was still relatively high.

The Aesthetic Evaluation of the Brow-Eye Continuum After Correction of Severe Congenital Ptosis in Children With Extended Frontalis Muscle Advancement Technique

BACKGROUND

Severe congenital ptosis is a common ocular deformity in pediatric patients that can significantly impact visual development and aesthetic appearance, leading to negative psychosocial outcomes. The frontalis muscle advancement technique is a well-established surgical treatment for severe congenital ptosis. Aesthetic changes of the brow-eye continuum often plays an important role in ptosis surgery.

METHODS

We conducted a single-center retrospective case series study of patients with severe congenital ptosis who underwent the frontalis muscle advancement technique at the Department of Plastic and Reconstructive Surgery, Xijing Hospital, Fourth Military Medical University between April 2020 and June 2021. The study aimed to evaluate the aesthetic changes of the eyebrow-eyelid continuum after surgery. The main outcome measurements included marginal reflex distance 1, palpebral fissure height, eyebrow position, upper eyelid to lower eyebrow distance, lower eyelid to upper eyebrow distance, and nasal base to lower eyelid distance.

RESULTS

The study included 48 patients (66 eyelids), with 30 unilateral and 18 bilateral patients. Our analysis found that eyebrow height decreased by an average of 4.8% postoperatively relative to preoperatively in all patients.

CONCLUSIONS

The frontalis muscle advancement technique has demonstrated effectiveness in achieving aesthetically pleasing outcomes in children with severe ptosis. It is crucial to pay careful attention to the brow-eye continuum during the correction process, as its harmony can greatly impact the final result.

Efficacy and Safety of Surgical Procedures for Congenital Moderate and Severe Blepharoptosis: A Network Meta-analysis

BACKGROUND

There are various surgical approaches to treat congenital moderate and severe blepharoptosis (CMSBP), but their efficacy and safety remain unclear owing to a lack of high-level evidence. This network meta-analysis aimed to evaluate the efficacy and safety of 3 classical operations: and their modifications frontal muscle flap suspension (FMS), levator palpebrae muscle shortening (LMS), conjoint fascial sheath suspension (CFSS), and modified CFSS.

METHODS

We searched the PubMed, MEDLINE, Cochrane Library, CNKI, and Wanfang databases until March 2022. A Bayesian network meta-analysis was conducted for the 5 most common treatments. Outcome indicators were the number of patients with good correction and adverse events.

RESULTS

Twenty-one studies were included, with 2402 eyes in 1863 patients. Five surgical methods were evaluated: FMS, LMS, CFSS, and conjoint fascial sheath suspension combined with levator muscle shortening (CFSS+LMS), or with levator palpebrae muscle composite flap suspension (CFS+L). Meta-analysis indicated that CFSS is more effective than LMS and FMS, but inferior to CFSS+LMS and CFS+L. Efficacy rates of CFSS+LMS and CFS+L were comparable. Frontal muscle flap suspension was more effective than LMS. Safety data meta-analysis found CFSS safer than FMS and LMS but with more complications than CFSS+LMS and CFS+L. Complication rates were comparable between CFS+L and CFSS+LMS, and also for FMS and LMS.

CONCLUSIONS

When correcting CMSBP, CFSS+LMS, and CFS+L may be better therapeutic strategies for effectiveness and safety. Conjoint fascial sheath suspension also yielded good surgical effects. Plastic surgeons should be cautious about LMS and FMS.

LEVEL OF EVIDENCE

Level IV.

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.

Surgical correction of severe congenital ptosis using a modified frontalis muscle advancement technique: A single-arm trial

PURPOSE

To describe our experience with a modified frontal muscle advancement flap to treat patients with severe congenital ptosis.

METHODS

Analysis of the clinical charts of 154 patients who underwent a modified frontal muscle advancement flap. The FM was exposed by a crease incision. The FM flap was created by deep dissection between the orbicularis muscle and orbital septum from the skin crease incision to the supraorbital margin and subcutaneous dissection from the inferior margin of the eyebrow to 0.5 cm above the eyebrow. No vertical incision was made on the FM flap to ensure an intact flap wide enough to cover the entire upper tarsal plate. Contour, symmetry of height, marginal reflex distance (MRD1), and complications were assessed. Mean follow-up was 10 months.

RESULTS

The mean patient age was 7.6 ± 5.6 (range, 2-18) years. The mean MRD1 was 3.2 ± 1.3 mm after the operation. All bilateral cases achieved symmetry and optimal lid contour; 17 unilateral cases were under corrected, with a success rate of 89.0%. Complications such as entropion, exposure keratitis, FM paralysis, frontal hypoesthesia, severe haematoma, and entropion were not observed in our series.

CONCLUSION

A modified frontal muscle advancement flap produced a high success rate with a clear field of vision, mild trauma, and few complications. This technique is relatively simple and should be considered for correcting severe congenital ptosis.Date of registration: 29-03-2020Trial registration number: ChiCTR2000031364Registration site: http://www.chictr.org/.

The Function-Preserving Frontalis Orbicularis Oculi Muscle Flap for the Correction of Severe Blepharoptosis With Poor Levator Function

BACKGROUND

Severe blepharoptosis with poor levator function (LF) has traditionally been managed with exogenous frontalis suspension but complications such as lagophthalmos, infection, and rejection are often reported.

OBJECTIVES

The aim of this study was to design a function-preserving frontalis orbicularis oculi muscle (FOOM) flap to correct severe blepharoptosis with poor LF. The long-term surgical outcome of the technique was assessed.

METHODS

This retrospective study included only adult patients with severe blepharoptosis and poor LF, all of whom had their surgery performed by the senior surgeon over a 6-year period. Clinical assessment of LF, palpebral fissure height (PFH), marginal reflex distance 1 (MRD1), duration of follow-up, and postoperative complications were recorded.

RESULTS

A total of 34 patients and 59 eyelids were recorded during a mean follow-up period of 17.7 months. Postoperative evaluation yielded mean [standard deviation] improvements of PFH gain of 5.62 [1.61] mm (P < 0.001), and MRD1 and PFH increases of 4.03 [0.82] mm (P < 0.001) and 8.94 [0.81] mm (P < 0.001), respectively. All patients demonstrated normalization of orbicularis function: no lagophthalmos was observed at the 8-month postoperative follow-up. Recurrence of ptosis was recorded in 4 eyelids (6.78%). Revisions were performed in 2 eyelids (3.39%). No infection or granuloma was noted.

CONCLUSIONS

The function-preserving FOOM flap is a useful vector for frontalis suspension. Not only does it effectively address lagophthalmos as well as other complications, but it provides aesthetically pleasing outcomes in patients with severe blepharoptosis and poor LF.

LEVEL OF EVIDENCE: 4

Treatment of Congenital Ptosis in Infants With Associated Amblyopia Using a Frontalis Muscle Flap Eyelid Reanimation Technique

PURPOSE

To determine the efficacy of a frontalis muscle flap eyelid reanimation technique for correction of severe congenital ptosis and associated amblyopia in infants.

METHODS

The authors performed a retrospective chart review of patients 12 months of age or younger with unilateral or bilateral congenital ptosis and associated amblyopia or deemed at high risk for amblyopia due to visual deprivation. Following ptosis repair via a frontalis muscle flap technique, primary outcomes of postoperative eyelid position and amblyopia reversal were assessed.

RESULTS

Seventeen eyes of 12 participants were included for study. Seven of these patients had simple congenital ptosis, and the remainder had ptosis as part of a syndrome. Nine were diagnosed with amblyopia preoperatively, and the remaining 3 were too young for acuity testing but had occlusion of the visual axis by the ptotic eyelid in primary gaze. Postoperatively, the mean margin-to-reflex distance 1 was 2.4 mm (range: 0.0-4.0), and 9 patients (75%) demonstrated no evidence of amblyopia. Only 2 patients had eyelid asymmetry greater than 2 mm, which in both cases was due to lack of frontalis activation by the patient secondary to ongoing visual impairment. The most common complication was lagophthalmos in 6 eyes (35.3%), with no significant associated surface keratopathy.

CONCLUSIONS

The frontalis muscle flap technique may offer a new and effective approach to treating infants with severe congenital ptosis causing poor eyelid excursion and associated amblyopia while avoiding use of an implant.

A clinical decision model based on machine learning for ptosis

Background

To establish a decision model based on two- (2D) and three-dimensional (3D) eye data of patients with ptosis for developing personalized surgery plans.

Methods

Data of this retrospective, case-control study was collected from March 2019 to June 2019 at the Department of Ophthalmology, Shanghai Ninth People’s Hospital, and then the patients were followed up for 3 months. One hundred fifty-two complete feature eyes from 100 voluntary patients with ptosis and satisfactory surgical results were selected, with 48 eyes excluded due to any severe condition or improper collection and shooting angle. Three experimental schemes were set as follows: use 2D distance alone, use 3D distance alone, and use two distances at the same time. The five most common evaluation indicators used in the binary classification problem to test the decision model were accuracy (ACC), precision, recall, F1-score, and area under the curve (AUC).

Results

For diagnostic discrimination, recall of “3D”, “2D” and “Both” schemes were 0.875, 0.875 and 0.938 respectively. And precision of the three schemes were 0.8333, 0.7778 and 1.0000 for the surgical procedure classification. Values of “Both” scheme that combined 2D and 3D data were the highest in two classifications.

Conclusions

In this study, 3D eye data are introduced into clinical practice to construct a decision model for ptosis surgery. Our decision model presents exceptional prediction effect, especially when 2D and 3D data employed jointly.

The Application of Temporal-Fasciae-Complex Sheet in Treating Severe Blepharoptosis

AIM

To introduce the application of the temporal-fasciae-complex sheet in treating severe blepharoptosis by frontalis suspension and evaluate its postoperative effect.

METHODS

Between 2008 and 2016, 25 patients (33 eyelids) underwent this procedure. A 3-cm incision in the temporal region was made to harvest a sheet of deep temporal fascia with the loose aponeurosis attached on both sides. The sheet was then grafted through a preseptal tunnel to perform the suspension. The margin reflex distance 1 after suspension (MRD1S), the margin reflex distance 1 as lifting eyebrow forcefully (MRD1F), the eyelid excursion and the closable eyelid function were used to evaluate the postoperative effect.

RESULTS

A total of 22 patients (30 eyelids) completed the study with a mean follow-up period of 23 ± 8.78 months. There was a statistically significant difference between the MRD1 and MRD1S (p < 0.05), the preoperative and postoperative MRD1F (p < 0.05), the preoperative and postoperative eyelid excursion (p < 0.05). All the upper palpebral margins were located above the pupils and no longer affected visual acuity in primary gaze. No severe complication and recurrence were documented within a maximum follow-up period of 36 months.

CONCLUSIONS

Frontalis suspension with the temporal-fasciae-complex sheet is an efficient method to correct severe blepharoptosis with less complications and recurrences. The application of the sheet can not only overcome the influence of adhesion but also lift the eyelid both functionally and cosmetically.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Classification of Obviously Asymmetric Palpebral Fissures and Correction Based on Double Eyelid Surgery of the Primary Type

Bilateral palpebral fissures (PF) are rarely symmetrical. Palpebral plastic surgery is common in the Chinese population. This study aimed to assess the classification of obviously asymmetric palpebral fissures (OAPF). In addition, double eyelid surgery-based correction for the primary subtype was examined. Various clinical signs and etiologies were examined, and OAPF were classified into 3 subtypes: primary, secondary, and aging. For the secondary and aging subtypes, curative surgeries target the relevant underlying conditions. Patients with the primary subtype underwent corrective surgery based on double eyelid operation. After 8 to 12 months of follow-up, the corrective effects of different surgeries were evaluated in patients (n = 48) with primary OAPF. Satisfying look was obtained in all 48 cases, with smooth double eyelid lines and shapes, and no overt asymmetry between the 2 eyes. Thirteen patients developed hypophasis after levator plication, which was resolved within 1 month. Preoperative and postoperative PF were significantly different (1.48 ± 0.24 versus 0.19 ± 0.09 mm; P < 0.05). Overall, patients with OAPF can be classified into the primary, secondary, and aging subtypes. The 48 cases with the primary subtype showed a satisfying look after double eyelid surgery-based correction.

Prevalence and risk factors of childhood blepharoptosis in Koreans: the Korea National Health and Nutrition Examination Survey

Purpose:

Childhood blepharoptosis may cause cosmetic and functional problems in children, but there is a paucity of studies about its epidemiology. This study aimed to investigate the prevalence of childhood blepharoptosis and associated risk factors in a representative Korean population.

Methods:

This cross-sectional nation-wide study analysed the data set acquired from the Korea National Health and Nutrition Examination Survey 2008–2012. A total of 8218 children aged 3–18 years were included. The prevalence of childhood blepharoptosis, defined as a margin reflex distance (MRD) of < 2 mm in either eye, was estimated, and the risk factors were identified using multivariate logistic regression analysis.

Results:

The mean age of participants was 11.3 ± 0.1 years, and 52.8 ± 0.6% were boys. The overall prevalence of childhood blepharoptosis in Korea was 8.0% (95% CI, 6.9–9.1%). Boys exhibited a higher prevalence of blepharoptosis than girls at most of ages. Levator function increased with age in the normal general population. The proportion of subjects exhibiting MRD1 ≥ 4.0 mm also increased significantly with age (p < 0.001). Male gender, higher body mass index, and urban residency were significantly associated with childhood blepharoptosis.

Conclusions:

The prevalence of childhood blepharoptosis is higher in urban obese boys. The increase of levator function with age should be considered in evaluations of childhood ptosis.

The inflammation influence on corneal surface after frontalis suspension surgery

AIM

To study the influence of frontalis muscle flap suspension on ocular surface by analyzing the clinical features and inflammatory cytokines.

METHODS

A prospective, observational case series. Thirty-one eyes of 25 patients with severe congenital blepharoptosis who underwent frontalis muscle flap suspension surgery with at least 6mo of follow-up were included in the study. The main outcome measures were margin reflex distance 1 (MRD₁), degree of lagophthalmos, ocular surface disease index (OSDI), fluorescein staining (Fl), tear break-up time (BUT), Schirmer I test, and inflammatory cytokine assay.

RESULTS

The degrees of lagophthalmos significantly increased after surgery. The OSDI scores significantly increased 1wk postoperatively and then decreased 4wk after operation. The Fl scores reflected corneal epithelial defects in sixteen patients at early stage postoperatively. The BUT and Schirmer I test values remained stable and did not show change compared to those before surgery. The inflammatory cytokines in conjunctival epithelial cells (including IL-1β, IL-6, IL-8, TNF-α, and IL-17A) significantly increased 1wk after the surgery (P<0.001), then returned to the normal level at 24wk postoperatively. The levels of inflammatory cytokine IL-1β, IL-6, IL-8, TNF-α, and IL-17A elevated significantly and were positively correlated with OSDI and Fl scores.

CONCLUSION

Frontalis muscle flap suspension surgery results in lagophthalmos in early period of post-operation and relieved after months. The elevation of inflammatory cytokines level may participate in the occurrence of corneal epithelial defects at the early postoperative stage.

The protective efficacy and safety of bandage contact lenses in children aged 5 to 11 after frontalis muscle flap suspension for congenital blepharoptosis: A single-center randomized controlled trial

BACKGROUND

Postoperative complications, lagophthalmos and exposure keratopathy sometimes occur after surgery for congenital blepharoptosis. Bandage contact lenses (BCL) can help prevent some ocular surface disorders. The study aims to evaluate the efficacy and safety of BCL for protection of the ocular surface in children aged 5 to 11 years after frontalis muscle flap suspension for congenital blepharoptosis.

METHODS

We conducted a prospective randomized clinical study of 30 eyes of 30 patients with congenital blepharoptosis consecutively enrolled at the Ophthalmology Ward of the Children's Hospital of Chongqing Medical University, China from September 1, 2016, to February 30, 2017. After frontalis muscle flap suspension surgery, patients were randomly assigned to undergo BCL application (BCL group, 15 eyes) or no BCL application (control group, 15 eyes). All patients were treated with bramycin 0.3% and polyvinyl alcohol drops after surgery. The primary outcomes were dry eye assessed by tear film break time (TFBUT), fluoresce in corneal staining (FCS) on slit-lamp on days 1, 3, and 15 postoperatively, and lower tear meniscus height (LTMH) on optical coherence tomography on days 1 and 15 postoperatively. Secondary outcomes were pairwise correlation of TFBUT, FCS and LTMH.

RESULTS

In the BCL group, abnormal TFBUT and FCS were only found in 2 patients (13.33%) on postoperative day 15. In the control group, the incidence of dry eye assessed by TFBUT was 67.00% (10/15 eyes) on day 1, 73.33% (11/15 eyes) on day 3, and 53.33% (8/15 eyes) on day 15 (P < .001). LTMH were significantly higher in the BCL group than the control group postoperatively (P < .001). Significant positive correlations were found between LTMH and TFBUT pre-operation and on days 1 and 15 post-operation. For LTMH and FCSS (R = -0.815, P < .001), and TFBUT and FCS (R = -0.837, P < .001), the Pearson coefficient was negative on postoperative day 1, but not correlated on day 15.

CONCLUSIONS

Silicone hydrogel BCL were safe and efficacious for protective use in children after frontalis muscle flap suspension for congenital blepharoptosis.

Suspensory Materials for Surgery of Blepharoptosis: A Systematic Review of Observational Studies

BACKGROUND

Frontalis suspension surgery is considered the procedure of choice in cases of blepharoptosis. Among all the materials used in this type of surgery, ophthalmic and plastic surgeons prefer to use autologous Fascia Lata. However, during years, other autogenous and exogenous materials have been introduced.

OBJECTIVES

The aim of this study was therefore that of systematically reviewing the functional results and the rate of complications of different synthetic materials, as compared to autogenous Fascia Lata. The primary objective was to determine the rates of Successful Surgeries (SSs) of these materials. The secondary objective was to assess the onset of complications. The following materials were investigated: Fascia Lata, Mersilene, polytetrafluoroethylene (PTFE) and Silicon.

DATA SOURCE AND METHODS

Following the Prisma procedure, on January 30th, 2016 we used the following electronic databases to select the studies: MEDLINE and Scopus.

RESULTS

The search strategy retrieved 48 publications that met the eligibility criteria of the systematic review. All studies were non-comparative. PTFE (n = 5) showed the best rate of SSs among the materials compared (statistically significant). Surgeries performed with autogenous Fascia Lata (n = 19) had a 87% rate of success those performed with Mersilene (n = 12)had 92% and those performed with Silicon (n = 17)88%. PTFE had the best outcome, with 99% success rate. As for complications, surgeries performed with PTFE had a higher rate of suture infections (1.9%) as compared to Fascia Lata, but lower incidence for all other complications.

CONCLUSIONS

Although most studies were good quality cohort studies, the overall quality of this evidence should be regarded as low due to their non-comparative design. Our data suggest that PTFE seems to be the most valid alternative material for frontalis suspension surgery, with low recurrence rates and good cosmetic and functional results.

Functional centre of the upper eyelid: the optimal point for eyelid lifting in ptosis surgery

AIMS

To establish the novel concept of a functional eyelid centre to determine the optimal point for eyelid lifting in ptosis surgery.

METHODS

This was a prospective study of 112 patients with congenital ptosis. The functional eyelid centre was defined as the point where the eyelid contour showed the best appearance when the upper eyelid was lifted manually. In patients who underwent frontalis suspension surgery using silicone rods, the postoperative outcome was assessed according to the fixation point of the rod.

RESULTS

The average horizontal fissure width and the distance from the medial canthus to the mid-pupillary line were 21.9 and 10.1 mm, respectively. The functional eyelid centre was located 4.28±0.98 mm temporal to the mid-pupillary line. The outcomes of silicone rod surgeries were excellent when the rod was fixated 4.4 mm nasal and 3.9 mm temporal from the functional eyelid centre. These positions corresponded to 0.1 mm nasal and 8.2 mm temporal from the mid-pupillary line.

CONCLUSIONS

The functional eyelid centre was located slightly temporal to the mid-pupillary line. A better eyelid contour in ptosis surgery is produced when eyelid lifting is centred around the functional eyelid centre.