Fascia lata versus silicone sling frontalis suspension for correction of congenital blepharoptosis.
Ptosis of the upper eyelid is a condition in which the upper eyelid margin is in an abnormal inferiorly displaced position.  It may cover a significant portion of the cornea and pupillary aperture so as to cause visual impairment. Congenital blepharoptosis results from a developmental dystrophy of the levator muscle of unknown aetiology. It may be associated with third nerve misdirection, Marcus-Gunn jaw-winking phenomenon or blepharophimosis syndrome.  Ptosis is usually graded as mild (up to 2 mm), moderate (3 mm) and severe (4 mm or more). In myogenic ptosis, there is either absence of levator function or the levator function is poor i.e. less than 4mm. In these patients, the diagnosis is established if there is failure of the upper lid to descend to the level of lower limbus in down gaze. In cases where the levator function is absent or is less than 4 mm, the most effective surgical approach is suspension of the upper lid to the frontalis muscle. In this way, the upper lid is elevated on raising the brows. Normally the upper lid margin rests about 2 mm below the upper limbus. Abnormal head posturing develops in bilateral cases and it can cause deprivation amblyopia, especially in unilateral cases. Congenital ptosis may, therefore, have a negative effect on the psychological development of the child. The ideal surgical treatment and age of intervention were controversial in the management of congenital ptosis, however congenital ptosis should be corrected in the early years of childhood, and amblyopia treatment commenced as soon as the diagnosis is established. 
Various materials including fascia lata [2,3], Palmaris tendon , deep temporal fascial graftal, Mersilenet [6,7], Gortext , silicone rods [9-11] and different sutures  have been used to fashion the frontalis sling. Recently frontalis muscle advancement  has been used to bypass the sling. The technique for making a sling has also been quite varied. Some people use a lid crease incision with tarsal fixation of the fascia lata compared to others who use supralash stab incisions to pass the fascia lata beneath the orbicularis without anchorage.  Fox pentagont  or Crawford double triangle  are the two different methods of passing the fascia lata. Cosmetic issues that are raised with standard frontalis suspension surgery include scarring in young children, unsatisfactory geometric tenting of the pretarsal and preseptal skin, obliteration of the eyelid crease and a poor tarso-corneal interface noted with brow elevation and depression. These may be related to the choice of sling material and to the superficial location of the sling in the eyelid.  Despite these drawbacks, all surgeons agree that the most successful material is autogenous fascia lata, and this technique has the lowest complication rate.  Fascia lata mostly completes its development in the first year of life.  When the length of the upper leg is approximately 20 cm, the length of the fascia lata is sufficient for frontalis suspension.
Materials and Methods
This study was conducted at GMC Srinagar, India from 1st January 2010 to 1st March 2012. Thirty patients, 14 females and 16 males of age ranging from 5 to 55 years, having congenital ptosis were included in the study. A detailed history and examination was performed. History included the age of onset of ptosis, its duration, reviewing old photographs (if the history is ambiguous), diplopia symptoms, variability of ptosis during the day and excessive fatigue. A complete examination including cyclorefraction, best corrected visual acuity, biomicroscopic evaluation of the lacrimal meniscus, extraocular movements, pupillary reactions and corneal sensation was performed. Ptosis examination included: lid fissure height, eyelid crease height, upper lid margin to reflex distance (MRD), scleral show, levator function, lagophthalmos, jaw winking and Bell's phenomenon (4+ implies complete disappearance of the cornea and zero corresponds to absence of Bell's phenomenon), inspection for abnormal head posture (e.g. chin elevation) and frontalis contraction. Informed consent was taken and patients were randomly divided into 2 groups I and II. Group I patients underwent frontalis sling suspension with autologous fascia lata while Group II patients underwent frontalis sling suspension with silicone sling. Difficulty in assessment of pre and postoperative measurements and inadequate length of fascia lata were the reasons for excluding children less than 5 years. Autogenous fascia lata was harvested in all patients using a fascia stripper through a 2.5 cm incision In both the groups, frontalis brow suspension was performed by employing the modified Fox technique. Stab incisions were made in the lid approximately 2 mm from the lid margin to avoid the lash roots and are made just lateral to the upper punctum and approximately 3 mm from the lateral canthus. Brow incisions were made at a position in line with the medial and lateral canthi. The superior incision was made directly above the mid position of the lid at a distance from the brow incisions to form an equilateral triangle. A Wright fascia needle was used to thread the fascia lata sling through the incisions in such a way so as to have each end exit through the superior incision, while as silicone sling came with a pre attached needle. Care was taken not to enlarge the stab incisions as the sling material was pulled through. The superior incision was undermined to accommodate the knot. Final lid height was determined by tightening the sling till the lid margin just lifts off the cornea. Vicryl 6/0 was used to reinforce the knot. Incisions were closed with vicryl 6/0. A frost was applied for 48 hrs.
Exclusion criteria included weak Bell's phenomenon (less than 50% of normal), positive phenylephrine test, jaw winking phenomenon, blepharophimosis syndrome, systemic or myopathic disorders with secondary ptosis such as myotonic dystrophy, myasthenia gravis, chronic progressive external ophthalmoplegia, and Graves' disease, history of intra or extra ocular and eyelid surgery, sharp or blunt trauma to the eyelids, eyelid tumors and scars and patients with vertical squint.
In both the groups, results were assessed at 4 weeks, 8 weeks and at 3 months. All the calculations were based on final results at 3 months. Functional improvement was judged on the basis of post-operative improvement in margin to reflex distance (MRD). MRD of > 3 mm was graded as satisfactory, whereas MRD of < 1.5 mm was considered poor. Satisfactory improvement in MRD was further graded as good (MRD > 3 mm) or moderate (> 2 mm < 3 mm).
Average post-operative MRD with brow up was 3.55 [+ or -] 0.73 mm in group I and 2.95 [+ or -] 0.17 mm in group II at 3 months after surgery. In Group I, 14 (93%) out of 15 showed satisfactory cosmetic and functional results. Among these, 12 (80%) patients had good MRD and 2 (13%) patients had moderate MRD. The remaining 1 (7%) of 15 patients had poor MRD. In Group II 11 (73%) out of 15 patients showed satisfactory cosmetic and functional results. The remaining 4 (27%) of 15 patients exhibited poor MRD. Under-correction was seen in 4 (27%) of 15 patients, granuloma formation was seen in 1 (7%) of 15 patient, exposure of silicon tube was seen in 1 (7%) of patient in fourth postoperative week, In 1 (7%) of 15 patient, recurrence of ptosis was seen due to slippage of silicone sling. Figures 1 and 2 summarize the functional results and postoperative complications respectively.
The surgical approach to congenital ptosis is generally based on the amount of levator function. Patients with congenital ptosis have been grossly divided into three groups based on the levator function: (1) those with poor levator function of 4 mm or less, (2) those with fair levator function of 5-7 mm, and (3) those with good levator fuction greater than 8 mm. Although congenital ptosis can be mild and innocuous it often produces functional limitation, changes in the neck and body posture, as well as impact aesthetic and psychological wellbeing of the patient. Frontalis muscle suspension is the gold standard for the treatment of congenital ptosis with poor levator function.  It creates a linkage between the frontalis muscle and the tarsus of the upper eyelid, which allows for a better eyelid position in primary gaze. Eyelid elevation is then performed with the use of the frontalis muscle. As already mentioned several materials have been used for the purpose but ever since 1966 when Tillet et al reported use of Silicone band No. 40 for frontalis sling suspension surgery the material has been found to have excellent biocompatibility and is being vastly accepted.
[FIGURE 3 OMITTED]
However autologous fascia lata has proven to be the method of choice in sling surgery for ptosis.I [21,22] Wagner, reported neither infection nor granuloma formation with banked fascia lata, however, the observed recurrence rate was 8.3%.  Silicone frontalis sling requires small skin incision, less surgical time and it can be performed in all eyes with ptosis with poor levator function. Grover et al in 2005 highlighted the complications of harvesting fascia lata including an unsightly scar in the thigh region, hematoma formation, keloid formation and herniation of muscle belly.  But in the present study no such complications were encountered. Moreover, a scar in the thigh area was not considered as an aesthetic blemish by the patients most probably because of cultural values. Literature review revealed that under-correction is more common in the treatment of congenital ptosis and the rate varies from 535% depending on the series. As pointed out, 1 patient in this group developed granuloma on 6th post-operative week which was later excised. Various studies reported that complication rate of granuloma formation varies from 3-7%.  Our results also match with the results demonstrated by Munira et al  as well as Usha et al reported one recurrence of ptosis due to slippage of silicone sling over the tarsus , while in the current study, we also encountered one recurrence of ptosis due to same reason.
Blepharoptosis surgery is one of the most common oculoplastic procedures; the aim of which is to clear the visual axis, reducing amblyopia in young patients and improving superior visual fields in adult patients. The secondary goal is to improve appearance by producing symmetric lid crease and contour in the upper lids. The visual impact of ptosis can be significant for the patient. The negative psychosocial impact of an abnormal eyelid position should not be discounted especially in young children and teenagers. Recent studies have identified a 3-10% incidence of amblyopia with severe congenital ptosis. We obtained clinically significant functional and cosmetic improvement with lower complication rates in patients in whom frontalis sling procedure was performed using fascia lata (93%) as compared to patients in whom silicone sling was used (73%). Large scale prospective studies are needed to evaluate the true outcome of different materials and sling designs in frontalis suspension surgery.
Source of Support: Nil
Conflict of interest: None declared
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Afroz Khan, Obaid Majid, Junaid Wani
Post Graduate Department of Ophthalmology, Government Medical College, Srinagar, J & K, India
Correspondence to: Obaid Majid (firstname.lastname@example.org) DOI: 10.5455/ijmsph.2014.180320142
Received Date: 06.03.2014 Accepted Date: 15.05.2014
Figure-1: Results of Frontalis Brow Suspension using Fascia Lata (Group I) and Silicone sling (Group II) showing significantly better results in group I than Group II Group I Group II Good (> 3) 12 11 Moderate (1.5-3) 2 0 Poor (< 1.5) 1 4 Figure-2: Indicates the post-operative complications encountered in both the groups which have been more in Group II than Group I Group I Group II Under 1 4 Correction Granuloma 0 1 Formation Exposure of 0 1 Silicone Sling Ptosis 0 1 Recurrence
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|Title Annotation:||RESEARCH ARTICLE|
|Author:||Khan, Afroz; Majid, Obaid; Wani, Junaid|
|Publication:||International Journal of Medical Science and Public Health|
|Date:||Jun 1, 2014|
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