Orbit, 2014; 33(4): 252–255 ! Informa Healthcare USA, Inc. ISSN: 0167-6830 print / 1744-5108 online DOI: 10.3109/01676830.2014.884146
RESEARCH REPORT
Modified Supramid Brow Suspension in Paediatric Ptosis Darakhshanda Khurram Butt1, A. Jayaprakash Patil1,2, and Yassir M. S. Abou-Rayyah1,3 1
Paediatric Ophthalmology Department, Great Ormond Street Hospital for Children, London, United Kingdom, King’s College Hospital, London, United Kingdom, and 3Moorfields Eye Hospital, London, United Kingdom
Orbit Downloaded from informahealthcare.com by University of Washington on 03/06/15 For personal use only.
2
ABSTRACT Purpose: To understand the safety and complication profile of the modified supramid brow suspension surgery in the paediatric ptosis. Design: Retrospective interventional case series. Methods: Review of medical notes of 32 patients who underwent supramid brow suspension surgery of the upper lid. Surgery was performed by a single surgeon at Great Ormond Street Hospital, London during 2007–2012. Complication rates were analysed. Results: Forty-six eyes of 32 patients underwent upper eye lid brow suspension surgery; 18 cases were unilateral and 14 bilateral. Mean follow-up period is 28 months after the surgery. Post-operative granulomatous reaction was noted in 6 eyes (13%) and prolonged exposure keratopathy in 2 eyes (4.3%). There were no cases of suture infection or exposure. No recurrence of ptosis was observed in any of the operated cases. Pupillary axis clearance was achieved in all eyes. Conclusion: Modified brow suspension surgery using supramid for upper eyelid ptosis is a safe and clinically useful procedure with low complication rate. Keywords: Amblyopia, brow suspension, granuloma, ptosis, supramid
INTRODUCTION
ptosis surgery in severe ptosis is to prevent amblyopia before a more definitive levator procedure is performed. The preferred material for brow suspension surgery is autogenous fascia lata. But in children less than 3–4 years the fascia lata is thin and lacks the tensile strength and more over technically is difficult to harvest adequate tissue.1 This makes it imperative to use alternative materials for brow suspension. Many alternative materials have been tried, including donor fascia lata, palmaris longus tendon, frontalis flap, sclera and synthetic materials such as prolene, polyfilament nylon, mersilene mesh, Gore-tex, silicon rods and supramid.2 Donor tissue always carries the inherent risk of transmitting infections, no matter how well it is screened for pathogens. This makes the option of using synthetic material more attractive for parents
Ptosis in paediatric age group presents its own challenges as to the time of intervention and technique of surgery. Ptosis surgery in children is based on the vision, individual child’s severity of ptosis and the strength of the levator palpebrae superioris muscle. In mild-to-moderate ptosis not obstructing the pupillary axis, surgery can be deferred until the pre-school years. If the ptosis is severe and is interfering with the vision, surgery will have to be performed at an earlier age, allowing maximal visual development. Brow suspension is one of the relatively easier operations to perform, and it is an effective procedure in the paediatric age group with ptosis secondary to poor levator function. The key advantage of brow
Received 14 June 2013; Revised 11 January 2014; Accepted 13 January 2014; Published online 28 April 2014 Correspondence: Dr. Yassir M.S. Abou-Rayyah, Consultant Ophthalmologist, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, Tel: 020 7405 9200 (ext 5818), E-mail: [email protected]
252
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Supramid Brow Suspension in Children 253 considering the brow suspension for their child. Synthetic materials are not devoid of any serious complications. There is a greater incidence of granuloma formation, infection, extrusion and late failure.2 Nevertheless, in children in whom fascia lata cannot be obtained, synthetic materials are preferred over donor tissue. Moreover the surgery at that age is intended solely to prevent amblyopia and it is a standby procedure before a more permanent procedure could be considered. Supramid is a 4-0 polyfilament cable-type alloplastic nylon ophthalmic suture. It is a material with high tensile strength, well-suited for finest, but firm sutures in microsurgery.3 Previous studies using supramid for brow suspension surgery are limited to few small case series and marred with conflicting results. In this study we present our results with supramid brow suspension in the treatment of ptosis in children with poor levator function. We evaluate the complication rates of the technique.
Incision sites were marked by using a sterile marker. Two stab incision sites approximately 8 mm apart were marked 2 mm above the lash line that was centered over the area of desired optimal elevation. Another two stab incisions sites were marked at the eyebrow, in line with the lateral and medial canthi. A forehead incision is then marked above and between these 2 brow marks to complete an isosceles triangle. Stab incisions from the skin down through the dermis to the subcutaneous plane at the premarked sites were made using a No. 15 blade. Using supramid 4-0 nylon suture with a doubleended needle, one end was introduced through the medial stab incision on the lid margin, passed in the epitarsal tissue horizontally and pierced out through the lateral lid stab incision. The needles are then reintroduced to their incision sites and passed upwards in the suborbicularis plane and pierced out from the corresponding brow exit sites. Two needles were then passed under the skin and pierced out from the forehead incision and tied together. Then through a separate skin incision the needles were brought out and cut flush with the skin.
MATERIALS AND METHODS A retrospective review of charts of 32 consecutive children who underwent unilateral or bilateral brow suspension using 4-0 supramid from January 2007 till January 2012 at Great Ormond Street Hospital for Children, London by a single surgeon (YAR) was performed. The study was approved the ethical committee of the hospital. All children who had undergone supramid brow surgery for ptosis with poor levator function (less than 4 mm) were included in the study. The age range at the time of surgery was 3.1–13.2 years. No exclusion criteria were identified for this study. The mean follow-up period was 2.4 years (range 5 to 36 months). Thirty-eight of 46 eyes had at least 12 months’ follow-up (82.6%). Two eyes had a short follow-up of 5 months. Data collected included, the age at the surgery, sex, diagnosis of ptosis and complications if any. All patients were observed 1 week, and 1, 3 and 6 months after the operation. Further follow-ups were individualised for each patient. Surgical success was defined as improved upper lid position to above the superior pupillary margin without any recurrence or major suture-related complications.
Surgical Procedure All the surgeries were performed by a single surgeon under general anaesthesia as a day case procedure. The surgical procedure involved performing frontalis sling suspension using modified Fox pentagon technique (Figure 1). An eyelid plate was used to prevent ocular trauma when needles were passed. !
2014 Informa Healthcare USA, Inc.
RESULTS Forty-six eyes of 32 patients underwent upper eye lid brow suspension surgery; 18 cases were unilateral and 14 bilateral. The demographics are described in Tables 1 and 2. Mean follow-up period is 28 months after the surgery. Post-operative granulomatous reaction was noted in 6 eyes (13%) and prolonged exposure keratopathy in 2 eyes (4.3%). There were no cases of suture infection or exposure. No recurrence of ptosis was observed in any of the operated cases. Pupillary axis clearance was achieved in all eyes. Complications are summarised in Table 3.
DISCUSSION Childhood ptosis can result in impaired visual development and can be cosmetically disfiguring. The timing and the type of surgery are dependent on severity of ptosis, presence of abnormal head posture, developmental delay and unsatisfactory facial appearance.1 The aim is to clear the visual axis to give the eye a chance to develop maximum vision and prevent amblyopia. Frontalis slings with alloplastic slings are well documented in the literature.4 However, forehead scars and late failures are the complications associated with it. The aim of our study was to ascertain the safety and effectiveness of the technique in elevating the eyelid temporarily for visual development until the child is old enough for definitive surgery using autologous fascia lata.5
Orbit Downloaded from informahealthcare.com by University of Washington on 03/06/15 For personal use only.
254 D. K. Butt et al.
FIGURE 1. (A–F) (A) Marking of the incision sites. Two markings 2 mm above the lash line, approximately 8 mm apart, centered over the area of desired optimal elevation. Two more markings at eyebrow, in line with the lateral and medial canthi. A forehead marking to complete an isosceles triangle. (B–E) After the frontalis sling suspension using modified Fox pentagon technique, the 2 needles of the supramid 4-0 nylon suture are passed under the skin and pierced out from the forehead incision and tied together. Then through a separate skin incision, the needles were brought out and cut flush with the skin. (F) Final appearance showing adequate and symmetrical lid lift. TABLE 1. Demographics of cohort. No. of patients Laterality Side of unilateral ptosis Age at surgery Follow-up period
32 (46 eyes) 18 Unilateral 14 Bilateral 12 Right eye 06 left eye 3.1–13.2 years 28 months
As the objective of the study was to confirm the safety and effectiveness, older children who had the supramid ptosis surgery were also included. The older children (44 years) had the supramid surgery in lieu of fascia lata were those with myogenic ptosis secondary to mitochondrial myopathy. They were either unstable systemically or were associated with other co-morbidities that prevented them from extensive surgical procedure such as harvesting fascia lata. Orbit
Supramid Brow Suspension in Children 255 TABLE 2. Diagnosis/cause of ptosis. Congenital
Myogenic Neurogenic/Paralytic Inflammatory Mechanical Craniofacial anomalies
12-Idiopathic congenital ptosis 2-Gausser syndrome 2-Cornelia De Lange syndrome 1-Myasthenia Gravis 8-Mitochondrial dystrophy 1-Oculomotor nerve palsy 2-Orbital inflammatory disease 3-Neurofibromatosis Type 1 1-Saethre-Chotzen syndrome
TABLE 3. Complications of surgery.
Orbit Downloaded from informahealthcare.com by University of Washington on 03/06/15 For personal use only.
Complication Granulomas Infection Exposure Keratopathy Extrusion/Suture exposure Recurrence of Ptosis
Number of Eyes 6 0 2 0 0
Patients achieved good cosmetic outcome at the end of 28 months of follow-up. Most of the techniques described in the literature employ the classic Crawford’s technique of double rhomboid with six skin incisions or Fox method with five skin incisions, thereby increasing the possibility of post-operative scar formation. In our study using the Fox five-skin-incision method, with modified sutural technique, after tying the knot, the needles come out of the separate incision sites, we were able to reduce the post-operative granuloma formation. In our technique, two bites 8 mm apart through orbicularis muscle and pretarsal tissue prevented the central notching. The peripheral parts of the lid on the medial and lateral sides were lifted appropriately, and the contour of the lid was adjusted accordingly. In our study, there was a predominance of unilateral ptosis (52.3%). The surgical timing of unilateral ptosis is different from bilateral cases. Unilateral ptosis occluding the pupillary axis warrants immediate surgical intervention to tackle amblyopia, while in bilateral ptosis, the child learns to use frontalis muscle and obtain a compensatory head posture, hence deferring the surgery for a reasonable period of time.6 Lagophthalmos is not uncommon after frontalis sling and has been reported in the literature.2 All patients experience lagophthalmos, and it might increase on down gaze, and some might develop
!
2014 Informa Healthcare USA, Inc.
mild corneal exposure, which can resolve quickly with the use of lubricant. In our cohort, there was lagophthalmos during the first 2 post-operative weeks, which was managed by frequent lubrication. Only 2 eyes of 2 patients experienced a prolonged exposure keratopathy 3 months post-operatively and were kept on lubricants for that period of time, resulting in complete corneal healing and no recurrence. There was no corneal infiltration or ulceration in any of these cases. Post-operative granuloma formation has been reported to occur in about 2% to 17% of patients varying with different suture materials.2 In our study it was noted in 13%, and the granulomatous response was subtle and did not require any further intervention. We acknowledge the short follow-up in some patients, but even in those with a year or more follow-up, the outcome remained unaltered. Frontalis suspension with supramid is a temporary procedure, and our results show that it can be safely performed, aimed at preventing amblyopia and facilitating visual rehabilitation and improved learning.
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES 1. Crawford JS, Doucet TW. Uses of fascia in ophthalmology and the benefits of autogenously sources. J Pediatr Ophthalmol Strabismus 1982;19:21–25. 2. 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. 3. Katowitz JA. Frontalis suspension in congenital ptosis using a polyfilament, cable-type suture. Arch Ophthalmol 1979;97:1659–1663. 4. Crawford JS. Repair of ptosis using frontalis muscle and fascia lata: a 20 year review. Ophthalm Surg Laser 1977;8: 31–40. 5. Beyer CK, Albert DM. The use and fate of fascia lata and sclera in ophthalmic plastic and reconstructive surgery. Ophthalmology 1981;88:869–886. 6. Lam DS, Ng JS, Chevy GP, et al. Autogenous Palmaris longus tendon as frontalis suspension material for ptosis correction in children. Am J Ophthalmol 1998;126: 109–115.
RESEARCH REPORT
Modified Supramid Brow Suspension in Paediatric Ptosis Darakhshanda Khurram Butt1, A. Jayaprakash Patil1,2, and Yassir M. S. Abou-Rayyah1,3 1
Paediatric Ophthalmology Department, Great Ormond Street Hospital for Children, London, United Kingdom, King’s College Hospital, London, United Kingdom, and 3Moorfields Eye Hospital, London, United Kingdom
Orbit Downloaded from informahealthcare.com by University of Washington on 03/06/15 For personal use only.
2
ABSTRACT Purpose: To understand the safety and complication profile of the modified supramid brow suspension surgery in the paediatric ptosis. Design: Retrospective interventional case series. Methods: Review of medical notes of 32 patients who underwent supramid brow suspension surgery of the upper lid. Surgery was performed by a single surgeon at Great Ormond Street Hospital, London during 2007–2012. Complication rates were analysed. Results: Forty-six eyes of 32 patients underwent upper eye lid brow suspension surgery; 18 cases were unilateral and 14 bilateral. Mean follow-up period is 28 months after the surgery. Post-operative granulomatous reaction was noted in 6 eyes (13%) and prolonged exposure keratopathy in 2 eyes (4.3%). There were no cases of suture infection or exposure. No recurrence of ptosis was observed in any of the operated cases. Pupillary axis clearance was achieved in all eyes. Conclusion: Modified brow suspension surgery using supramid for upper eyelid ptosis is a safe and clinically useful procedure with low complication rate. Keywords: Amblyopia, brow suspension, granuloma, ptosis, supramid
INTRODUCTION
ptosis surgery in severe ptosis is to prevent amblyopia before a more definitive levator procedure is performed. The preferred material for brow suspension surgery is autogenous fascia lata. But in children less than 3–4 years the fascia lata is thin and lacks the tensile strength and more over technically is difficult to harvest adequate tissue.1 This makes it imperative to use alternative materials for brow suspension. Many alternative materials have been tried, including donor fascia lata, palmaris longus tendon, frontalis flap, sclera and synthetic materials such as prolene, polyfilament nylon, mersilene mesh, Gore-tex, silicon rods and supramid.2 Donor tissue always carries the inherent risk of transmitting infections, no matter how well it is screened for pathogens. This makes the option of using synthetic material more attractive for parents
Ptosis in paediatric age group presents its own challenges as to the time of intervention and technique of surgery. Ptosis surgery in children is based on the vision, individual child’s severity of ptosis and the strength of the levator palpebrae superioris muscle. In mild-to-moderate ptosis not obstructing the pupillary axis, surgery can be deferred until the pre-school years. If the ptosis is severe and is interfering with the vision, surgery will have to be performed at an earlier age, allowing maximal visual development. Brow suspension is one of the relatively easier operations to perform, and it is an effective procedure in the paediatric age group with ptosis secondary to poor levator function. The key advantage of brow
Received 14 June 2013; Revised 11 January 2014; Accepted 13 January 2014; Published online 28 April 2014 Correspondence: Dr. Yassir M.S. Abou-Rayyah, Consultant Ophthalmologist, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, Tel: 020 7405 9200 (ext 5818), E-mail: [email protected]
252
Orbit Downloaded from informahealthcare.com by University of Washington on 03/06/15 For personal use only.
Supramid Brow Suspension in Children 253 considering the brow suspension for their child. Synthetic materials are not devoid of any serious complications. There is a greater incidence of granuloma formation, infection, extrusion and late failure.2 Nevertheless, in children in whom fascia lata cannot be obtained, synthetic materials are preferred over donor tissue. Moreover the surgery at that age is intended solely to prevent amblyopia and it is a standby procedure before a more permanent procedure could be considered. Supramid is a 4-0 polyfilament cable-type alloplastic nylon ophthalmic suture. It is a material with high tensile strength, well-suited for finest, but firm sutures in microsurgery.3 Previous studies using supramid for brow suspension surgery are limited to few small case series and marred with conflicting results. In this study we present our results with supramid brow suspension in the treatment of ptosis in children with poor levator function. We evaluate the complication rates of the technique.
Incision sites were marked by using a sterile marker. Two stab incision sites approximately 8 mm apart were marked 2 mm above the lash line that was centered over the area of desired optimal elevation. Another two stab incisions sites were marked at the eyebrow, in line with the lateral and medial canthi. A forehead incision is then marked above and between these 2 brow marks to complete an isosceles triangle. Stab incisions from the skin down through the dermis to the subcutaneous plane at the premarked sites were made using a No. 15 blade. Using supramid 4-0 nylon suture with a doubleended needle, one end was introduced through the medial stab incision on the lid margin, passed in the epitarsal tissue horizontally and pierced out through the lateral lid stab incision. The needles are then reintroduced to their incision sites and passed upwards in the suborbicularis plane and pierced out from the corresponding brow exit sites. Two needles were then passed under the skin and pierced out from the forehead incision and tied together. Then through a separate skin incision the needles were brought out and cut flush with the skin.
MATERIALS AND METHODS A retrospective review of charts of 32 consecutive children who underwent unilateral or bilateral brow suspension using 4-0 supramid from January 2007 till January 2012 at Great Ormond Street Hospital for Children, London by a single surgeon (YAR) was performed. The study was approved the ethical committee of the hospital. All children who had undergone supramid brow surgery for ptosis with poor levator function (less than 4 mm) were included in the study. The age range at the time of surgery was 3.1–13.2 years. No exclusion criteria were identified for this study. The mean follow-up period was 2.4 years (range 5 to 36 months). Thirty-eight of 46 eyes had at least 12 months’ follow-up (82.6%). Two eyes had a short follow-up of 5 months. Data collected included, the age at the surgery, sex, diagnosis of ptosis and complications if any. All patients were observed 1 week, and 1, 3 and 6 months after the operation. Further follow-ups were individualised for each patient. Surgical success was defined as improved upper lid position to above the superior pupillary margin without any recurrence or major suture-related complications.
Surgical Procedure All the surgeries were performed by a single surgeon under general anaesthesia as a day case procedure. The surgical procedure involved performing frontalis sling suspension using modified Fox pentagon technique (Figure 1). An eyelid plate was used to prevent ocular trauma when needles were passed. !
2014 Informa Healthcare USA, Inc.
RESULTS Forty-six eyes of 32 patients underwent upper eye lid brow suspension surgery; 18 cases were unilateral and 14 bilateral. The demographics are described in Tables 1 and 2. Mean follow-up period is 28 months after the surgery. Post-operative granulomatous reaction was noted in 6 eyes (13%) and prolonged exposure keratopathy in 2 eyes (4.3%). There were no cases of suture infection or exposure. No recurrence of ptosis was observed in any of the operated cases. Pupillary axis clearance was achieved in all eyes. Complications are summarised in Table 3.
DISCUSSION Childhood ptosis can result in impaired visual development and can be cosmetically disfiguring. The timing and the type of surgery are dependent on severity of ptosis, presence of abnormal head posture, developmental delay and unsatisfactory facial appearance.1 The aim is to clear the visual axis to give the eye a chance to develop maximum vision and prevent amblyopia. Frontalis slings with alloplastic slings are well documented in the literature.4 However, forehead scars and late failures are the complications associated with it. The aim of our study was to ascertain the safety and effectiveness of the technique in elevating the eyelid temporarily for visual development until the child is old enough for definitive surgery using autologous fascia lata.5
Orbit Downloaded from informahealthcare.com by University of Washington on 03/06/15 For personal use only.
254 D. K. Butt et al.
FIGURE 1. (A–F) (A) Marking of the incision sites. Two markings 2 mm above the lash line, approximately 8 mm apart, centered over the area of desired optimal elevation. Two more markings at eyebrow, in line with the lateral and medial canthi. A forehead marking to complete an isosceles triangle. (B–E) After the frontalis sling suspension using modified Fox pentagon technique, the 2 needles of the supramid 4-0 nylon suture are passed under the skin and pierced out from the forehead incision and tied together. Then through a separate skin incision, the needles were brought out and cut flush with the skin. (F) Final appearance showing adequate and symmetrical lid lift. TABLE 1. Demographics of cohort. No. of patients Laterality Side of unilateral ptosis Age at surgery Follow-up period
32 (46 eyes) 18 Unilateral 14 Bilateral 12 Right eye 06 left eye 3.1–13.2 years 28 months
As the objective of the study was to confirm the safety and effectiveness, older children who had the supramid ptosis surgery were also included. The older children (44 years) had the supramid surgery in lieu of fascia lata were those with myogenic ptosis secondary to mitochondrial myopathy. They were either unstable systemically or were associated with other co-morbidities that prevented them from extensive surgical procedure such as harvesting fascia lata. Orbit
Supramid Brow Suspension in Children 255 TABLE 2. Diagnosis/cause of ptosis. Congenital
Myogenic Neurogenic/Paralytic Inflammatory Mechanical Craniofacial anomalies
12-Idiopathic congenital ptosis 2-Gausser syndrome 2-Cornelia De Lange syndrome 1-Myasthenia Gravis 8-Mitochondrial dystrophy 1-Oculomotor nerve palsy 2-Orbital inflammatory disease 3-Neurofibromatosis Type 1 1-Saethre-Chotzen syndrome
TABLE 3. Complications of surgery.
Orbit Downloaded from informahealthcare.com by University of Washington on 03/06/15 For personal use only.
Complication Granulomas Infection Exposure Keratopathy Extrusion/Suture exposure Recurrence of Ptosis
Number of Eyes 6 0 2 0 0
Patients achieved good cosmetic outcome at the end of 28 months of follow-up. Most of the techniques described in the literature employ the classic Crawford’s technique of double rhomboid with six skin incisions or Fox method with five skin incisions, thereby increasing the possibility of post-operative scar formation. In our study using the Fox five-skin-incision method, with modified sutural technique, after tying the knot, the needles come out of the separate incision sites, we were able to reduce the post-operative granuloma formation. In our technique, two bites 8 mm apart through orbicularis muscle and pretarsal tissue prevented the central notching. The peripheral parts of the lid on the medial and lateral sides were lifted appropriately, and the contour of the lid was adjusted accordingly. In our study, there was a predominance of unilateral ptosis (52.3%). The surgical timing of unilateral ptosis is different from bilateral cases. Unilateral ptosis occluding the pupillary axis warrants immediate surgical intervention to tackle amblyopia, while in bilateral ptosis, the child learns to use frontalis muscle and obtain a compensatory head posture, hence deferring the surgery for a reasonable period of time.6 Lagophthalmos is not uncommon after frontalis sling and has been reported in the literature.2 All patients experience lagophthalmos, and it might increase on down gaze, and some might develop
!
2014 Informa Healthcare USA, Inc.
mild corneal exposure, which can resolve quickly with the use of lubricant. In our cohort, there was lagophthalmos during the first 2 post-operative weeks, which was managed by frequent lubrication. Only 2 eyes of 2 patients experienced a prolonged exposure keratopathy 3 months post-operatively and were kept on lubricants for that period of time, resulting in complete corneal healing and no recurrence. There was no corneal infiltration or ulceration in any of these cases. Post-operative granuloma formation has been reported to occur in about 2% to 17% of patients varying with different suture materials.2 In our study it was noted in 13%, and the granulomatous response was subtle and did not require any further intervention. We acknowledge the short follow-up in some patients, but even in those with a year or more follow-up, the outcome remained unaltered. Frontalis suspension with supramid is a temporary procedure, and our results show that it can be safely performed, aimed at preventing amblyopia and facilitating visual rehabilitation and improved learning.
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES 1. Crawford JS, Doucet TW. Uses of fascia in ophthalmology and the benefits of autogenously sources. J Pediatr Ophthalmol Strabismus 1982;19:21–25. 2. 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. 3. Katowitz JA. Frontalis suspension in congenital ptosis using a polyfilament, cable-type suture. Arch Ophthalmol 1979;97:1659–1663. 4. Crawford JS. Repair of ptosis using frontalis muscle and fascia lata: a 20 year review. Ophthalm Surg Laser 1977;8: 31–40. 5. Beyer CK, Albert DM. The use and fate of fascia lata and sclera in ophthalmic plastic and reconstructive surgery. Ophthalmology 1981;88:869–886. 6. Lam DS, Ng JS, Chevy GP, et al. Autogenous Palmaris longus tendon as frontalis suspension material for ptosis correction in children. Am J Ophthalmol 1998;126: 109–115.
