Orbit, 2014; 33(2): 91–95 ! Informa UK Ltd. ISSN: 0167-6830 print / 1744-5108 online DOI: 10.3109/01676830.2013.841714
ORIGINAL ARTICLE
Comparing Open and Closed Techniques of Frontalis Suspension with Silicone Rod for the Treatment Congenital Blepharoptosis Mohammad Etezad Razavi, Mohammad Khalifeh, and Ahmad Yazdani
ABSTRACT Purpose: To compare open and closed methods of the frontalis suspension operation with a silicone rod in the treatment of congenital blepharoptosis. Methods: Forty-four cases with unilateral or bilateral congenital ptosis with a poor levator function of54 mm were divided randomly into two groups. Each group underwent an eyelid crease incision operation (open) or a supralash stab incision (closed). Ptosis was measured by the difference between the upper eyelid margin reflex distance (MRD) of the affected eyelids of the unilateral and bilateral cases. Frequent follow-up examinations were performed up to 12 months post-surgery. Results: Associated ophthalmologic findings showed that amblyopia, strabismus, wound discharge and knot dehiscence problems were present in 36.6%, 27.3%, 8.5% and 8.5% of the patients, respectively. There was no significant difference between the abovementioned associated ophthalmic findings of the two operative methods studied (P = 0.37). The difference in the surgical methods and MRD 3, 6 and 12 months after operation did not reach statistical significance. Similar results for good MRD (35MRD55) were found in closed (54.5%, 12/22) and open (54.5%, 12/22) methods, while 40.9% (9/22) and 45.5% (10/22) of cases were attributed to the under correction group in the closed and open methods, respectively. In bilaterally operated cases, MRD was more symmetrical than in unilaterally operated eyes. The symmetry of MRD and the eyelid crease was more prevalent in the open technique group. Conclusions: The frontalis sling operation using a silicone rod exhibited better results, in terms of symmetry, in the open technique in comparison to the closed method. Keywords: Frontalis sling operation, congenital belpharoptosis, silicone brow suspension
INTRODUCTION
depends on several factors, such as age, degree of ptosis, levator muscle function and cornea status.4 The purpose of the present study is to compare the open and closed methods of the frontalis sling operation with a silicone rod for congenital ptosis.
20 14
Orbit Downloaded from informahealthcare.com by Kainan University on 04/07/15 For personal use only.
Eye Research Center, Khatam-Al-Anbia Eye Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
Congenital ptosis is a specific form of ptosis present at birth. It is a vertical narrowing of the palpebral fissure, secondary to the dropping of the upper eyelid to a lower place than the normal position which is associated with abnormality of the dystrophic levator muscle.1 This condition is generally unilateral (70%), however, in some cases it may be bilateral and can be isolated or associated with the dysfunction of one or more extraocular muscles and/or other systemic conditions.2,3 Correction of ptosis considers the use of different surgical methods. The selection of the appropriate operative approach for congenital ptosis
MATERIALS AND METHODS In the present study, 44 eyes with congenital ptosis and poor levator function were divided randomly into two groups. The patients excluded from the study presented either unilateral or bilateral ptosis with a poor levator function above of 4 mm.
Correspondence: Dr. Mohammad Etezad Razavi, Associate Professor of Ophthalmology, Eye Research Center of Mashhad University of Medical Sciences, Khatam-Al-Anbia Eye Hospital, Abutaleb Junction, Ghareni Blvd. 9195961151, Mashhad, Iran. E-mail: [email protected], [email protected]
91
92 M. Estezad Razavi et al. Furthermore, any patients with a history of weak Bells phenomenon, jaw winking phenomenon, blepharophimosis syndrome, thyroid eye disease, myasthenia gravis, or any previous eye surgery and trauma were also excluded from the study population. Complete pre-operative examinations, including visual acuity measurements, extraocular motility, cycloplegic refraction and funduscopy, were performed on all participants. Ptosis was evaluated by the difference between the upper eyelid margin reflex distance (MRD) of the affected eyelids of the unilateral and bilateral cases. In addition, follow-up examinations were performed 3, 6 and 12 months after surgery.
Orbit Downloaded from informahealthcare.com by Kainan University on 04/07/15 For personal use only.
Ethical Considerations An informed consent was obtained from each patient (or the patient’s parent or legal guardian) after the nature of the surgical procedures had been explained. The research followed the tenets of the Declaration of Helsinki and was approved by the Mashhad University of Medical Sciences Research Ethics Committee.
Surgical Procedure All surgeries were performed under general anesthesia with the Fox pentagon procedure technique on the upper lid. For both of the study groups, a 0.9-mm silicone rod was employed. The eyelid skin was marked on the medial and lateral parts. For the closed group, two stab incisions on the upper lid were made 2 mm from the lid margin. Temporal and nasal incisions were made, extending to within 3 mm of the lateral and medial canthi. In addition, three incisions (lateral, medial and forehead) were made on the eyebrow. For the open group, the major incision (10 mm) was made on the upper lid approximately 4 to 5 mm above the lid margin of the upper lid skin and pretarsal muscle down to the tarsus. Then, three incisions (lateral, medial and forehead) were made on the eyebrow. The selection of the eyelid incision was compared to the healthy site in unilateral ptosis and the eyelid crease site in bilateral ptosis. Lateral and medial eyebrow incisions were made approximately 5 mm above the orbital rim parallel to the canthi lines toward the temporal and nasal, respectively. In addition, a forehead incision was made 10 mm above the orbital rim centrally (Figure 1). A lid guard was inserted for ocular protection. In the closed group, the Wright needle was passed from the lateral brow to the lateral lid incision and from the medial brow to the medial lid incision, each time withdrawing the silicone rod back along the needle
FIGURE 1 Fox pentagon sling procedure (closed type).
track. The Wright needle was directed from the central forehead incision to the lateral and medial brow incisions, respectively, drawing the two ends of the silicone rod out of the central incision. Two parts of the extracted silicone rods sutured together with the square knot and secured with a 5-0 mersilene suture. The skin brow incisions were closed with chromic sutures and the eyelid incisions did not need suturing. Antibiotic ointment was prescribed three times daily on the eyelid incisions and inside the eye. In the open group, a silicon rod was fixed all along the upper lid tarsus (passing approximately through half of the tarsus height) with Mersilene sutures (5-0). The Wright needle entered the nasal incision above the eyebrow down to the periosteal lining and continued to the back of the orbital septum. Then, the needle was directed from the inner lid and passed along the medial side of the lid incision. Afterwards, the silicone rod was conducted from the inner lid and passed through the inner brow incision. Again, the needle entered from the temporal brow incision and passed through the temporal lid incision. Subsequently silicone rod was pulled up to the lateral part of eyelid incision. Then, the Wright needle was directed from the central forehead incision to the lateral and medial brow incision. A square knot regulated the eyelid margin height in the limbus position and was fixed by mersilene suture. The lid incision was sutured with a silk or chromic suture.
Statistical Analysis Data analysis was performed using SPSS statistical software (version 11.5, SPSS, Inc., Chicago, Orbit
Congenital Belpharoptosis Surgery Techniques
Orbit Downloaded from informahealthcare.com by Kainan University on 04/07/15 For personal use only.
Illinois, USA). Data are expressed in mean standard deviations. Student’s t test was used to compare preoperative MRD (PMRD), the preoperative amount of ptosis, and associated ptosis with ocular function findings. Bilateral and unilateral ptosis cases were analyzed and compared separately. Three, 6 and 12 months after surgery, the post-operative MRD of the two study groups was compared by the Mann– Whitney test. In addition, the improvement of ptosis was defined as the difference between final MRD (FMRD) and pre-operative MRD rates. The MRD asymmetries were compared in the closed and open surgical methods of the unilateral and bilateral cases by an independent sample t test. p Values50.05 was considered statistically significant.
RESULTS Patient’s Characteristics Forty-four patients with congenital ptosis underwent open (age, mean SD: 10.33 7.58 years old) and closed (age, mean SD: 11.82 5.83 years old) frontalis sling operation. Patients in both groups were matched for age (p = 0.35). Seventy-five percent of patients were male and 54.5% of patients were operated on their left eye. Associated ophthalmic findings showed that amblyopia was present in a total of 16 (36.6%) patients (10 cases in closed and 6 cases in open surgery) and strabismus in 6 (27.3%) patients (2 cases in the closed and 4 cases in the open method). There was no significant difference between the associated ophthalmic findings of the two operative methods studied (p = 0.37). Also, there were no serious side effects observed in the study groups (p = 0.31). Only wound discharge and knot dehiscence problems were simultaneously present for two (8.5%) patients in the open surgery group.
93
significant (p50.005). Estimation of the margin reflex distance (MRD) was considered as three groups: under correction (MRD53), good (35MRD55) and over correction (MRD45). Most of the individuals participating in this study were in the good MRD group (24 cases) and only one patient in the closed group was in over-correction. The remaining patients (9 cases in the closed group vs 10 cases in the open group) had under correction MRD. There was no significant difference between the final MRD of the two surgical techniques studied (p40.05). However, surgical success (good result) was higher among those who underwent a bilateral operation (54.4%) than a unilateral operation (35.6%). There was no significant differences between surgical methods and MRD 3, 6 and 12 months after surgery (p = 031; p = 0.44, p = 0.8, respectively) (Figure 2). Neither did the difference between the laterality in surgical methods and MRD on the different follow-up dates reach statistical significance (Table 1).
DISCUSSION The results of the present study showed that the frontalis sling operation with a silicone rod provides satisfactory cosmetic results due to the significant increase of final MRD compared to that of preoperative MRD. An accurate evaluation of the open loop facial sling can correct the problems of severe congenital blepharoptosis so as to achieve the desired lid level.5 Although good final MRD results were found for the open surgical technique, these differences did not reach statistical significance between the two operative techniques studied. Considering previously published articles, Bagheri and colleagues compared two methods: a triangle sling and a double triangle sling of the facia lata for frontalis suspension.6 It was confirmed that the sling
Surgical Outcomes Considering laterality, 18 (41%) and 26 (59%) of the patients were attributed to unilateral and bilateral groups, respectively. Eyelid height asymmetry is classified into three categories: good, poor and fair, as described by the height difference of the two eyelids, less or equal to one millimeter (mm), more than 2 mm and between 1 to 2 mm, respectively. There was a statistically significant difference related to eyelid height asymmetry between the two surgical methods (p50.001). In addition, all the patients who had gone open surgery (22 cases) and 10 cases (45.5%) that had had closed method were assigned to the good category. In addition, the difference between ptosis laterality, the surgical method and eyelid height asymmetry was !
2014 Informa Healthcare USA, Inc.
FIGURE 2 Operative MRD after 3, 6 and 12 months follow-up periods. Data are presented as Mean SD.
94 M. Estezad Razavi et al. TABLE 1 Relationship between laterality and MRD. Operative method (Mean SD)
Variable Unilateral
MRD
Increase of MRD after operation
Before 3 Month 6 Month 12 Month
Bilateral
Close
Open
p Value
Close
Open
p Value
0.66 1.21 3.33 1.37 3.00 1.59 2.83 1.80 3.50 1.29
1.16 1.32 2.00 1.26 1.66 1.21 1.50 1.04 2.66 1.96
0.61 0.05 0.09 0.11 0.43
0.50 0.52 2.90 1.19 2.70 1.41 2.30 1.88 1.90 1.44
1.25 0.94 3.06 0.85 2.93 0.85 2.75 0.93 4.00 1.42
0.000 0.68 0.59 0.42 0.001
Orbit Downloaded from informahealthcare.com by Kainan University on 04/07/15 For personal use only.
Data are presented as Mean SD.
triangle method was safe, easy and rapid and produced acceptable results. Moreover, no difference was found between the two groups in regard to function (palpebral fissure height) and early or late complications during the follow-ups. In addition, the current study considered the pentagon sling method, or Fox procedure, with a silicone rod. In another study, Leibovitch et al.7 concluded that frontalis suspension using autogeneous facia should be proposed as a possible procedure for correcting congenital petosis in children younger than 3 years old and as an effective treatment for poor levator function. However, in the present study, although most of the patients (29/44) were under 10 years old, the sling operation using a silicone rod was evaluated. For congenital ptosis, Lee et al.8 evaluated a three-year follow-up of the frontalis sling operation with a silicone rode by closed method as opposed to preserved facia lata. They found the recurrence rate of the frontalis sling to be 29%, 11% for the silicone rod group and 63% and 41% in the fascia lata group (in bilateral and unilateral lids, respectively). They confirmed that better results are achieved in this operation by employing a silicone rod instead of fascia lata. In another study, Yagci and Egrilmez compared the cosmetic results of the open and closed frontalis sling operation technique by using fascia lata autogen on patients with congenital ptosis and poor levator function.9 They reviewed 27 patients (45 eyelids) who had gone the sling operation and found that the eyelid crease symmetry was acceptable in 46.6% and 76.6% of the subjects in the closed and open groups, respectively. Therefore, these results illustrated the eyelid crease approach as functionally and cosmetically better than the closed frontalis sling operation. It should be noted that, although the current study evaluated the sling operation using a silicone rod, similar results were obtained for closed 54.5% (12/22) and open 54.5% (12/22) methods in good MRD, while 40.9% (9/22) and 45.5% (10/22) were attributed to the under correction MRD group in closed and open groups, respectively.
The open surgical method promised the creation of an eyelid crease of one eye matching the eyelid crease of the other eye, although this symmetry is maintained if one of the eyes is under-corrected. However, in the closed method, low under-correction is expected and the symmetry of the two eyelids is not suitable, with the creation of eyelid crease when employing a tensile of silicone rod. Therefore, the current study concluded that better results cosmetically are obtained from the open technique in comparison to those of the closed method. Considering previous studies, Allard and Durairaj evaluated current recommendations for the correction of congential ptosis. They presented all the advantages and disadvantages of each of these procedures with clear recommendations for avoiding complications.10 Furthermore, fascia lata is not always a feasible option for all patients, as the patient needs to be at least 3 years old in order to have sufficient length size to provide suitable fascia lata.11 It is worth noting that in addition to congenital ptosis, the frontalis sling operation technique is also commonly considered for several eyelid disorders such as, myogenic or neurogenic ptosis, blepharophimosis syndrome, cranial nerve III palsy, and Marcus–Gunn jaw winking syndrome.8,12,13 Two incision approaches have also been developed for the frontalis sling operation: the eyelid crease incision (open technique) and the supralash stab incision (closed technique). Recently, different alternative materials for creating sling-like autogenous or banked fascia lata have been tested along with alloplastic materials that include polypropylene, silicone, nylon monofilament, polyester, and polytetrafluoroethylene (PTFE).14 Although there is no general agreement on which material is superior when compared to the others,15,16 a few studies have recommended using the silicone rod.8,17 In conclusion, the frontalis sling operation using a silicone rod exhibited better results, in terms of eyelid crease symmetry, for the open technique in comparison to the closed method, but without any significant changes in final good MRD results. Orbit
Congenital Belpharoptosis Surgery Techniques
DECLARATION OF INTEREST This study has been financially supported by Eye Research Center of Mashhad University of Medical Sciences. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Orbit Downloaded from informahealthcare.com by Kainan University on 04/07/15 For personal use only.
REFERENCES 1. Nerrad JA. Oculoplastic Surgery. St Louis, MO: Mosby, 2001. 2. Smith B, McCord CD, Baylis H. Surgical treatment of blepharoptosis. Am J Ophthalmol 1969;68:92–99. 3. Sakol PJ, Mannor G, Massaro BM. Congenital and acquired blepharoptosis. Curr Opin Ophthalmol 1999;10:335–339. 4. Tyers AG, Collin JRO. Ptosis In: Colour Atlas of Ophthalmic Plastic Surgery. Boston, MA: ButterworthHeinemann, 2001. 5. Arajy ZY. Open loop fascial sling for severe congenital blepharoptosis. J Craniomaxillofac Surg 2012;40:129–133. 6. Bagheri A, Aletaha M, Abrishami M, Salour SH. Comparing two methods of fascia lata use for frontalis suspension. Bina J Ophthalmol 2006;11:318–325. 7. Leibovitch I, Leibovitch L, Dray J-P. Long-term results of frontalis suspension using autogenous fascia lata for congenital ptosis in children under 3 years of age. Am J Ophthalmol 2003;136:866–871.
!
2014 Informa Healthcare USA, Inc.
95
8. Lee MJ, Oh JY, Choung H-K, et al. Frontalis sling operation using silicone rod compared with preserved fascia lata for congenital ptosis: a three-year follow-up study. Ophthalmology 2009;116:123–129. 9. Yagci A, Egrilmez S. Comparison of cosmetic results in frontalis sling operations: the eyelid crease incision versus the supralash stab incision. J Pediatr Ophthalmol Strabismus 2003;40:213–216. 10. Allard FD, Durairaj VD. Current techniques in surgical correction of congenital ptosis. Middle East Afr J Ophthalmol 2010;17:129–133. 11. Ramirez OM, Pena G. Frontalis muscle advancement: a dynamic structure for the treatment of severe congenital eyelid ptosis. Plast Reconstr Surg 2004;113:1841–1849. 12. Wong VA, Beckingsale PS, Oley CA, Sullivan TJ. Management of myogenic ptosis. Ophthalmology 2002;109: 1023–1031. 13. Khwarg SI, Tarbet KJ, Dortzbach RK, Lucarelli MJ. Management of moderate-to-severe marcus-gunn jawwinking ptosis. Ophthalmology 1999;106:1191–1196. 14. Ben Simon GJ, Macedo AA, Schwarcz RM, et al. Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material. Am J Ophthalmol 2005;140:877–885. 15. Wagner RS, Mauriello Jr. JA, Nelson LB, et al. Treatment of congenital ptosis with frontalis suspension: a comparison of suspensory materials. Ophthalmology 1984;91: 245–248. 16. Wasserman BN, Sprunger DT, Helveston EM. Comparison of materials used in frontalis suspension. Arch Ophthalmol 2001;119:687–691. 17. Bernardini FP, de Conciliis C, Devoto MH. Frontalis suspension sling using a silicone rod in patients affected by myogenic blepharoptosis. Orbit 2002;21:195–198.
ORIGINAL ARTICLE
Comparing Open and Closed Techniques of Frontalis Suspension with Silicone Rod for the Treatment Congenital Blepharoptosis Mohammad Etezad Razavi, Mohammad Khalifeh, and Ahmad Yazdani
ABSTRACT Purpose: To compare open and closed methods of the frontalis suspension operation with a silicone rod in the treatment of congenital blepharoptosis. Methods: Forty-four cases with unilateral or bilateral congenital ptosis with a poor levator function of54 mm were divided randomly into two groups. Each group underwent an eyelid crease incision operation (open) or a supralash stab incision (closed). Ptosis was measured by the difference between the upper eyelid margin reflex distance (MRD) of the affected eyelids of the unilateral and bilateral cases. Frequent follow-up examinations were performed up to 12 months post-surgery. Results: Associated ophthalmologic findings showed that amblyopia, strabismus, wound discharge and knot dehiscence problems were present in 36.6%, 27.3%, 8.5% and 8.5% of the patients, respectively. There was no significant difference between the abovementioned associated ophthalmic findings of the two operative methods studied (P = 0.37). The difference in the surgical methods and MRD 3, 6 and 12 months after operation did not reach statistical significance. Similar results for good MRD (35MRD55) were found in closed (54.5%, 12/22) and open (54.5%, 12/22) methods, while 40.9% (9/22) and 45.5% (10/22) of cases were attributed to the under correction group in the closed and open methods, respectively. In bilaterally operated cases, MRD was more symmetrical than in unilaterally operated eyes. The symmetry of MRD and the eyelid crease was more prevalent in the open technique group. Conclusions: The frontalis sling operation using a silicone rod exhibited better results, in terms of symmetry, in the open technique in comparison to the closed method. Keywords: Frontalis sling operation, congenital belpharoptosis, silicone brow suspension
INTRODUCTION
depends on several factors, such as age, degree of ptosis, levator muscle function and cornea status.4 The purpose of the present study is to compare the open and closed methods of the frontalis sling operation with a silicone rod for congenital ptosis.
20 14
Orbit Downloaded from informahealthcare.com by Kainan University on 04/07/15 For personal use only.
Eye Research Center, Khatam-Al-Anbia Eye Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
Congenital ptosis is a specific form of ptosis present at birth. It is a vertical narrowing of the palpebral fissure, secondary to the dropping of the upper eyelid to a lower place than the normal position which is associated with abnormality of the dystrophic levator muscle.1 This condition is generally unilateral (70%), however, in some cases it may be bilateral and can be isolated or associated with the dysfunction of one or more extraocular muscles and/or other systemic conditions.2,3 Correction of ptosis considers the use of different surgical methods. The selection of the appropriate operative approach for congenital ptosis
MATERIALS AND METHODS In the present study, 44 eyes with congenital ptosis and poor levator function were divided randomly into two groups. The patients excluded from the study presented either unilateral or bilateral ptosis with a poor levator function above of 4 mm.
Correspondence: Dr. Mohammad Etezad Razavi, Associate Professor of Ophthalmology, Eye Research Center of Mashhad University of Medical Sciences, Khatam-Al-Anbia Eye Hospital, Abutaleb Junction, Ghareni Blvd. 9195961151, Mashhad, Iran. E-mail: [email protected], [email protected]
91
92 M. Estezad Razavi et al. Furthermore, any patients with a history of weak Bells phenomenon, jaw winking phenomenon, blepharophimosis syndrome, thyroid eye disease, myasthenia gravis, or any previous eye surgery and trauma were also excluded from the study population. Complete pre-operative examinations, including visual acuity measurements, extraocular motility, cycloplegic refraction and funduscopy, were performed on all participants. Ptosis was evaluated by the difference between the upper eyelid margin reflex distance (MRD) of the affected eyelids of the unilateral and bilateral cases. In addition, follow-up examinations were performed 3, 6 and 12 months after surgery.
Orbit Downloaded from informahealthcare.com by Kainan University on 04/07/15 For personal use only.
Ethical Considerations An informed consent was obtained from each patient (or the patient’s parent or legal guardian) after the nature of the surgical procedures had been explained. The research followed the tenets of the Declaration of Helsinki and was approved by the Mashhad University of Medical Sciences Research Ethics Committee.
Surgical Procedure All surgeries were performed under general anesthesia with the Fox pentagon procedure technique on the upper lid. For both of the study groups, a 0.9-mm silicone rod was employed. The eyelid skin was marked on the medial and lateral parts. For the closed group, two stab incisions on the upper lid were made 2 mm from the lid margin. Temporal and nasal incisions were made, extending to within 3 mm of the lateral and medial canthi. In addition, three incisions (lateral, medial and forehead) were made on the eyebrow. For the open group, the major incision (10 mm) was made on the upper lid approximately 4 to 5 mm above the lid margin of the upper lid skin and pretarsal muscle down to the tarsus. Then, three incisions (lateral, medial and forehead) were made on the eyebrow. The selection of the eyelid incision was compared to the healthy site in unilateral ptosis and the eyelid crease site in bilateral ptosis. Lateral and medial eyebrow incisions were made approximately 5 mm above the orbital rim parallel to the canthi lines toward the temporal and nasal, respectively. In addition, a forehead incision was made 10 mm above the orbital rim centrally (Figure 1). A lid guard was inserted for ocular protection. In the closed group, the Wright needle was passed from the lateral brow to the lateral lid incision and from the medial brow to the medial lid incision, each time withdrawing the silicone rod back along the needle
FIGURE 1 Fox pentagon sling procedure (closed type).
track. The Wright needle was directed from the central forehead incision to the lateral and medial brow incisions, respectively, drawing the two ends of the silicone rod out of the central incision. Two parts of the extracted silicone rods sutured together with the square knot and secured with a 5-0 mersilene suture. The skin brow incisions were closed with chromic sutures and the eyelid incisions did not need suturing. Antibiotic ointment was prescribed three times daily on the eyelid incisions and inside the eye. In the open group, a silicon rod was fixed all along the upper lid tarsus (passing approximately through half of the tarsus height) with Mersilene sutures (5-0). The Wright needle entered the nasal incision above the eyebrow down to the periosteal lining and continued to the back of the orbital septum. Then, the needle was directed from the inner lid and passed along the medial side of the lid incision. Afterwards, the silicone rod was conducted from the inner lid and passed through the inner brow incision. Again, the needle entered from the temporal brow incision and passed through the temporal lid incision. Subsequently silicone rod was pulled up to the lateral part of eyelid incision. Then, the Wright needle was directed from the central forehead incision to the lateral and medial brow incision. A square knot regulated the eyelid margin height in the limbus position and was fixed by mersilene suture. The lid incision was sutured with a silk or chromic suture.
Statistical Analysis Data analysis was performed using SPSS statistical software (version 11.5, SPSS, Inc., Chicago, Orbit
Congenital Belpharoptosis Surgery Techniques
Orbit Downloaded from informahealthcare.com by Kainan University on 04/07/15 For personal use only.
Illinois, USA). Data are expressed in mean standard deviations. Student’s t test was used to compare preoperative MRD (PMRD), the preoperative amount of ptosis, and associated ptosis with ocular function findings. Bilateral and unilateral ptosis cases were analyzed and compared separately. Three, 6 and 12 months after surgery, the post-operative MRD of the two study groups was compared by the Mann– Whitney test. In addition, the improvement of ptosis was defined as the difference between final MRD (FMRD) and pre-operative MRD rates. The MRD asymmetries were compared in the closed and open surgical methods of the unilateral and bilateral cases by an independent sample t test. p Values50.05 was considered statistically significant.
RESULTS Patient’s Characteristics Forty-four patients with congenital ptosis underwent open (age, mean SD: 10.33 7.58 years old) and closed (age, mean SD: 11.82 5.83 years old) frontalis sling operation. Patients in both groups were matched for age (p = 0.35). Seventy-five percent of patients were male and 54.5% of patients were operated on their left eye. Associated ophthalmic findings showed that amblyopia was present in a total of 16 (36.6%) patients (10 cases in closed and 6 cases in open surgery) and strabismus in 6 (27.3%) patients (2 cases in the closed and 4 cases in the open method). There was no significant difference between the associated ophthalmic findings of the two operative methods studied (p = 0.37). Also, there were no serious side effects observed in the study groups (p = 0.31). Only wound discharge and knot dehiscence problems were simultaneously present for two (8.5%) patients in the open surgery group.
93
significant (p50.005). Estimation of the margin reflex distance (MRD) was considered as three groups: under correction (MRD53), good (35MRD55) and over correction (MRD45). Most of the individuals participating in this study were in the good MRD group (24 cases) and only one patient in the closed group was in over-correction. The remaining patients (9 cases in the closed group vs 10 cases in the open group) had under correction MRD. There was no significant difference between the final MRD of the two surgical techniques studied (p40.05). However, surgical success (good result) was higher among those who underwent a bilateral operation (54.4%) than a unilateral operation (35.6%). There was no significant differences between surgical methods and MRD 3, 6 and 12 months after surgery (p = 031; p = 0.44, p = 0.8, respectively) (Figure 2). Neither did the difference between the laterality in surgical methods and MRD on the different follow-up dates reach statistical significance (Table 1).
DISCUSSION The results of the present study showed that the frontalis sling operation with a silicone rod provides satisfactory cosmetic results due to the significant increase of final MRD compared to that of preoperative MRD. An accurate evaluation of the open loop facial sling can correct the problems of severe congenital blepharoptosis so as to achieve the desired lid level.5 Although good final MRD results were found for the open surgical technique, these differences did not reach statistical significance between the two operative techniques studied. Considering previously published articles, Bagheri and colleagues compared two methods: a triangle sling and a double triangle sling of the facia lata for frontalis suspension.6 It was confirmed that the sling
Surgical Outcomes Considering laterality, 18 (41%) and 26 (59%) of the patients were attributed to unilateral and bilateral groups, respectively. Eyelid height asymmetry is classified into three categories: good, poor and fair, as described by the height difference of the two eyelids, less or equal to one millimeter (mm), more than 2 mm and between 1 to 2 mm, respectively. There was a statistically significant difference related to eyelid height asymmetry between the two surgical methods (p50.001). In addition, all the patients who had gone open surgery (22 cases) and 10 cases (45.5%) that had had closed method were assigned to the good category. In addition, the difference between ptosis laterality, the surgical method and eyelid height asymmetry was !
2014 Informa Healthcare USA, Inc.
FIGURE 2 Operative MRD after 3, 6 and 12 months follow-up periods. Data are presented as Mean SD.
94 M. Estezad Razavi et al. TABLE 1 Relationship between laterality and MRD. Operative method (Mean SD)
Variable Unilateral
MRD
Increase of MRD after operation
Before 3 Month 6 Month 12 Month
Bilateral
Close
Open
p Value
Close
Open
p Value
0.66 1.21 3.33 1.37 3.00 1.59 2.83 1.80 3.50 1.29
1.16 1.32 2.00 1.26 1.66 1.21 1.50 1.04 2.66 1.96
0.61 0.05 0.09 0.11 0.43
0.50 0.52 2.90 1.19 2.70 1.41 2.30 1.88 1.90 1.44
1.25 0.94 3.06 0.85 2.93 0.85 2.75 0.93 4.00 1.42
0.000 0.68 0.59 0.42 0.001
Orbit Downloaded from informahealthcare.com by Kainan University on 04/07/15 For personal use only.
Data are presented as Mean SD.
triangle method was safe, easy and rapid and produced acceptable results. Moreover, no difference was found between the two groups in regard to function (palpebral fissure height) and early or late complications during the follow-ups. In addition, the current study considered the pentagon sling method, or Fox procedure, with a silicone rod. In another study, Leibovitch et al.7 concluded that frontalis suspension using autogeneous facia should be proposed as a possible procedure for correcting congenital petosis in children younger than 3 years old and as an effective treatment for poor levator function. However, in the present study, although most of the patients (29/44) were under 10 years old, the sling operation using a silicone rod was evaluated. For congenital ptosis, Lee et al.8 evaluated a three-year follow-up of the frontalis sling operation with a silicone rode by closed method as opposed to preserved facia lata. They found the recurrence rate of the frontalis sling to be 29%, 11% for the silicone rod group and 63% and 41% in the fascia lata group (in bilateral and unilateral lids, respectively). They confirmed that better results are achieved in this operation by employing a silicone rod instead of fascia lata. In another study, Yagci and Egrilmez compared the cosmetic results of the open and closed frontalis sling operation technique by using fascia lata autogen on patients with congenital ptosis and poor levator function.9 They reviewed 27 patients (45 eyelids) who had gone the sling operation and found that the eyelid crease symmetry was acceptable in 46.6% and 76.6% of the subjects in the closed and open groups, respectively. Therefore, these results illustrated the eyelid crease approach as functionally and cosmetically better than the closed frontalis sling operation. It should be noted that, although the current study evaluated the sling operation using a silicone rod, similar results were obtained for closed 54.5% (12/22) and open 54.5% (12/22) methods in good MRD, while 40.9% (9/22) and 45.5% (10/22) were attributed to the under correction MRD group in closed and open groups, respectively.
The open surgical method promised the creation of an eyelid crease of one eye matching the eyelid crease of the other eye, although this symmetry is maintained if one of the eyes is under-corrected. However, in the closed method, low under-correction is expected and the symmetry of the two eyelids is not suitable, with the creation of eyelid crease when employing a tensile of silicone rod. Therefore, the current study concluded that better results cosmetically are obtained from the open technique in comparison to those of the closed method. Considering previous studies, Allard and Durairaj evaluated current recommendations for the correction of congential ptosis. They presented all the advantages and disadvantages of each of these procedures with clear recommendations for avoiding complications.10 Furthermore, fascia lata is not always a feasible option for all patients, as the patient needs to be at least 3 years old in order to have sufficient length size to provide suitable fascia lata.11 It is worth noting that in addition to congenital ptosis, the frontalis sling operation technique is also commonly considered for several eyelid disorders such as, myogenic or neurogenic ptosis, blepharophimosis syndrome, cranial nerve III palsy, and Marcus–Gunn jaw winking syndrome.8,12,13 Two incision approaches have also been developed for the frontalis sling operation: the eyelid crease incision (open technique) and the supralash stab incision (closed technique). Recently, different alternative materials for creating sling-like autogenous or banked fascia lata have been tested along with alloplastic materials that include polypropylene, silicone, nylon monofilament, polyester, and polytetrafluoroethylene (PTFE).14 Although there is no general agreement on which material is superior when compared to the others,15,16 a few studies have recommended using the silicone rod.8,17 In conclusion, the frontalis sling operation using a silicone rod exhibited better results, in terms of eyelid crease symmetry, for the open technique in comparison to the closed method, but without any significant changes in final good MRD results. Orbit
Congenital Belpharoptosis Surgery Techniques
DECLARATION OF INTEREST This study has been financially supported by Eye Research Center of Mashhad University of Medical Sciences. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Orbit Downloaded from informahealthcare.com by Kainan University on 04/07/15 For personal use only.
REFERENCES 1. Nerrad JA. Oculoplastic Surgery. St Louis, MO: Mosby, 2001. 2. Smith B, McCord CD, Baylis H. Surgical treatment of blepharoptosis. Am J Ophthalmol 1969;68:92–99. 3. Sakol PJ, Mannor G, Massaro BM. Congenital and acquired blepharoptosis. Curr Opin Ophthalmol 1999;10:335–339. 4. Tyers AG, Collin JRO. Ptosis In: Colour Atlas of Ophthalmic Plastic Surgery. Boston, MA: ButterworthHeinemann, 2001. 5. Arajy ZY. Open loop fascial sling for severe congenital blepharoptosis. J Craniomaxillofac Surg 2012;40:129–133. 6. Bagheri A, Aletaha M, Abrishami M, Salour SH. Comparing two methods of fascia lata use for frontalis suspension. Bina J Ophthalmol 2006;11:318–325. 7. Leibovitch I, Leibovitch L, Dray J-P. Long-term results of frontalis suspension using autogenous fascia lata for congenital ptosis in children under 3 years of age. Am J Ophthalmol 2003;136:866–871.
!
2014 Informa Healthcare USA, Inc.
95
8. Lee MJ, Oh JY, Choung H-K, et al. Frontalis sling operation using silicone rod compared with preserved fascia lata for congenital ptosis: a three-year follow-up study. Ophthalmology 2009;116:123–129. 9. Yagci A, Egrilmez S. Comparison of cosmetic results in frontalis sling operations: the eyelid crease incision versus the supralash stab incision. J Pediatr Ophthalmol Strabismus 2003;40:213–216. 10. Allard FD, Durairaj VD. Current techniques in surgical correction of congenital ptosis. Middle East Afr J Ophthalmol 2010;17:129–133. 11. Ramirez OM, Pena G. Frontalis muscle advancement: a dynamic structure for the treatment of severe congenital eyelid ptosis. Plast Reconstr Surg 2004;113:1841–1849. 12. Wong VA, Beckingsale PS, Oley CA, Sullivan TJ. Management of myogenic ptosis. Ophthalmology 2002;109: 1023–1031. 13. Khwarg SI, Tarbet KJ, Dortzbach RK, Lucarelli MJ. Management of moderate-to-severe marcus-gunn jawwinking ptosis. Ophthalmology 1999;106:1191–1196. 14. Ben Simon GJ, Macedo AA, Schwarcz RM, et al. Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material. Am J Ophthalmol 2005;140:877–885. 15. Wagner RS, Mauriello Jr. JA, Nelson LB, et al. Treatment of congenital ptosis with frontalis suspension: a comparison of suspensory materials. Ophthalmology 1984;91: 245–248. 16. Wasserman BN, Sprunger DT, Helveston EM. Comparison of materials used in frontalis suspension. Arch Ophthalmol 2001;119:687–691. 17. Bernardini FP, de Conciliis C, Devoto MH. Frontalis suspension sling using a silicone rod in patients affected by myogenic blepharoptosis. Orbit 2002;21:195–198.
