ADJUSTABLE EYELID AND EYEBROW SUSPENSION FOR BLEPHAROPTOSIS M E L V I N R. C A R L S O N , M.D.,
AND A R T H U R JAMPOLSKY,
San Francisco,
M.D.
California
Severe blepharoptosis, when associated with little or no levator muscle function (less than 4 mm levator muscle action), is usually surgically corrected by the brow suspension technique. 1 - 3 The goal of the surgery is to elevate the blepharoptic eye lid so that it is in a normal position for direct forward gaze and that its position and contour match that of the opposite eye. Current techniques are not complete ly satisfactory, because often one cannot accurately estimate where the position of the eyelid will fall postoperatively. A symmetrical bilateral result is difficult to achieve, and eyelid contour may not be ideal and symmetrical. Several reports 4 - 7 have described fascia lata suspension procedures in which the eyelid height can be adjusted postopera tively. We describe herein an adjustable eyebrow suspension technique that we devised, which allows intraoperative and postoperative alteration of both the eyelid position and the eyelid contour.
lid position. The loop sutures allow addi tional adjustable control of the suspen sion material so that eyelid contour can be altered. Three skin markings are made 3 to 4 mm above and parallel to the ciliary margin. One is placed centrally, another at the midpoint between the center of the eyelid and the inner canthus, and the other at the midpoint between the center of the eyelid and the outer canthus. Simi lar skin markings are made just above the eyebrow. One is centrally placed and the others are approximately 15 mm to each side. Skin incisions are then made through each skin marking, direct along wrinkle lines. The eyelid incisions are made to the depth of the tarsus. The brow incisions are made to the periosteum of the frontal bone. The choice of suspen sion material can be varied according to the preference of the surgeon. Although 4-0 silk suture was used in our cases, the technique should work equally well with other materials.
M A T E R I A L AND M E T H O D S
With a Wright fascia needle or a large curve needle, one end of the suspension material is passed from the center eye brow incision and allowed to exit through the lateral eyebrow incision. A loop su ture (a 5-0 or 6-0 smooth nonabsorbable suture) is tied around the suspension ma terial at this point. These loop sutures allow manipulation of eyelid position and contour by easily exposing the rhomboid suture, both during the operation and for postoperative adjustment. The suspen sion material is then passed from the lateral eyebrow incision, through the lat eral portion of the upper eyelid beneath the orbicularis muscle, and brought out
The essential feature of the procedure is to use two separate rhomboid suspension slings, which have removable loop su tures placed at points where the suspen sion material forms a bend. The suspen sion material is tied at the eyebrow in a bow knot to allow adjustment of the eyeFrom the Smith-Kettlewell Institute of Visual Sciences, San Francisco, California. This study was supported by Grant No. 5 P30 EY01186, and Train ing Grant No. 5 T32 EYO7027 from the National Institutes of Health, and the Smith-Kettlewell Eye Research Foundation. Reprint requests to Arthur Jampolsky, M.D., Smith-Kettlewell Institute of Visual Sciences, 2232 Webster St., San Francisco, CA 94115.
AMERICAN JOURNAL O F OPHTHALMOLOGY 88:109-112, 1979
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through the lateral upper eyelid incision. Again, a loop suture is similarly placed around the suspension material at this point. The suspension material is then passed horizontally between the tarsus and orbicularis to exit at the central eyelid incision. No loop suture is necessary at this point. The suspension material is then brought up through the upper eyelid and allowed to exit at the central eyebrow incision (Fig. 1). A second rhomboid is similarly formed by threading the sus pension material through the medial brow, medial eyelid, central eyelid, and central eyebrow incisions. Intraoperative adjustment of eyelid position and contour is now possible. The end of the suspension material from the central eyelid incision is grasped (at the central brow incision) and gentle traction applied until desired elevation of the cen tral portion of the eyelid has been achieved. It can be held at this point with a small hemostat at skin level. Eyelid contour is next evaluated and tension of the sling suspension material at the medi al and lateral skin incisions can be locally adjusted with the loop sutures. If there is insufficient elevation (or drooping) at ei ther position, the corresponding loop su-
Fig. 1 (Carlson and Jampolsky). Placement of the temporal rhomboid suspension sling. Note the loop sutures (black) around the suspension material (white).
JULY, 1979
ture at the eyebrow can be pulled to increase the tension on the suspension material. The tension can similarly be reduced by pulling on the loop suture at the eyelid margin. When the eyelid posi tion and the eyelid margin contour have been adjusted to their desired position and there is no slack in the suspension material, the hemostats are removed and the suspension material is tied in a bow knot (Fig. 2). The skin incisions are sutured with small approximating sutures in an inter rupted fashion, allowing the loop sutures to remain exposed. Antibiotic ointment is applied to the incisional sites and the lower eyelid is elevated with a Frost su ture. Postoperative adjustment of the eyelid is performed when the patient is alert and awake (without obtunding drugs), usually four to 12 hours after surgery. The patient is seated and instructed to look straight ahead. Eyelid position and contour are assessed. If eyelid elevation "is not ideal, adjustment, under sterile conditions, can be made by loosening the bow knot in the suspension material and retying it after adjustment of the height of the eyelid has been made. This procedure can be repeat ed until optimal eyelid elevation has been achieved. Similarly, the eyelid contour
Fig. 2 (Carlson and Jampolsky). Adjustable eyelid-brow suspension at completion of intraopera tive adjustment. Skin incisions have been sutured.
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can be altered by pulling on the appropri ate loop sutures to expose and readjust the tension of the suspension material at the eyelid margin and the eyebrow. When the adjustment has been completed, the suspension material is tied, the excess material excised, and the loop sutures are removed. The skin incision is allowed to heal over the tied knot of the sling materi al. Occasionally, one may wish to add additional skin closure. The Frost suture is removed in two or three days. Eyelid edema may be present postoperatively. If edema is minimal, adjustment can be made and should reflect the final positioning of the eyelid when all healing is complete. If there is considerable ede ma, adjustment and final tying of the su ture should be delayed until the edema has subsided. A sterile dressing can be placed over the eye and eyebrow to avoid any contamination of the wound. DISCUSSION
The standard eyebrow suspension pro cedure for blepharoptosis correction is an uncomplicated technique. The results, however, are not always ideal. Under and over corrections of eyelid elevation and abnormal curvature of the eyelid margin may occur. 8 The goal of the procedure is a normal position of the eyelid in straight ahead gaze, symmetrical with the oppo site eye, and it is desirable to adjust the surgical result in straight ahead gaze with the patient alert. Adjustable surgical procedures are not new. Repositioning of the eye in strabis mus surgery with the adjustable rectus recession technique is an established pro cedure. 9 - 1 1 Whenever the results of a sur gical procedure are unpredictable, a tech nique which allows for postoperative ad justment is desirable. For the strabismus surgeon, the two goals of balanced pri mary position alignment and balanced rotations can best be achieved if adjust ment is possible when the patient is alert
111
with full muscle tonus present. The same is true for the blepharoptosis surgeon. Snyder and Norton 4 originally de scribed the postoperative adjustable frontalis sling procedure. They used bovine fascia attached to stainless steel wires that were brought out through the scalp of the hairline. The wires were twisted over cotton bolsters externally and the eyelid could be raised or lowered by loosening or tightening the wires. The wires were left in place for 30 days and they had good results in 21 cases. Argamaso 5 and Argamaso and Lewin 6 reported a technique using autogenous fascia lata for a postoperative adjustable sling. The fascia was brought to the exte rior through hairline incisions and trans fixed with vascular clips or sterile pins. Adjustment was made within two to five days and the external fascia allowed to slough off. Results in ten patients indicat ed stable long-term effects. Mustarde 7 described a postoperative adjustable fascia lata frontalis sling tech nique that used a capstan-shaped button located at the eyebrow. The height of the upper eyelid could be altered by twisting the button. Adjustment was made 24 to 48 hours after surgery. The exteriorized ends of the fascia sloughed away at skin level within two to three weeks. None of the above postoperative adjust able frontalis sling procedures allow postoperative alteration of eyelid margin contour. Beard 8 reported poor eyelid con tour (or peaking) as a complication of eyebrow suspension. Occasionally, it can be relieved by massage. Otherwise, expo sure and incision of the suspension mate rial is necessary to allow the elevated part of the eyelid to fall. Our technique allows intraoperative and postoperative altera tion of eyelid contour and should mark edly lessen this complication. We used our adjustable eyebrow sus pension procedure in two patients. In both cases, postoperative adjustment of
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AMERICAN JOURNAL OF OPHTHALMOLOGY
eyelid position was necessary to alter an undercorrection. One patient required al teration of eyelid contour to eliminate a peaking of the eyelid. No change in the eyelid elevation or eyelid contour has been noted in either case in a one-year period after surgery. SUMMARY
We devised a technique for an adjusta ble frontalis sling that allows for intraoperative and postoperative alteration of both eyelid elevation and eyelid contour. REFERENCES 1. Fox, S. A.: Congenital ptosis. 2. Frontalis sling. J. Pediatr. Ophthalmol. 3:25, 1966. 2. Crawford, J. S.: Repair of ptosis using frontalis muscle and fascia lata. Trans. Am. Acad. Ophthal mol. Otolaryngol. 60:672, 1956. 3. Bear, C : Ptosis, 2nd ed. St. Louis, C. V. Mosby, 1976 p. 170.
JULY, 1979
4. Snyder, C. C , and Norton, W. W.: Eyelid pto sis. Plast. Reconstr. Surg. 27:586, 1961. 5. Argamaso, R. B.: An adjustable fascia lata sling for the correction of blepharoptosis. Br. J. Plast. Surg. 27:274, 1974. 6. Argamaso, R. B., and Lewin, M. L.: Fascia lata sling in blepharoptosis. Enhancement of result by postoperative adjustment. J. Pediatr. Ophthalmol. 13:51, 1976. 7. Mustarde, J. D.: Problems and possibilities in ptosis surgery. Plast. Reconstr. Surg. 56:381, 1975. 8. Beard, C : Ptosis, 2nd ed. St. Louis, C. V. Mosby, 1976, p p . 251-256. 9. Jampolsky, A.: Strabismus reoperation tech niques. Trans Am. Acad. Ophthalmol. Otolaryngol. 79:704, 1975. 10. Rosenbaum, A. L., Metz, H. S., Carlson, M., and Jampolsky, A.: Adjustable rectus muscle reces sion surgery. A follow-up study. Arch. Ophthalmol. 95:817, 1977. 11. Jampolsky, A.: Adjustable strabismus surgical procedures. In Symposium on Strabismus, New Orleans Academy of Ophthalmology. St. Louis, C. V. Mosby, 1978, p p . 321-349.
AND A R T H U R JAMPOLSKY,
San Francisco,
M.D.
California
Severe blepharoptosis, when associated with little or no levator muscle function (less than 4 mm levator muscle action), is usually surgically corrected by the brow suspension technique. 1 - 3 The goal of the surgery is to elevate the blepharoptic eye lid so that it is in a normal position for direct forward gaze and that its position and contour match that of the opposite eye. Current techniques are not complete ly satisfactory, because often one cannot accurately estimate where the position of the eyelid will fall postoperatively. A symmetrical bilateral result is difficult to achieve, and eyelid contour may not be ideal and symmetrical. Several reports 4 - 7 have described fascia lata suspension procedures in which the eyelid height can be adjusted postopera tively. We describe herein an adjustable eyebrow suspension technique that we devised, which allows intraoperative and postoperative alteration of both the eyelid position and the eyelid contour.
lid position. The loop sutures allow addi tional adjustable control of the suspen sion material so that eyelid contour can be altered. Three skin markings are made 3 to 4 mm above and parallel to the ciliary margin. One is placed centrally, another at the midpoint between the center of the eyelid and the inner canthus, and the other at the midpoint between the center of the eyelid and the outer canthus. Simi lar skin markings are made just above the eyebrow. One is centrally placed and the others are approximately 15 mm to each side. Skin incisions are then made through each skin marking, direct along wrinkle lines. The eyelid incisions are made to the depth of the tarsus. The brow incisions are made to the periosteum of the frontal bone. The choice of suspen sion material can be varied according to the preference of the surgeon. Although 4-0 silk suture was used in our cases, the technique should work equally well with other materials.
M A T E R I A L AND M E T H O D S
With a Wright fascia needle or a large curve needle, one end of the suspension material is passed from the center eye brow incision and allowed to exit through the lateral eyebrow incision. A loop su ture (a 5-0 or 6-0 smooth nonabsorbable suture) is tied around the suspension ma terial at this point. These loop sutures allow manipulation of eyelid position and contour by easily exposing the rhomboid suture, both during the operation and for postoperative adjustment. The suspen sion material is then passed from the lateral eyebrow incision, through the lat eral portion of the upper eyelid beneath the orbicularis muscle, and brought out
The essential feature of the procedure is to use two separate rhomboid suspension slings, which have removable loop su tures placed at points where the suspen sion material forms a bend. The suspen sion material is tied at the eyebrow in a bow knot to allow adjustment of the eyeFrom the Smith-Kettlewell Institute of Visual Sciences, San Francisco, California. This study was supported by Grant No. 5 P30 EY01186, and Train ing Grant No. 5 T32 EYO7027 from the National Institutes of Health, and the Smith-Kettlewell Eye Research Foundation. Reprint requests to Arthur Jampolsky, M.D., Smith-Kettlewell Institute of Visual Sciences, 2232 Webster St., San Francisco, CA 94115.
AMERICAN JOURNAL O F OPHTHALMOLOGY 88:109-112, 1979
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AMERICAN JOURNAL OF OPHTHALMOLOGY
through the lateral upper eyelid incision. Again, a loop suture is similarly placed around the suspension material at this point. The suspension material is then passed horizontally between the tarsus and orbicularis to exit at the central eyelid incision. No loop suture is necessary at this point. The suspension material is then brought up through the upper eyelid and allowed to exit at the central eyebrow incision (Fig. 1). A second rhomboid is similarly formed by threading the sus pension material through the medial brow, medial eyelid, central eyelid, and central eyebrow incisions. Intraoperative adjustment of eyelid position and contour is now possible. The end of the suspension material from the central eyelid incision is grasped (at the central brow incision) and gentle traction applied until desired elevation of the cen tral portion of the eyelid has been achieved. It can be held at this point with a small hemostat at skin level. Eyelid contour is next evaluated and tension of the sling suspension material at the medi al and lateral skin incisions can be locally adjusted with the loop sutures. If there is insufficient elevation (or drooping) at ei ther position, the corresponding loop su-
Fig. 1 (Carlson and Jampolsky). Placement of the temporal rhomboid suspension sling. Note the loop sutures (black) around the suspension material (white).
JULY, 1979
ture at the eyebrow can be pulled to increase the tension on the suspension material. The tension can similarly be reduced by pulling on the loop suture at the eyelid margin. When the eyelid posi tion and the eyelid margin contour have been adjusted to their desired position and there is no slack in the suspension material, the hemostats are removed and the suspension material is tied in a bow knot (Fig. 2). The skin incisions are sutured with small approximating sutures in an inter rupted fashion, allowing the loop sutures to remain exposed. Antibiotic ointment is applied to the incisional sites and the lower eyelid is elevated with a Frost su ture. Postoperative adjustment of the eyelid is performed when the patient is alert and awake (without obtunding drugs), usually four to 12 hours after surgery. The patient is seated and instructed to look straight ahead. Eyelid position and contour are assessed. If eyelid elevation "is not ideal, adjustment, under sterile conditions, can be made by loosening the bow knot in the suspension material and retying it after adjustment of the height of the eyelid has been made. This procedure can be repeat ed until optimal eyelid elevation has been achieved. Similarly, the eyelid contour
Fig. 2 (Carlson and Jampolsky). Adjustable eyelid-brow suspension at completion of intraopera tive adjustment. Skin incisions have been sutured.
VOL. 88, NO. 1
ADJUSTABLE EYELID AND EYEBROW SUSPENSION
can be altered by pulling on the appropri ate loop sutures to expose and readjust the tension of the suspension material at the eyelid margin and the eyebrow. When the adjustment has been completed, the suspension material is tied, the excess material excised, and the loop sutures are removed. The skin incision is allowed to heal over the tied knot of the sling materi al. Occasionally, one may wish to add additional skin closure. The Frost suture is removed in two or three days. Eyelid edema may be present postoperatively. If edema is minimal, adjustment can be made and should reflect the final positioning of the eyelid when all healing is complete. If there is considerable ede ma, adjustment and final tying of the su ture should be delayed until the edema has subsided. A sterile dressing can be placed over the eye and eyebrow to avoid any contamination of the wound. DISCUSSION
The standard eyebrow suspension pro cedure for blepharoptosis correction is an uncomplicated technique. The results, however, are not always ideal. Under and over corrections of eyelid elevation and abnormal curvature of the eyelid margin may occur. 8 The goal of the procedure is a normal position of the eyelid in straight ahead gaze, symmetrical with the oppo site eye, and it is desirable to adjust the surgical result in straight ahead gaze with the patient alert. Adjustable surgical procedures are not new. Repositioning of the eye in strabis mus surgery with the adjustable rectus recession technique is an established pro cedure. 9 - 1 1 Whenever the results of a sur gical procedure are unpredictable, a tech nique which allows for postoperative ad justment is desirable. For the strabismus surgeon, the two goals of balanced pri mary position alignment and balanced rotations can best be achieved if adjust ment is possible when the patient is alert
111
with full muscle tonus present. The same is true for the blepharoptosis surgeon. Snyder and Norton 4 originally de scribed the postoperative adjustable frontalis sling procedure. They used bovine fascia attached to stainless steel wires that were brought out through the scalp of the hairline. The wires were twisted over cotton bolsters externally and the eyelid could be raised or lowered by loosening or tightening the wires. The wires were left in place for 30 days and they had good results in 21 cases. Argamaso 5 and Argamaso and Lewin 6 reported a technique using autogenous fascia lata for a postoperative adjustable sling. The fascia was brought to the exte rior through hairline incisions and trans fixed with vascular clips or sterile pins. Adjustment was made within two to five days and the external fascia allowed to slough off. Results in ten patients indicat ed stable long-term effects. Mustarde 7 described a postoperative adjustable fascia lata frontalis sling tech nique that used a capstan-shaped button located at the eyebrow. The height of the upper eyelid could be altered by twisting the button. Adjustment was made 24 to 48 hours after surgery. The exteriorized ends of the fascia sloughed away at skin level within two to three weeks. None of the above postoperative adjust able frontalis sling procedures allow postoperative alteration of eyelid margin contour. Beard 8 reported poor eyelid con tour (or peaking) as a complication of eyebrow suspension. Occasionally, it can be relieved by massage. Otherwise, expo sure and incision of the suspension mate rial is necessary to allow the elevated part of the eyelid to fall. Our technique allows intraoperative and postoperative altera tion of eyelid contour and should mark edly lessen this complication. We used our adjustable eyebrow sus pension procedure in two patients. In both cases, postoperative adjustment of
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AMERICAN JOURNAL OF OPHTHALMOLOGY
eyelid position was necessary to alter an undercorrection. One patient required al teration of eyelid contour to eliminate a peaking of the eyelid. No change in the eyelid elevation or eyelid contour has been noted in either case in a one-year period after surgery. SUMMARY
We devised a technique for an adjusta ble frontalis sling that allows for intraoperative and postoperative alteration of both eyelid elevation and eyelid contour. REFERENCES 1. Fox, S. A.: Congenital ptosis. 2. Frontalis sling. J. Pediatr. Ophthalmol. 3:25, 1966. 2. Crawford, J. S.: Repair of ptosis using frontalis muscle and fascia lata. Trans. Am. Acad. Ophthal mol. Otolaryngol. 60:672, 1956. 3. Bear, C : Ptosis, 2nd ed. St. Louis, C. V. Mosby, 1976 p. 170.
JULY, 1979
4. Snyder, C. C , and Norton, W. W.: Eyelid pto sis. Plast. Reconstr. Surg. 27:586, 1961. 5. Argamaso, R. B.: An adjustable fascia lata sling for the correction of blepharoptosis. Br. J. Plast. Surg. 27:274, 1974. 6. Argamaso, R. B., and Lewin, M. L.: Fascia lata sling in blepharoptosis. Enhancement of result by postoperative adjustment. J. Pediatr. Ophthalmol. 13:51, 1976. 7. Mustarde, J. D.: Problems and possibilities in ptosis surgery. Plast. Reconstr. Surg. 56:381, 1975. 8. Beard, C : Ptosis, 2nd ed. St. Louis, C. V. Mosby, 1976, p p . 251-256. 9. Jampolsky, A.: Strabismus reoperation tech niques. Trans Am. Acad. Ophthalmol. Otolaryngol. 79:704, 1975. 10. Rosenbaum, A. L., Metz, H. S., Carlson, M., and Jampolsky, A.: Adjustable rectus muscle reces sion surgery. A follow-up study. Arch. Ophthalmol. 95:817, 1977. 11. Jampolsky, A.: Adjustable strabismus surgical procedures. In Symposium on Strabismus, New Orleans Academy of Ophthalmology. St. Louis, C. V. Mosby, 1978, p p . 321-349.
