Severe ptosis in children represents a significant problem in pediatric ophthalmology. The severity of ptosis is generally correlated with the degree of levator function. When the levator function is poor (less than 4 mm), the main cause is anomalous innervation of the muscle during embryogenesis.1 In these cases, frontalis suspension is the optimal procedure. This surgical approach links contraction of the frontalis muscle directly to the upper eyelid, thereby clearing the central visual axis.
Several different materials and surgical techniques have been used to achieve frontalis suspension.2,3 The purpose of the current study was to demonstrate the authors' collective experience in the use of braided polyester (Ethibond EXCEL; Ethicon, Somerville, NJ), a low-cost and readily available material, in the management of severe or recurrent ptosis in children and young adults. The authors also compared the results of two surgical techniques used in brow suspension for congenital ptosis in the patient cohort.
Patients and Methods
This was a retrospective, non-randomized record review of 30 patients (43 eyelid procedures) affected by congenital or severe acquired ptosis who underwent frontalis suspension with braided polyester from 2008 to 2016. All surgeries were performed under general anesthesia. The study was approved by the Research Committee of the Hospital Metropolitano (Quito, Ecuador) and the Billings Institutional Review Board (Billings, Montana).
Seventeen patients had unilateral ptosis and 13 had bilateral ptosis. The study included 16 males and 14 females. Age at time of surgery ranged from 10 to 213 months (mean age: 68 months). Average follow-up at the final recorded visit was 38.6 months (range: 6 to 96 months).
Most (25) patients had a diagnosis of severe congenital ptosis. The remaining patients included 1 with blepharophimosis syndrome, 2 with congenital fibrosis of extraocular muscles, and 1 with Kearnes–Sayer syndrome. One patient had sustained post-traumatic bilateral III nerve palsy (Figure 1). Sixteen of the 43 eyelids had undergone previous ptosis surgery. All patients had minimal levator function (0 to 4 mm) documented prior to surgical intervention.
A 14-year-old girl with complete bilateral III nerve palsy (A) before and (B) after strabismus surgery and frontalis suspension with braided polyester (48 months' follow-up).
For each case, the following information was documented: preoperative diagnosis, visual acuity (or fixation preference), medical comorbidities, previous eyelid surgery performed (if any), type of procedure performed, thickness of the suture used, palpebral fissure height, and marginal reflex distance (MRD1) measured preoperatively and postoperatively. Palpebral fissure height, levator function, and MRD1 were measured using a transparent metric ruler with the patient's head maintained in a neutral position. Observation of the Krimsky reflex with the patient fixating on a point source of light enabled determination of the MRD1 both before and after surgical intervention. All complications were documented, including overcorrection and undercorrection, granuloma formation, and localized cellulitis.
Two surgical techniques were used depending on the surgeon's preference: the base-down triangle technique as first described by Wright (and modified by Crawford)4,5 and the Fox pentagon technique.6 In both approaches, suture material was passed subcutaneously (closed technique) from the brow frontalis muscle layer directly into the upper eyelid without direct tarsal fixation. The base-down triangle technique (2 sutures, 3 eyelid margin incisions/3 brow incisions) was used for 23 eyelids and the Fox pentagon technique (1 suture, 2 eyelid margin incisions/3 brow incisions) was used in the remaining 20 eyelids (Figure 2). Three different thicknesses of the braided polyester suture were used: braided polyester 2-0 (in 28 eyelids), #1 (in 1 eyelid), and #2 (in 14 eyelids).
(Left) Base-down triangle technique and (right) Pentagon technique.
The postoperative effectiveness of braided polyester in elevating the upper eyelid was evaluated by determining the eyelid fissure height, the MRD1, and the recurrence of ptosis. Functional success was defined as clearing of the central visual axis resulting in a postoperative MRD1 of at least 1 mm without chin-up posture.
Functional success was obtained in 90.6% of the cases (39 of 43 procedures). The MRD1 increased an average of 2.09 mm overall (2.51 mm with the base-down triangle technique and 1.70 mm with the Fox pentagon technique). This difference was of borderline statistical significance (P = .05). The palpebral fissure height increased an average of 3.67 mm overall (4.60 with the base-down triangle technique and 2.45 mm with the Fox pentagon technique). This difference was highly statistically significant (P = .00027). The base-down triangle technique appeared to be superior to the Fox pentagon technique in the current series (Table 1). This difference occurred in each surgical data set (single surgeon) in which both techniques were used.
Results Comparing Base-down Triangle Versus Pentagon Technique and MRD1 Versus VPF
Postoperative complications included untied suture (n = 2), suture dehiscence (n = 1), cellulitis (n = 2), and granuloma (n = 1).
Frontalis suspension can be achieved using several different suspension materials. Two general categories of materials are used for this procedure: endogeneous and exogenous. Endogenous materials include preserved7–9 or fresh10 autogenous fascia lata, temporalis fascia,11 palmaris longus tendon,12 and umbilical vein.13 Exogenous materials include most commonly silicone rod,14–16 Mersilene mesh (Ethicon),17,18 Supramid (S. Jackson, Alexandria, VA),19 and Gore-Tex (W.L. Gore and Associates, Newark, NJ).20,21
Historically, the most commonly used material for performing frontalis suspension is autogenous fascia lata. The use of this material was first described by Payr in 1908.4 In 1928, Wright22 further popularized the use of fascia lata as a satisfactory suspensory material for the surgical treatment of congenital ptosis. For many surgeons, this represents the ideal material for brow suspension.23
Autogenous fascia lata (harvested from the patient's thigh) usually provides optimal results. However, some surgeons are reluctant to stray from familiar territory in the upper eyelid. In addition, obtaining autogenous fascia lata in patients younger than 4 years may not be possible due to inadequate femur length and the immaturity of the fascia lata.4 The potential comorbidity of harvesting autogenous fascia lata from a separate operative site can be significant. Wheatcroft et al.24 reported a series of 24 consecutive patients; 67% of patients described pain on walking lasting from 1 to 30 days, 38% demonstrated limping in the early postoperative period, and 38% complained of a cosmetically undesirable wound over the long term.
Preserved fascia offers a reasonable alternative but has been associated with a higher recurrence rate in several studies.6–9 Silicon rods have also been a popular exogenous material used in frontalis suspension. However, some investigators have noted it has a high rate of extrusion.23
Other exogenous materials, including Supramid and other multifilament cable sutures, have also been used frequently, but the rate of recurrence is high (up to 28%). This may occur as sutures erode into the surrounding tissues, thus producing recurrent ptosis.25 Cost continues to remain a significant issue in the use of many of these materials.2,3,23
The use of braided polyester for frontalis suspension has been reported and discussed in two published studies. In the first study, braided polyester (Ticron; United States Surgical, Norwalk, CT) was used in a small series of 11 cases.2 Among these 11 cases, 1 infection and 3 recurrences were reported, all within the first 6 months. The diameter of the suture used in this series was not noted.2 In the second study, braided polyester (Ethibond 4-0; Ethicon) was compared to polytetrafluoroethylene.21 Their series consisted of 30 cases and included the following complications: 1 slippage of the knots, 1 bilateral abscess, and 1 bilateral suture granuloma. They also noted that the amount of ptosis correction achieved was significantly better in the group where polytetrafluoroethylene was used.21
The material used in these two articles is not directly comparable to the material used in the current study. Ticron is braided polyethylene terephthalate coated with silicone, whereas Ethibond is made of braided polyethylene terephthalate coated with polybutylate for easier tying.26 In the second study,21 the thickness of the Ethibond used was 4-0, which is considerably smaller in diameter than the size 2-0, #1, or #2 braided polyester used in the current study.
Braided polyester is not degraded and likely produces a degree of fibrovascular ingrowth due to the braided nature of its composition. This may assist in maintaining the functionality of the suspension procedure for a longer period.
In our experience, other important advantages of this material include the following:
Availability: this is a suture found in any surgical unit because it is used in many other types of general surgical procedures.
Ease of handling: this suture is easy to tie, the knots are easy to bury, and the material itself is easy to pass within the muscular layers of the frontalis and orbicularis.
Availability of different thickness of the suture: although not examined in the current study cohort, thinner sutures may be more appropriate in infants and toddlers and larger diameter suture material may be more suitable for use in older children and young adults.
Some varieties of braided polyester (ie, CX22D 2-0 and X406T #2) have a large double-armed tapered semi-circular needle attached to the suture, thereby eliminating the need to use the Wright needle (Figure 3).
Ethibond X406T (Ethicon, Somerville, NJ) has a large double-armed tapered semi-circular needle attached to the suture suitable to perform the procedure, eliminating the need to use a Wright needle.
Long interval of success: one of the current patients had 8 years of follow-up, with a continued clear visual axis noted (Figure 4).
Preoperative (upper row) and postoperative (lower row) pictures of the patients with the longest follow-up. (A) 96 months, (B) 67 months, (C) 38 months, and (D) 56 months.
Low cost of this material compared to other exogenous materials makes it ideal for use in developing countries (Figure 5).
Cost of various sling materials. Supramid is manufactured by S. Jackson, Alexandria, VA, and Ethibond is manufactured by Ethicon, Somerville, NJ.
Low incidence of complications found in the current patients (6 of 43 cases).
The observation that this material has worked in cases where other materials have failed.
The green color of the suture makes it easy to recognize if removal is necessary.
A recent study comparing open and closed techniques with silicone rod for brow suspension included a comment that defining success in brow suspension is often “widely divergent” and is dependent on both the authors' viewpoint and the precise definition of postoperative success.27 We agree with Galindo-Ferreiro et al.27 that comparison between studies should be interpreted with caution. The current study group elected closed suture placement and found that the base-down triangle approach was more effective in elevating the upper eyelid, and therefore increasing the vertical palpebral fissure; this occurred within each surgical data set (single surgeon) in which both techniques were used.
Weaknesses of the current study include the retrospective nature, non-masked observers, and different surgeons. Although ptosis etiology was not identical in all cases, levator function was uniformly poor. Delayed undercorrection could also potentially occur with more prolonged follow-up.
The use of braided polyester for frontalis suspension in the treatment of severe congenital ptosis appeared to be both safe and effective in the authors' collective experience. This material is easy to obtain and use, resulted in few complications, and produced a longstanding effect in clearing the visual axis. The base-down triangle technique was demonstrated to be superior to the Fox pentagon technique in the current patient cohort. The low cost of braided polyester makes it especially useful in developing countries where the cost and availability of other materials can represent a significant barrier to treatment.
- Lemagne JM, Colonval S, Moens B, Brucher JM. Anatomical modification of the levator muscle of the eyelid in congenital ptosis [in French]. Bull Soc Belge Ophthalmol. 1992;243:23–27.
- Wasserman BN, Sprunger DT, Helveston EM. Comparison of materials used in frontalis suspension. Arch Ophthalmol. 2001;119:687–691. doi:10.1001/archopht.119.5.687 [CrossRef]
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- Crawford JS. Repair of ptosis using frontalis muscle and fascia lata. Trans Am Acad Ophthalmol Otolaryngol. 1956;60:672–678.
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- Qiu SS, Hontanilla B. Congenital ptosis of the upper eyelid corrected by a modified frontalis suspension technique using autogenous tendon. Ann Plast Surg. 2011;67:129–133. doi:10.1097/SAP.0b013e3181f3e5eb [CrossRef]
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Results Comparing Base-down Triangle Versus Pentagon Technique and MRD1 Versus VPF
|Parameter||Base-down Triangle (23 Procedures)||Fox Pentagon (20 Procedures)||P|
|MRD1||2.51 mm||1.70 mm||.05|
|VPF||4.60 mm||2.45 mm||.00027|