Frontalis sling surgery: silicon rod versus autogenous fascia lata in congenital ptosis.
Frontalis suspension is a surgical procedure of choice in patients with severe ptosis associated with poor or absent levator function.  Ptosis may be congenital wherein the levator muscle is dystrophic, or it may be associated with Marcus Gunn jaw-winking and neurogenic or myogenic causes such as third nerve palsy, blepharophimosis syndrome, myasthenia gravis, and so on. Frontalis suspension is commonly performed in severe congenital ptosis but can also be used in ptosis with neurogenic and myogenic causes. Surgical correction is indicated when congenital ptosis leads to amblyopia, abnormal head posture, and cosmetic problems. The degree of ptosis, levator palpebrae superioris function, age of the patient, and the condition of the cornea determine the choice of the surgical procedure. When the levator function is absent or less than 4 mm, suspension of the upper lid to the frontalis muscle is the procedure of choice. 
Different materials are used for suspension which include biological and synthetic materials. Autogenous fascia lata (AFL) is the material of choice [2-5]; however, it is not only difficult to harvest needing surgical expertise but also causes scarring to the patients leg.  Discovery of alternative materials helped to overcome these difficulties. Preserved fascia lata (FL) has been a common option, along with synthetic materials such as silicon rod, nylon polypropylene, and polytetrafluoroethylene being used. [4-12] Although there are many studies that compare these materials, but no general consensus as to which material is superior to other has been reached. [4,5,7,12] In this study, we have compared the cosmetic results of silicon rod with AFL in frontalis sling surgeries (FSSs) for patients with severe congenital ptosis with a postoperative follow-up of 3 years.
Materials and Methods
A retrospective study was conducted on patients who underwent sling surgery for congenital ptosis in the Department of Ophthalmology at Government Medical College, Srinagar, which is a tertiary-care teaching hospital in Jammu and Kashmir, India, from January 2009 to January 2012. Medical records of patients who had undergone FSS as a primary procedure for simple congenital ptosis (unilateral or bilateral) were reviewed. A total of 42 patients were studied among which 22 (12 male and 10 female subjects) were in silicon rod group (SRG) and 20 (11 male and 9 female subjects) in fascia lata group (FLG).
Preoperative examination included best-corrected visual acuity, cycloplegic refraction, slit-lamp examination, and fundus examination with 78 D, and checking of extraocular movements. Ptosis evaluation included palpebral fissure height, median reflex distance (MRD), levator function, jaw-winking phenomenon, Bell's phenomenon, and corneal sensations. Amount of ptosis was defined as the difference between MRD of the affected eye when compared with MRD of the normal eye in unilateral cases, whereas, in bilateral cases, the definition was 4 mm minus MRD of affected eyes assuming 4 mm as normal MRD. The two groups were compared with respect to age, preoperative MRD, preoperative amount of ptosis, and levator function using Mann-Whitney U test and independent t test. Postoperative MRD were also compared with independent t test. A p < 0.05 was considered statistically significant.
All surgeries were performed under general anesthesia. For harvesting FL, two incisions of 2-2.5 cm long were made in a line between lateral condyl of tibia and anterior superior iliac spine. First incision was made starting about 5 cm above the knee and second incision 10 cm above the first incision. Incisions are deep enough until FL was seen as a white glistening sheet. FL was dissected from the subcutaneous tissue with blunt dissection using long-handled scissors with blunt retractors used to facilitate the dissection. Two longitudinal incisions were made parallel to each other in the length of FL 10-15 mm apart, and, finally, a transverse cut at the upper end was made. Dissection of FL from underlying muscle was done with the help of scissors inserted from both the incisions. The inferior end of the FL strip was cut, grasped, and drawn out of the incision. The final dimensions of FL strip were approximately 15 cm by 1-1.5 cm. The FL defect was left open whereas subcutaneous tissue was sutured with 4 o plain catgut and skin incision with 5 o silk suture. Gauze dressings were placed over the wound. Systemic antibiotics and anti-inflammatory agents were given for 5-7 days and sutures removed after 10-12 days. The strip of FL was cleaned of the subcutaneous tissue with a blade under the microscope. It was cut into strips of 1-2 mm width and 10-15 mm length.
In both the groups, sling surgery was performed using the Fox method. Two stab incisions were made above the upper lid margin. In addition, two stab incisions above the eye brow and one centrally in the forehead deep to periosteum were also made. Using blunt scissors, a pocket was dissected under the frontalis muscle in forehead incision. Two sutures were preplaced through the tarsus in the lid margin incisions using 8-0 vicryl. The silicon rod was passed through the incisions in a pentagon fashion so that two ends meet at the central forehead incision. Two preplaced sutures were tied over the silicon rod at the lid margin incisions, and the two ends were passed through the sleeve and the eyelid margin level adjusted at superior limbus; the sleeve was buried into the forehead pocket, and the incisions were sutured. In FLG, same technique was used as in the SRG. Using a Wright needle, a pentagon base down was completed with FL strips. FL strips were not sutured to the tarsus. The two ends of FL were brought out at the forehead incision after adjusting the lid margin level at the limbus. The two sides of FL were overlapped and sutured using 6-0 silk; the ends were cut short and buried under the pocket beneath the incision. Postoperatively, antibiotic ointment and lubricating drops were used as per the requirement and any corneal exposure.
Fifty-four patients underwent ptosis sling surgery during the enrolment period out of which 42 patients with congenital ptosis underwent sling surgery fulfilled our inclusion criteria. Twenty-two patients (34 eyelids) underwent surgery using silicon rod as suspension material, and 20 patients (30 eyelids) underwent surgery using AFL as a suspension material.
The mean age of the patients was 45.50 [+ or -] 11.56 months in SRG and 44.75 [+ or -] 11.38 months in FLG. There was no statistically significant difference found with respect to age, preoperative MRD, preoperative amount of ptosis, and preoperative levator function between the two groups as shown in Table 1. Data of follow-ups at 3 and 6 months, 1 year, and 3 years after surgery were collected. Mean follow-up time was 38 [+ or -] 8.33 months in SRG and 37 [+ or -] 7.74 months in FLG. The results were classified into three categories: good when MRD was 3 mm, poor when MRD was <1 mm, and fair with MRD 2 or 2.5 mm. The postoperative MRD of each group at follow-up is shown in Table 2. The postoperative MRD did not show any statistically significant difference between the two groups. In SRG, of the 34 eyes, 21 showed good results and 7 eyes fair results, with 6 eyes (17.6%) showing recurrence. One patient developed infection of the forehead wound probably because of constant scratching of the wound by the patient in the second postoperative week, which was managed with oral antibiotics and dressings. In FLG, of the 30 eyes, 18 eyes showed good results and 8 eyes fair results, whereas 6 (20%) patients showed recurrence in this group.
Exposure keratopathy was seen in one patient in FLG, which was managed by lubricating drops, antibiotic ointment, and overnight patching. The postoperative complications other than ptosis recurrence are summarized in Table 3.
The risks of amblyopia are very high in small children if the congenital ptosis is severe enough to obscure the visual axis. Hence, surgical correction is necessary to prevent this serious complication, and the frontalis suspension is the procedure of choice for severe ptosis.  Different materials are available for this procedure, but the most commonly used is the AFL. [1,2] However, harvesting FL in children younger than 3 years of age is difficult, and even if harvested, the amount of material is insufficient,  besides causing complications such as pain, difficulty in walking, keloid formation, and muscle herniation among others. To overcome such problems, many synthetic and biological materials have been tried for frontalis suspension. One of these being banked FL,  but there were many reports of inflammatory reactions with this material  and concern about possible transmission of infectious diseases. Banked FL also shows decreased efficacy over long-term period. [4,13] Therefore, many synthetic materials were used as an alternative graft for sling surgery with varying success and complication rates. [2,4,5,14] Polytetrafluoroethylene (Gortex) was used as a suspension material, but the disadvantage was recurrence and granuloma formation. [4,5] Supramid, another synthetic material, was also used for frontalis suspension in small children but recurrence rate was high because of degradation of Supramid by hydrolysis ; therefore, this suture is used for temporary lid elevation.  Use of silicon band was first reported by Tillett and Tillett  in FSS in patients of ptosis with poor levator function. Since then, many studies were dedicated to the use of silicon rod in FSS. [18,16-18] Silicon rod is an elastic synthetic material that is cheap, nonreacting, easily available, and adjustable. These properties make it a suitable suspension material for ptosis.
Recurrence of ptosis in silicon rod patients is varied ranging from 7-44%, [7,8,12] whereas Lee et al.  believed that these wide ranges of postoperative recurrences may be because of different follow-up periods, different configurations of sling, and heterogeneity of diseases. In our study, the results at the end of follow-up period were comparable with 17.6% recurrence seen in SRG versus 20% recurrence in the FLG. The cosmetic results were similar, and parent satisfaction was good in both the groups. However, in FLG, there were some concerns about the leg scar by the parents in addition to the discomfort secondary to pain on walking. Overall, parent satisfaction was better in SRG because there was no trauma to the leg. Surgeon satisfaction was also better in SRG than FLG as the procedure was easy, less time consuming, and easily adjustable in case of undercorrection or overcorrection when compared with FLG. (Surgeon and parent satisfaction was measured on Likert scale of 1-5.)
Our results were better than those in the study by Lee et al.,  who conducted a retrospective study comparing silicon rod versus preserved FL in congenital ptosis, where the recurrence rate was 29% in bilateral cases and 11% in unilateral cases in SRG and 63% in bilateral and 43% in unilateral cases in FLG. Hersh et al.  also compared silicon rod with preserved FL and found similar functional results between the two groups; however, recurrence rate was lower in SRG. Wasserman et al.  also did a retrospective medical record analysis of patients who underwent sling surgery with different materials and found an overall recurrence rate of 31.4% and 51.4% in FLG, which were much higher than those in our study.
We concluded that, our hospital being a high patient volume center with resource constraints such as less availability of surgeons at times, silicon rod is an excellent alternative to AFL for frontalis suspension in congenital ptosis. Silicon rod surgery requires less surgical expertise, time, and instruments, with the added advantage of results being similar to FL sling along with minimal complications.
[1.] Crawford JS. Repair of ptosis using frontalis muscle and fascia lata. Trans Am Acad Ophthalmol Otolaryngol 1956;60:672-8.
[2.] Crawford JS. Frontalis sling operation. J Pediatr Ophthalmol Strabismus 1982;19:253-5.
[3.] Crawford JS. Recent trends in ptosis surgery. Ann Ophthalmol 1975;7:1263-7.
[4.] Wasserman BN, Sprunger DT, Helveston EM. Comparison of materials used in frontalis suspension. Arch Ophthalmol 2001;119:687-91.
[5.] Wagner RS, Mauriello JA Jr, Nelson LB, Calhoun JH, Flanagan JC, Harley RD. Treatment of congenital ptosis with frontalis suspension: a comparison of suspensory materials. Ophthalmology 1984;91:245-8.
[6.] Esmaeli B, Chung H, Pashby RC. Long-term results of frontalis suspension using irradiated, banked fascia lata. Ophthal Plast Reconstr Surg 1998;14:159-63.
[7.] Hersh D, Martin FJ, Rowe N. Comparison of silastic and banked fascia lata in pediatric frontalis suspension. J Pediatr Ophthalmol Strabismus 2006;43:212-8.
[8.] Carter SR, Meecham WJ, Seiff SR. Silicone frontalis slings for the correction of blepharoptosis: indications and efficacy. Ophthalmology 1996;103:623-30.
[9.] Mehta P, Patel P, Olver JM. Functional results and complications of Mersilene mesh use for frontalis suspension ptosis surgery. Br J Ophthalmol 2004;88:361-4.
[10.] Bajaj MS, Sastry SS, Ghose S, Betharia SM, Pushker N. Evaluation of polytetrafluoroethylene suture for frontalis suspension as compared to polybutylate-coated braided polyester. Clin Experiment Ophthalmol 2004;32:415-9.
[11.] Liu D. Blepharoptosis correction with frontalis suspension using a supramid sling: duration of effect. Am J Ophthalmol 1999;128:772-3.
[12.] Ben Simon GJ, Macedo AA, Schwarcz RM, Wang DY, McCann JD, Goldberg RA. Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material. Am J Ophthalmol 2005;140:877-85.
[13.] Wilson ME, Johnson RW. Congenital ptosis. Long-term results of treatment using lyophilized fascia lata for frontalis suspensions. Ophthalmology 1991;98:1234-7.
[14.] Steinkogler FJ, Kuchar A, Huber E, Arocker-Mettinger E. Gore-Tex soft-tissue patch frontalis suspension technique in congenital ptosis and in blepharophimosis-ptosis syndrome. Plast Reconstr Surg 1993;92:1057-60.
[15.] Kook KH, Lew H, Chang JH, Kim HY, Ye J, Lee SY. Scanning electron microscopic studies of Supramid Extra from the patients displaying recurrent ptosis after frontalis suspension. Am J Ophthalmol 2004;138:756-63.
[16.] Tillett CW, Tillett GM. Silicone sling in the correction of ptosis. Am J Ophthalmol 1966;62:521-3.
[17.] Older JJ, Dunne PB. Silicone slings for the correction of ptosis associated with progressive external ophthalmoplegia. Ophthalmic Surg 1984;15:379-81.
[18.] Leone CR Jr, Shore JW, Van Gemert JV. Silicone rod frontalis sling for the correction of blepharoptosis. Ophthalmic Surg 1981;12:881-7.
[19.] Lee MJ, Oh JY, Choung HK, Kim NJ, Sung MS, Khwarg SI. Frontalis sling operation using silicone rod compared with preserved fascia lata for congenital ptosis a three-year follow-up study. Ophthalmology 2009;116:123-9.
Source of Support: Nil, Conflict of Interest: None declared.
Sheikh Mohammad Farooq, Ejaz Aakbar Wani
Department of Ophthalmology Government Medical College, Srinagar, Kashmir, India
Correspondence to: Farooq Mohammad Sheikh, E-mail: firstname.lastname@example.org
Received January 18, 2015. Accepted June 17, 2015
Table 1: Statistical analysis of preoperative ptosis measurements Group Mean [+ or -] SD Mean name difference MRD (mm) SRG -1.318 [+ or -] 0.945 0.182 FLG -1.500 [+ or -] 0.607 Amount of ptosis (mm) SRG 3.545 [+ or -] 0.510 0.195 FLG 3.350 [+ or -] 0.489 Levator function (mm) SRG 3.364 [+ or -] 1.002 0.186 FLG 3.550 [+ or -] 0.945 95%CI Group Lower Upper Cal. t (df) P name limit limit MRD (mm) SRG -0.319 0.683 0.733 (40) 0.468 FLG Amount of ptosis (mm) SRG -0.117 0.508 1.265 (40) 0.213 FLG Levator function (mm) SRG -0.795 0.423 -0.619 (40) 0.54 FLG FLG, fascia lata group; SRG, silicon rod group; MRD, median reflex distance. Table 2: MRD at Follow ups Follow-up Group MRD mean [+ or -] SD Mean name difference 3 months SRG 3.136 [+ or -] 0.710 -0.214 FLG 3.350 [+ or -] 0.587 6 months SRG 3.227 [+ or -] 0.752 -0.073 FLG 3.300 [+ or -] 0.657 1 year SRG 3.273 [+ or -] 0.703 -0.077 FLG 3.350 [+ or -] 0.587 3 years SRG 2.477 [+ or -] 0.449 -0.148 SLG 2.625 [+ or -] 0.535 95%CI Follow-up Lower Upper Cal. t (df) P limit limit 3 months -0.622 0.195 -1.056 (40) 0.297 6 months -0.515 0.37 -0.332 (40) 0.741 1 year -0.483 0.329 -0.385 (40) 0.703 3 years -0.455 0.159 -0.972 (40) 0.337 SRG, silicon rod group; FLG, fascia lata group. Table 3: Postoperative complications Complications Silicon rod Fascia lata group, n = 22 group, n = 20 Lagophthalmos 1 1 Exposure keratopathy 1 0 Infections 1 0 Lid crease asymmetry 2 3 Entropion 1 2
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|Title Annotation:||Research Article|
|Author:||Farooq, Sheikh Mohammad; Wani, Ejaz Aakbar|
|Publication:||International Journal of Medical Science and Public Health|
|Date:||Jan 1, 2016|
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