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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 2  |  Page : 502-506

Comparison of fasica lata and prolene suture in frontalis suspension surgery: frontalis muscle suspension


Departement of Ophthalmology, Faculty of Medicine, Menoufiya University, Shebin el kom, Menoufia, Egypt

Date of Submission17-Aug-2016
Date of Acceptance04-Oct-2016
Date of Web Publication25-Sep-2017

Correspondence Address:
Sara A Nage
Department of Ophthalmology, Faculty of Medicine, Menoufia University, Shebin el kom, Menoufia, 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.215450

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  Abstract 

Objectives
The aim of the study was to compare prolene suture, polytetrafluoroethylene sheet, and fascia lata for frontalis suspension surgery in the treatment of congenital ptosis with poor levator function.
Background
Eyelid frontalis suspension surgery is a common operative procedure used to correct severe blepharoptosis in eyes with poor levator muscle function. The main indication for frontalis suspension surgery is severe blepharoptosis secondary to myogenic, neurogenic, mechanical, and traumatic disorders.
Patients and methods
Eyelids were divided into three groups. In groupI(20 eyelids), the upper-eyelid tarsus was suspended to the frontalis muscle using autogenous fascia lata. In groupII(20 eyelids), the upper-eyelid tarsus was suspended to the frontalis muscle using a ribbon of 0.3mm Gore-tex sheet. In groupIII(20 eyelids), the upper-eyelid tarsus was suspended to the frontalis muscle using prolene suture. Follow-up of eyelid level and reporting of postoperative complications and incidence of recurrence were done.
Results
At 12months postoperatively(end of the follow-up period), there was no statistically significant difference between groupI and groupII regarding eyelid level. Fascia lata-related complications were detected in three eyelids of groupI. Gore-tex-related complications were detected in five eyelids of groupII. Prolene-related complications were detected in eight eyelids of groupIII. There was no statistically significant difference in complications between the three groups. The recurrence rate was 5%(one of 20 eyelids) in groupI, 10%(two of 20 eyelids) in groupII, and 40%(eight of 20 eyelids) in groupIII. The difference in recurrence rates was statistically nonsignificant.
Conclusion
Fascia lata is a good sling material, followed by Gore-tex sheet. Prolene suture has many complications and is associated with a high rate of recurrence.

Keywords: fascia lata, frontalis suspension, gore.tex, prolene, ptosis


How to cite this article:
Farahat HG, Badawi NM, Mandour SS, Nage SA. Comparison of fasica lata and prolene suture in frontalis suspension surgery: frontalis muscle suspension. Menoufia Med J 2017;30:502-6

How to cite this URL:
Farahat HG, Badawi NM, Mandour SS, Nage SA. Comparison of fasica lata and prolene suture in frontalis suspension surgery: frontalis muscle suspension. Menoufia Med J [serial online] 2017 [cited 2019 Aug 19];30:502-6. Available from: http://www.mmj.eg.net/text.asp?2017/30/2/502/215450


  Introduction Top


Frontalis sling operation is the classic procedure adopted for treatment of upper-eyelid ptosis with poor levator function[1]. In this procedure a sling material is used to connect the upper-eyelid tarsus to the frontalis muscle. The patient then uses the frontalis muscle to open the eyelids[2]. Because of its long-lasting effect and few complications, the fascia lata has been established as the gold standard sling material for this procedure. However, several sling materials have been used, such as expanded polytetrafluoroethylene(Gore-tex) and prolene, to improve the outcomes and to avoid the drawbacks of the fascia lata [3].

The aim of this study is to compare the outcomes from the use of prolene suture, fascia lata, and Gore-tex as a frontalis sling material fixed directly to the tarsus after exposure through an open technique.


  Patients and Methods Top


This is a prospective randomized study conducted on 60 eyelids of 40patients who attended the health service in Menoufia University Hospitals in Shebin El Kom from August 2013 to May 2016. The patients included in the study had severe ptosis with poor levator function(less than 4mm excursion on looking up from a downward gaze). Exclusion criteria included presence of recurrent ptosis, having levator muscle function of more than 4mm, or history of previous upper-eyelid surgery. Patients were randomly enrolled into three groups. GroupI included 20 eyelids of 13patients who underwent frontalis suspension using autogenous fascia lata. GroupII included 20 eyelids of 15patients who underwent frontalis suspension using Gore-tex sheet. GroupIII included 20 eyelids of 12patients who underwent frontalis suspension using prolene suture.

A complete ophthalmic examination, including best-corrected visual acuity testing, slit-lamp examination, fundus examination, and examination of ocular motility, was carried out on all patients. Margin reflex distance I(MRDI) and levator muscle function were documented. Corneal sensations, manifestations of dry eye, and presence or absence of Bell's phenomenon were checked. Written informed consent was taken from all patients after explanation of the procedure and its consequences. Follow-up examinations were performed in all patients to assess eyelid position and symmetry and any postoperative complications. Recurrence of ptosis was defined by a decrease of MRDI by 1mm or more than the immediate stable postoperative level.

Surgical technique

As for groupI, surgery was performed under general anesthesia in all patients older than 3years because of the need to retrieve the fascia lata. The upper eyelid was infiltrated with 2% lidocaine with 1:100000 epinephrine.

An autogenous fascia lata strip of about 13cm long and 3mm wide was passed in a closed cerclage-type manner through skin entry by way of two supralash and three suprabrow incisions forming a single loop design. Two stab incision sites that were~10mm apart were marked 3mm above the lash line that was centered over the area of the desired maximal elevation. Another two stab incision sites were marked above the eyebrow, approximately in line with the lateral and medial canthi; additional stab incision sites were made above the eyebrow in the middle of the previous incisions.

The fascia lata strip was threaded, using Wright needle, in a suborbicularis plane between the five stab wounds forming a pentagon(Fox method). The two ends of the fascia strip were retrieved from the middle suprabrow incision tied together and fixed to the underlying frontalis muscle using 5/0 vicryl stitches after adjustment of the upper-eyelid level. The incision sites were closed with 6/0 vicryl suture.

In groupII, surgery was performed under general anesthesia in all children. The upper eyelid was infiltrated with 2% lidocaine with 1:100000 epinephrine. Crease incision was marked and made, followed by dissection of the orbicularis muscle to expose the tarsus. Asingle suprabrow incision was made, centered between the medial and lateral limbus. A ribbon of25 × 6mm was cut from the Gore-tex sheet, measuring 0.3mm in thickness. The ribbon was cut at one end along its long axis for 15mm forming an inverted Y configuration. Dissection was performed through the orbicularis muscle to expose the tarsus. The two limbs of the split end of the Gore-tex ribbon were anchored directly onto the tarsus with four 6/0 vicryl sutures. The other end was passed from the crease incision to the suprabrow through a deep, pretarsal passage. The Gore-tex ribbon was then tied carefully to the underlying frontalis muscle using 5/0 vicryl stitches and adjusted to achieve the desired eyelid elevation and contour. The skin incision sites were closed with 6/0 silk sutures.

In groupIII, surgery was performed under general anesthesia in all patients The upper eyelid was infiltrated with 2% lidocaine with 1:100000 epinephrine. The same technique was performed in groupIII using prolene suture as in the fascia lata group.

Statistical analysis

Statistical analysis was performed using SPSS, version16 (IBM corporation, Somers, NewYork, USA). The paired t-test was used to detect the difference between preoperative and postoperative data in the study groups, and the independent-sample test was used to calculate the difference between the two groups in numerical variables. Fisher exact and Pearson c2-tests were used to calculate the difference between groups in terms of categorical variables.


  Results Top


In groupI the mean age was 9.07±3.4years (range: 4–15years); seven(53.8%) cases were male and six(46.2%) cases were female. In groupII the mean age was 8.4±4.1years(range: 3–16years); eight(53.3%) cases were male and seven(46.7%) cases were female. In groupIII the mean age was 7.08±3.89years (range: 3–14years); five(41.7%) cases were male and seven(58.3%) cases were female[Table1]. One month postoperatively, the mean MRDI was 3.61±0.5mm in groupI, 3.33±0.61mm in groupII, and 3.33±0.61mm in groupIII, with no statistically significant difference between the three groups(P=0.685). At 12months postoperatively, the mean MRDI was 3.46±0.5mm in groupI, 3.06±0.7mm in groupII, and 2.6±0.65 in groupIII, with no statistically significant difference between the three groups(P=0.656). However, there was a statistically significant difference between preoperative and postoperative MRDI values in each group(P=0.001)[Table2],[Table3],[Table4].
Table 1: Sex distribution in each group

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Table 2: Comparsion of preoperative and postoperative mean value of margin reflex distance I in the fascia lata group

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Table 3: Comparison of preoperative and postoperative mean value of margin reflex distance I in the polytetrafluoroethylene sheet group (n=20)

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Table 4: Comparison of preoperative and postoperative mean value of margin reflex distance I in the prolene group (n=20)

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Regarding complications, two(10%) eyelids in groupIII had undercorrection, which required revision in the first postoperative week. Undercorrection did not occur in groupsI and II.

One eyelid each had overcorrection in groupsI, II, and III(5%). Gore-tex-related complications were detected in three eyelids of groupII(two of them had infection at the suprabrow incision that was treated medically and one eyelid had Gore-tex exposure and was managed surgically as well). Prolene-related complications were detected in five eyelids of groupIII(three of them had infection at the suprabrow incision that was treated medically and two eyelids had prolene exposure and were managed surgically). No exposure or infection occurred in groupI. Donor site complications in groupI were in the form of herniation of vastus lateralis muscle in 1case. There was significant difference in complications between the three groups[Table5].
Table 5: Incidence of complications in the three groups (n=20)

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The recurrence rate was 5%(one of 20 eyelids) in groupI, 10% (two of 20 eyelids) in groupII, and 40%(eight of 20) in groupIII. The difference between groupsI and II was statistically nonsignificant(P=0.648). The difference between groupsI and III was statistically significant(P=0.008). The difference between groupsI and II was statistically noninsignificant(P=0.648). The difference between groupsII and III was statistically significant(P=0.028).


  Discussion Top


Frontalis suspension using autogenous fascia lata is still considered the gold standard for congenital ptosis repair. When a piece of free fascia is transplanted in the same animal, the fascia receives an adequate supply of lymph, which allows continuous survival of the graft[3]. Thus, autogenous fascia lata is considered to be a living graft, which can provide long-lasting adequate elevation of the upper eyelid. Further, the fascia lata sling has a low risk of complications such as infection, granuloma formation, extrusion, and breakage[4].

The current study was designed to compare the results from the use of autogenous fascia lata, Gore-tex sheet, and porolene suture for frontalis suspension in severe congenital ptosis with poor levator function over a 12-month follow-up period. There was no significant difference regarding age, sex, MRDI, and degree of levator excursion.

Gore-tex is a synthetic microporous polymer comprising nodules interconnected by multidirectional minute fibers[5]. It is one of the most biologically and chemically inert, biocompatible and autoclavable materials. However, Gore-tex is associated with a high risk for soft tissue complications, possibly caused by its highly porous nature, which allows for proliferation of bacterial contaminants and abscess formation. Although Gore-tex has many micropores, these pores are too small to allow tissue in-growth. In addition, its hydrophobic character also prevents tissue integration. Therefore, the removal of Gore-tex and length adjustment are easy because only the fibrovascular tissue surrounds Gore-tex.

In the current study, postoperative MRDI at follow-up visits was significantly larger than the preoperative level in each group independently. There was a statistically significant difference between the three groups regarding the operative time. Longer operative time was reported in groupI because of the time consumed in harvesting the fascia lata from the donor site. There was no statistically significant difference between the three groups regarding the complications over the follow-up period. However, there were complications with the use of polytetrafluoroethylene sheet in groupII. For example, infection occurred in two(10%) eyelids and was treated with intensive systemic antibiotics. Overcorrection and hematoma occurred in oneeach(5%) eyelid. Overcorrection was treated by reoperation after the first postoperative week and hematoma was treated medically. The recurrence rate was 10% in one eyelid. This agrees with the results of Hayashi etal.[5], who used the same technique for frontalis suspension with polytetrafluoroethylene sheet and found three(15%) eyelids complicated by infection(which responded to medical treatment) and two(10%) eyelids each with undercorrection and exposure of sling material. Undercorrection was treated by revision of surgery after 1month. Exposure of sling was treated by removal of the suture and by medical treatment. Hematoma occurred in two(10%) eyelids with prolene, but resolved spontenously. Overcorrection occurred in two(10%) eyelids and was treated by massage of the lid.

In the current study, the recurrence rate was 10% (three eyelids) in the fascia lata group, 16.7% (five eyelids) in the Gore-tex sheet group, and 40%(eight eyelids) in the prolene group. In another study by Nakaochi and colleagues who used the same technique for Gore-tex suspension, partial recurrence was found in 37% of cases among whom most were children. There was no need for redo surgery in any of these cases in the 1-year follow-up period of the study[6]. In addition, there was one case of exposure of the Gore-Tex sheet in a 71-year-old man who experienced more bleeding than the other patients, and wound recovery was slow[6].

Polypropylene suture is a monofilament suture(prolene) that is sometimes used for frontalis suspension surgery. Polypropylene suture are mainly used as a temporary suspension material to prevent amblyopia in young children who are planned to undergo surgery with autogenous fascia lata when they are older. The main advantages of the polypropylene suture are the low risk of scarring and soft tissue complications, easy removal, and no interference with future use of autogenous fascia lata. This suture can sometimes break and produces visible suture tension lines and causes deformity of the eyelid margin. The monofilament nature of this suture material impedes tissue integration, thereby causing slippage and ptosis recurrence. In prolene groupIII, there were three(15%) eyelidscomplicated by infection that responded to medical treatment, and two(10%) eyelids each with undercorrection and exposure of sling material. Undercorrection was treated by revision of surgery after 1month. Exposure of sling was treated by removal of the suture and by medical treatment. Hematoma occurred in two eyelids in the prolene group(10%) but resolved spontenously. Overcorrection occurred in two(10%) eyelids and was treated by massage of the lid. The recurrence rate was 40%(eight eyelids) in the prolene group. However, Chow etal. found that the recurrence rate with prolene was 22% and only one(4%) patient developed a complication in the form of wound infection. The high recurrence in our study may be due to[7],[8] infection.

The recurrent ptosis rate of autogenous fascia lata hasbeenreported to be as low as 5%; the complication rate of fascia lata was 5%; the complication was due to overcorrection in one eyelid after 6months due to contraction of the fascia lata but it was cosmetically and functionally acceptable and hence no surgical interference was needed. Donor site complication occurred in one(7%) case in the form of herniation of quadriceps muscle. It happened because of premature removal of the pressure bandage(less than 2weeks); therefore, the patient was referred to a plastic surgeon who confirmed the diagnosis clinically and by ultrasound and decided to reclose the wound. Further, hematoma occurred in one(5%) eyelid but resolved spontenously.

We concluded that the fascia lata is a good sling material followed by Gore-tex sheet. Prolene suture has many complications and is associated with a high rate of recurrence and is hence best avoided. However, more studies with a longer follow-up period are required to confirm our finding.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
MokashiA, REStead, AbercrombiLC. Brow suspension using 3-0 prolene. Eye 2011; 25:819–822.  Back to cited text no. 1
    
2.
ArajyZY. Open loop fascial sling for severe congenital blepharoptosis. JCraniomaxillofac Surg2012; 40:129–133.  Back to cited text no. 2
    
3.
BouazzaM, ElbelhadjiM, MchachiA, BenhmidouneL, AmraouiA. Treatment of congenital ptosis by frontalis suspension with monofilament polypropylene suture. JFr Ophtalmol2014; 37:520–525.  Back to cited text no. 3
    
4.
GazareenSS, DawoodAE, EllakwaAF, ElelaDH, SeragAA. The role of serum apelin in diabetic patients with retinopathy. Menoufia Med J 2016; 29:22–29.  Back to cited text no. 4
  [Full text]  
5.
HayashiK, KatoriN, KasaiK, KamisasanukiT. Comparison of nylon monofilament suture and polytetrafluoroethylene sheet for frontalis suspension. Am J Opthalmol2013; 155:654–663.  Back to cited text no. 5
    
6.
NakauchiK, MitoH, MimuraO. Frontal suspension for congenital ptosis using an expanded polytetrafluoroethylene(Gore-Tex) sheet: one year follow up. Clin Ophthalmol 2013; 7:131–136.  Back to cited text no. 6
    
7.
NgSG, ChowK, N Deva. Prolene frontalis suspension in paediatric ptosis. Eye 2011; 25:735–739.  Back to cited text no. 7
    
8.
MatayoshiS, PereiraIC, RossatoLA. Surgical treatment ofcongenital blepharoptosis. Rev Bras Oftalmol 2014; 73:154–160.  Back to cited text no. 8
    



 
 
    Tables

  [Table1], [Table2], [Table3], [Table4], [Table5]



 

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