Bilateral frontalis sling for surgical correction of unilateral and bilateral severe congenital ptosis with poor levator function

Objective@#This study evaluated the functional and cosmetic outcomes after bilateral frontalis sling repair using either expanded polytetrafluoroethylene (ePTFE) or silicone rod for unilateral or bilateral severe congenital ptosis with poor levator function.@*Methods@#This was a non-comparative, interventional case series involving 30 patients with unilateral or bilateral severe congenital ptosis who underwent bilateral frontalis sling repair from February 2012 to November 2018. Medical records including pre- and postoperative photographs were reviewed. The functional and cosmetic outcomes were assessed.@*Results@#There were 15 patients with severe congenital ptosis who underwent ePTFE surgery and 15 patients who had silicone rod surgery. Baseline levator function measured was less than 5 mm in all patients. The mean follow-up duration after surgery was 15.6+6.9 months. Satisfactory eyelid contour was observed in all patients (100%). Postoperatively, all had good to excellent primary eyelid position and effective frontalis action on eyelid elevation. Complications included exposure of the silicone sling material after trauma at the brow area (n=1) and recurrence of ptosis (n=2).@*Conclusion@#Bilateral frontalis suspension in patients with severe congenital ptosis, whether bilateral or unilateral, resulted in excellent functional and cosmetic outcomes using ePTFE or silicone rod.

Efficacy of autogenous fascia lata and silicone aurosling in correction of congenital blepharoptosis by frontalis suspension

The purpose of this study is to assess the outcomes of frontalis sling using fascia lata and silicone aurosling for congenital unilateral ptosis patients with poor levator function. Material and Methods: Retrospective study of archival cases from 22 patients from author's center. All the patients with unilateral ptosis with poor levator function were included excluding those having poor Bell's phenomenon and associated pathology like jaw winking, 3rd nerve misdirection, squint, impaired corneal sensitivity, and neoplastic lesions. Patients were diagnosed based on the history and clinical examination including measurements. Corrections were performed by single surgeon. Marginal reflex distance-1 (MRD1) values observed preoperatively, immediate postoperatively, and late postoperatively in both groups. Results: Of the 22 cases, 12 were treated with fascia while the remaining 10 were treated with silicone aurosling material. The mean age of the fascia group was 11.42 ± 3.55 years while it was 14 ± 4.2 years for the silicone group. There were 10 males and 12 females in the study group. The mean follow-up in the study group was 20.14 ± 2.05 months, and the difference between the groups was not statistically significant. The difference between the two groups at the preoperative and immediate postoperative did not vary with statistical significance (P = 0.926 and P = 0.242, respectively). The late postoperative MRD1 did vary significantly between the two groups. The mean late postoperative MRD1 for fascia group was 3.67 ± 0.32 with a range of 3.1–4.15 while for the silicone group was 3.2 ± 0.46 with a range of 2.5–4. The difference was statistically significant (P = 0.023). Discussion and Conclusion: The stability of the change in silicone aurosling group was relatively less as compared to the fascia lata. The recent material aspect study of such silicone aurosling material indicates that they are susceptible to damage and that cause the loss of stability. More studies with larger sample size and longer follow-up are needed.

Using 17-gauge Spinal Anesthesia Needle as an Insertion Guide for Frontalis Sling Surgery with Silicone Rod

PURPOSE: In this study we investigated the surgical outcome and effectiveness of using a 17-gauge spinal anesthesia needle for guiding insertion of the silicone rod in frontalis sling surgery for patients having severe myogenic or neurogenic ptosis with risk of exposure keratopathy. METHODS: This study included on 8 patients (11 eyes) who previously received frontalis sling surgery with a 17-gauge spinal anesthesia needle because of severe myogenic or neurogenic ptosis with risk of exposure keratopathy. We investigated the technique, surgical outcome, and clinical features following frontalis sling surgery, and evaluated the advantages of using a 17-gauge spinal anesthesia needle. RESULTS: The mean age of patients was 54 years. Third nerve palsy was the most common etiology in severe ptosis with risk of exposure keratopathy (5 of 8, 62.5%). Main advantages of the 17-gauge spinal anesthesia needle are smaller skin incision that allows for minimal damage during tissue passage and easy guide for insertion. Other advantages included sterilization, minimizing infections, sharpness without distortion because it is disposable, and economic value. The mean follow-up period was 21.4 months, and the upper lid margin of all patients was adequately high above the pupil margin. Additionally, no major complications were observed in the patients. CONCLUSIONS: Frontalis sling surgery with a silicone rod is a safe and effective method for patients with severe myogenic or neurogenic ptosis with risk of exposure keratopathy. The 17-gauge spinal anesthesia needle is useful and economical in frontalis sling surgery for guiding insertion of the silicon rod as an alternative option to the Wright needle.

Frontalis sling surgery: do we really need the Wright needle? / Suspensão ao músculo frontal: realmente precisamos da agulha de Wright?

ABSTRACT Purpose: The aim of this study is to describe a variation in technique of the frontalis sling surgery with silicone rods and its results, using an alternative needle with similar effectiveness to the Wright needle at a reduced cost. Methods: This was a prospective, interventional, noncomparative study of patients with severe ptosis who underwent surgical correction using a simple and modified frontalis sling surgery technique. Patients were included in this study from January 2012 to January 2014. 23 surgeries were performed on 15 patients. The minimum "follow-up" was 12 months. Results: Most patients had congenital ptosis (86%) and the average preoperative margin reflex distance 1 (MRD1) was -1.1 mm (range -3 to 0 mm). 1 week post-operation, this was 2.7 mm ( 1.8 to 3.8 mm), 1.8 mm after 1 month and 1.7 mm (1 to 2.5 mm) after one year. The satisfaction rate was 80% (12 patients). Among the dissatisfied patients, one had extrusion and infection with subsequent explantation of the wire, one had asymmetry greater than 2 mm and one had persistent lagophthalmos and punctate keratitis, with subsequent explantation of silicone. Conclusion: The use of silicone rods with tarsal fixation using an alternative needle was effective in the treatment of severe ptosis with few complication rates, a low rate of dissatisfaction and good stability of the results in the follow-up period.

RESUMO Objetivos: O objetivo deste estudo é descrever uma variação da técnica cirúrgica da suspensão ao músculo frontal com fio de silicone e seus resultados, utilizando uma agulha alternativa à agulha de Wright, com a mesma eficácia e melhor razão custo-benefício. Métodos: Foram analisados prospectivamente todos os casos de blefaroptose severa submetidos à correção cirúrgica, utilizando a técnica de suspensão ao músculo frontal modificada, no período de janeiro de 2012 à janeiro de 2014. Foram realizadas 23 cirurgias em 15 pacientes. O "follow-up" mínimo foi de 12 meses. Resultados: A grande maioria dos pacientes apresentavam blefaroptose congênita (86%), a média da distância margem reflexo pré-operatória foi de -1,1mm (-3 a 0 mm), no pós-operatório de 1 semana foi de 2,7 mm (1,8 a 3,8 mm), após 1 mês foi de 1,8 mm e após 1 ano, de 1,7mm (1 a 2,5 mm). O índice de satisfação foi de 80% (12 pacientes). Dos 3 pacientes insatisfeitos, 1 teve extrusão e infecção com posterior explante do fio, 1 apresentou assimetria maior que 2mm e 1 evoluiu com lagoftalmo persistente e ceratite puntacta, com posterior explante do silicone. Conclusão: O uso do fio de silicone com fixação tarsal usando uma agulha alternativa, se mostrou eficaz no tratamento da blefaroptose severa, com poucas complicações, baixo índice de insatisfação e boa estabilidade dos resultados no período de seguimento.

Ptosis Repair Using Preserved Fascia Lata with the Modified Direct Tarsal Fixation Technique

PURPOSE: To evaluate the clinical outcome of frontalis sling operation using preserved fascia lata with modified direct tarsal fixation in congenital ptosis patients. METHODS: Forty-seven congenital ptosis patients (60 eyes) who underwent a frontalis sling operation using preserved fascia lata with modified direct tarsal fixation method between March 2001 and December 2008 with a mean follow-up time of 52 months (range, 26 to 122 months) were included in this study. The medical records were reviewed retrospectively. RESULTS: A retrospective chart review was conducted in patients who were diagnosed with congenital ptosis and underwent frontalis suspension surgery using preserved fascia lata with modified direct tarsal fixation from 2001 through 2008 at Dong-A University Hospital. The patients were 34 males and 14 females. The age of the patients ranged from 1 to 18 years with an average age of 4.51 years. At a mean follow-up of 60 months, good final results were achieved in 46 eyes (76.6%), fair in 8 eyes (13.3%), and poor in 6 eyes (10%). The poor results consisted of undercorrection of 1 eye and recurrence in 5 eyes. The accumulative survival rate was 87.2%, with all recurrences occurring within 12 months postoperatively. CONCLUSIONS: Frontalis sling operation by preserved fascia lata with modified direct tarsal fixation appears to be an effective treatment for severe congenital ptosis, showing good long term results.

Frontalis Suspension Using a Silicone Rod in Blepharoptosis Patients with Poor Ocular Motility

PURPOSE: To determine the efficacy of frontalis sling operation with silicone rods in patients with compromised corneal protective mechanisms. METHODS: The authors retrospectively studied 6 consecutive patients (7 eyelids) with severe blepharoptosis with poor ocular motility who had undergone frontalis sling operations using silicone rods. RESULTS: Preoperative diagnoses included third nerve palsy in 4 patients, double elevator palsy in 1 patient, and suspicious oculopharyngeal muscular dystrophy in 1 patient. With a mean follow up of 27.7 months, a good final lid height was achieved in all 7 eyelids. Mild exposure keratopathy occurred postoperatively in 3 patients. During the follow-up period, no other significant complications, such as extrusion of the sling or infection, occurred. CONCLUSIONS: Silicone rods are effective and safe materials for use in frontalis suspension in treating blepharoptosis in patients with inadequate or absent Bell's phenomenon, resulting in poor eye protective mechanisms associated with an increased incidence of corneal exposure.

Frontalis Sling Operation by Fixation of Preserved Fascia Lata to Tarsus in Congenital Blepharoptosis Patients

PURPOSE: To evaluate the efficacy of tarsal fixation of fascia in frontalis sling surgery using preserved fascia lata in congenital ptosis patients. METHODS: The authors retrospectively investigated the surgical results of congenital ptosis patients who underwent frontalis sling procedure using preserved fascia lata with or without tarsal fixation. Thirty-nine patients were included in the group with tarsal fixation of fascia and 43 in the group without tarsal fixation. The average age at operation was 59.3 months in the tarsal fixation group, and 64.7 months in the group without tarsal fixation. We compared the recurrence rates between the two groups using the survival analysis. RESULTS: Recurrence occurred in 13 patients of the tarsal fixation group (33.3%) and in 20 of the group without tarsal fixation (46.5%). The two groups' median survival times from operation to recurrence were 28.4 months and 26.1 months, respectively (p=0.64). CONCLUSIONS: Tarsal fixation of fascia did not have a significant influence on recurrence rates in congenital ptosis patients who underwent a frontalis sling operation using preserved fascia lata.

Frontalis Sling Operation Using Silicone Rod in Congenital Blepharoptosis Patients

PURPOSE: To evaluate the results of frontalis sling operation using silicone rod in congenital ptosis patients. METHODS: The authors retrospectively investigated the surgical results of congenital ptosis patients who underwent frontalis sling operation using silicone rod and were followed up for at least 12 months postoperatively. We compared their results with those of congenital ptosis patients who underwent frontalis sling operation using preserved fascia lata. RESULTS: Twenty nine patients were included in the silicone rod group and 81 in the preserved fascia lata group. The average age at operation was 70.5 months in the silicone rod group, and 62.2 months in the preserved fascia lata group. At 12-month follow-up, good lid height was achieved in 9 patients (31.0%), fair in 17 (58.6%), and poor in 3 (10.4%) among the 29 patients of the silicone rod group. Of the 81 patients with preserved fascia lata, 22 (27.2%) were good, 44 (54.3%) were fair, and 15 (18.5%) were poor at postoperative 12 months. Chronic exposure keratopathy occurred postoperatively in one patient of the preserved fascia lata group and early recurrence due to spontaneous break of silicone rod developed in one patient of the silicone rod group. CONCLUSIONS: At 12-month follow-up, frontalis sling operation using silicone rod showed equal or better results compared with the operation using preserved fascia lata. However, longer follow-up is required to confirm the long-term results of frontalis sling operation using silicone rod.

Outcomes of Anterior Levator Resection and Frontalis Sling in Congenital Ptosis with Poor Levator Function

PURPOSE: To compare anterior levator resection with frontalis sling in congenital ptosis with poor levator function. METHODS: We performed a retrospective review of 19 patients (25 eyes) undergoing anterior levator resection and 25 patients (28 eyes) undergoing frontalis sling for congenital ptosis with poor levator action of 5 mm or less from January 1995 to December 2001. RESULTS: The mean postoperative MRD1 were 2.4+/-0.95 mm in the anterior levator resection group and, 2.6+/-0.94 mm in the frontalis sling group. Surgical outcomes were good, fair and poor in 11, 10, and 4 eyes of the anterior levator resection group and in 14, 9, and 5 eyes of the frontalis sling group, respectively. Success rates were 84.0% and 82.1% in each group. There were no statistically significant differences between the two groups (P>0.05). CONCLUSIONS: In congenital ptosis with poor levator function, the surgical outcomes of anterior levator resection were as good as those of frontalis sling.

Outcomes of Anterior Levator Resection and Frontalis Sling in Congenital Ptosis with Poor Levator Function

PURPOSE: To compare anterior levator resection with frontalis sling in congenital ptosis with poor levator function. METHODS: We performed a retrospective review of 19 patients (25 eyes) undergoing anterior levator resection and 25 patients (28 eyes) undergoing frontalis sling for congenital ptosis with poor levator action of 5 mm or less from January 1995 to December 2001. RESULTS: The mean postoperative MRD1 were 2.4+/-0.95 mm in the anterior levator resection group and, 2.6+/-0.94 mm in the frontalis sling group. Surgical outcomes were good, fair and poor in 11, 10, and 4 eyes of the anterior levator resection group and in 14, 9, and 5 eyes of the frontalis sling group, respectively. Success rates were 84.0% and 82.1% in each group. There were no statistically significant differences between the two groups (P>0.05). CONCLUSIONS: In congenital ptosis with poor levator function, the surgical outcomes of anterior levator resection were as good as those of frontalis sling.

The Frontalis Sling Operation Using Preserved Fascia Lata: Modified Crawford Technique

PURPOSE: For the correction of ptosis with very poor levator function, frontalis sling operation with various materials has been used. The purpose of this study was to evaluate the effect of the modified Crawford technique using preserved fascia lata. METHODS: The photographs and charts of 46 patients who underwent frontalis sling operation using preserved fascia lata from June 2001 to February 2004 at our hospital were retrospectively reviewed. The eyelid crease approach was used with the suturing of the sling material directly to the tarsus. RESULTS: The patients were 27 males and 19 females. There were 20 (44%) unilateral cases and 26 (56%) bilateral cases. The age of the patients ranged from 1 to 65 years at the time of surgery, with an average age of 8.3 years. The success rate was 93% (43/46 patients) for a mean postoperative follow-up of 9 months (range 4~26 months). The complications consisted of one case of overcorrection and 2 cases of undercorrection. Knot exposure occurred in 2 cases. CONCLUSIONS: The modified Crawford technique using preserved fascia lata appears to be an effective treatment for severe ptosis. The lid crease formation provides good cosmetic results and the direct suturing of the preserved fascia lata to the tarsus prevents its migration.

Frontalis Suspension Using Autogenous Fascia Lata

PURPOSE: To investigate the effect of frontalis sling operation with autogenous fascia lata. METHODS: We reviewed the medical records of 83 ptosis patients who had undergone frontalis sling with autogenous fascia lata from December 1997 to April 2003, and who were followed up for six months or more. We retrospectively evaluated the clinical features and the surgery outcomes. RESULTS: There were 55 males and 28 females with age ranging from 3 to 42 years (mean, 10.8 years). The ptosis was unilateral in 29 patients and bilateral in 54. With a mean follow-up of 23.3 months (range 6-70 months), 74 patients (89.1%) showed good results and 9 (10.8%) showed fair results. The summation of these two results indicated an overall satisfactory result of 100%. Superficial punctate keratopathy was the most common complication (38.5%), but most of them were transient and improved with time. Other complications were entropion (8.4%) and peripheral corneal opacity (2.4%). CONCLUSIONS: We conclude that frontalis sling using autogenous fascia lata may be the best method for ptosis management in patients who have a severe ptosis with poor levator function.

Comparison of Frontalis Sling and Levator Resection for Recurrence after Frontalis Sling in Congenital Ptosis

PURPOSE: To compare the success rate of two procedures frontalis sling operation and maximal levator resection for recurred congenital ptosis. METHODS: In the 44 eyes in 30 patients who had recurrence after frontalis sling using banked fascia lata, 21 eyes received frontalis sling operation using autogenous fascia lata (Group I), and the other 23 eyes received maximal levator resection with aponeurotic approach (Group II). Follow up was made at one month, three months, six months and one year after the operation. RESULTS: Six months after the operation, Group I showed 81.0% while Group II showed 78.3% in success rate. One year after the operation, Group I had 76.2%, while Group II had 73.9% in success rate. There were no significant statistical difference between the two groups (p=0.744, 0.707). CONCLUSIONS: In cases of recurrence after frontalis sling using banked fascia lata in treating congenital ptosis patients, we found the frontalis sling using autogenous fascia lata to be effective. The maximal levator resection may be used as an alternative procedure.

The Preventive Effect of Porous Polyethylene Sheet on the Slippage of Prolene(R) Loop Placed in the Subcutaneous Tissue of Rabbits

PURPOSE: To investigate the role of porous polyethylene sheet in preventing the recurrence of ptosis after frontalis sling with Prolene(R) and the safety of porous polyethylene sheet. METHODS: Prolene(R) was placed subcutaneously in the thigh of white rabbits. In one group, Prolene(R) was placed with porous polyethylene sheet (treated group) and in the other group, Prolene(R) was placed without porous polyethylene sheet (control group). Prolene(R) was tightened and the loosening of the skin was evaluated at 1, 2, 4 and 8 weeks postoperatively. At the same time, the occurence of complications such as infection, granuloma formation was observed. Histologic examination was done at 2, 4 and 8 weeks postoperatively. RESULTS: In the treated group, skin loosening was progressed significantly for 2 weeks (p<0.05, Mann-Whitney U test) but thereafter there was no significant progression. In control group, skin loosening was progressed for 8 weeks (p<0.05, Mann-Whitney U test). Skin loosening was more severe in the control group at each follow-up evaluation (p<0.05, Wilcoxon signed ranks test). No complication was observed during the follow-up period of 8 weeks. On histologic examination, inflammatory reaction and fibrosis ere seen around Prolene(R) in the control group and fibrovascular ingrowth into the pores of porous polyethylene sheet was seen in the treated group. CONCLUSIONS: This study shows that porous polyethylene sheet can be safely used to prevent the slippage of Prolene(R) and the use of porous polyethylene sheet will be helpful in preventing the recurrence of ptosis after frontalis sling with Prolene(R).

Frontalis Suspension Using Preserved Fascia Lata for Severe Congenital Ptosis Under 2 years of Age

PURPOSE: To investigate the effect of frontalis sling operation with preserved fascia lata before 2 years of age when amblyopia has existed or is suspiscious. METHODS: We reviewed the medical charts of ptosis patients who undergone frontalis sling with preserved fascia lata before 2 years of age from December 1994 through February 2000. Thirty four patients was included. RESULTS: There were 21 men and 13 women with ages ranging from 5 to 23 months(mean, 13.4 months). With a mean follow-up of 22 months(range 6-60months), 30 patients(88%) achieved normal or near normal eyelid position. Four slings eventually failed, requiring repeat procedure with autogenous fascia lata(2 cases) or preserved fascia lata(1 case). Three patients achieved good results. CONCLUSIONS: Our findings suggest that the frontalis sling using preserved fasica lata has good potential for ptosis management in children before 2 years of age

Use of Temporalis Fascia for Frontalis Sling

PURPOSE: A wide variety of surgical materials have been used for blepharoptosis such as catgut, silicone, 4-0 nylon polyfilament cable-type ophthalmic suture (Supramid(R)), autogenous tendon (palmaris longus),banked sclera, dura mater, fascia lata, and temporalis fascia. The aim of this study was to evaluate the effect of frontalis suspensory surgery with temporalis fascia. METHODS: The authors studied 91 frontalis slings (71 patients) performed from 1993 to 1999 at our hospital for repair of blepharoptosis. Results with temporalis fascia (group A) as the suspensory material were compared to those with autogenous (group B) and preserved (group C) fascia lata. RESULTS: The success rates of group A (31 lids 21 patients), group B (28 lids 24 patients), group C (32lids 26 patients) were 80.6%, 75%, 78.1% respectively. But there was no statistically significant difference in each groups (P>0.05). CONCLUSIONS: We concluded that temporalis fascia for frontalis sling could be used as suspensory material successfully. Moreover, long term and further evaluations must be considered.

A Clinical Study on Surgical Results of Frontalis Sling in Relation to the Operative Age

To evaluate and compare the efficacy of frontalis sling using fascia lata by the operative ages. Thirty-two congenital blepharoptosis patients(36 eyes)were divided into three groups: Group 1(below 2 years old, 12 eyes), Group 2(between 3 years and 5 years old, 14 eyes)and Group 3(over 6 years old, 10 eyes). Frontalis sling by double triangle of Crawford was performed with fascia lata, and were followed up for 1, 3 and 6 months. Success rate of frontalis suspension operation is graded as poor(below 1mm), fair(2 mm)and good(above 3 mm)based on MRD 1: In Group 1; 0%, 8.3%, 91.7%at 1 month, 16.7%, 33.3%, 50%at 3 months, 50%, 33.4%, 16.6%, at 6 months. In Group 2; 0%, 7.2%, 92.8% at 1 months, 0%, 14.3%, 85.7% at 3 months, 14.3%, 14.3% 71.4% at 6 months. n Group 3; only 10%had fair at 6 months, most had good results. There were congenital blepharoptosis combined with systemic disease and reoperations(2 cases) were done by with frontalis sling in only group 1. Therefore, it is suggested that the correction of congenital blepharoptosis be delayed until the child is 3-5 or above 6 years old, if the incidence of amblyopia is small.

Frontalis Sling Operation Using Preserved Fascia Lata

In this prospective study, 208 cases of ptosis were repaired using dried preserved fascia lata as suspension material for frontalis sling procedure during 1990 to 1996. The average age at operation was 9.2 years with the range of 2 months to 56 years. One hundred forty one patients (91.0%) of the 155 patients with follow-up of more than 3 months and 99 (90.8%) of the 109 patients with follow-up of more than 6 months showed satisfactory results respectively. Among 12 unsatisfactory cases six patients underwent reoperation and achieved satisfactory results. Exposure keratitis was the most common complication (39.4%)but most of them were transient. The authors report frontalis sling operation using preserved fascia lata with 96.3% of success rate with few complications.

The Operation of Unaffected Normal Eye in Unilateral Ptosis

Moderate to severe unilateral ptosis has previously been treated with levator resection or frontalis sling and cosmetic double fold in the opposite eyelid. This method often resulted in undesirable asymmetrical lid lag phenomenon in down gaze. From December 1991 to December 1994, we treated 65 cases of unilateral ptosis with frontalis sling or levator resection, and simultaneously cosmetic frontalis sling have been performed in the unaffected normal eyes of 41 patients and cosmetic double fold have been performed in the unaffected normal eyes of 11 patients. After 6 months of operation, authors survey the patients content. The number of cases of content were 4(36.36%) in 11 cosmetic double fold group and 31(75.6%) in 41 cosmetic frontalis sling group. The content after cosmetic frontalis sling was higher than cosmetic double fold. Asymmetrical lid lag phenomenon on downward gaze which is inevitable complication postoperatively was reduced by means of cosmetic frontalis sling of unafeected normal eye in unilatral ptosis. The authors expect that the patient will be more satisfied with the result of symmetrical lid lag in down gaze after cosmetic frontalis sling of unaffected normal eye in aesthetic aspect.

A Clinical Report on the Use of Autogenous Levator Muscle Transposition and Bilateral Frontalis Sling for Ptotic lid in Neurogenic Blepharo-ptosis

The authors performed frontalis sling operation using autogenous levator muscle transposition for ptotic lid between February, 1989 and March, 1993. Four cases were Marcus-Gunn ptosis and one case was paralytic ptosis with aberrant regeneration in patient with oculomotor nerve palsy. The postoperative surgical results were satisfactory cosmetically.