|Year : 2017 | Volume
| Issue : 2 | Page : 502-506
Comparison of fasica lata and prolene suture in frontalis suspension surgery: frontalis muscle suspension
Hassan G Farahat, Nermeen M Badawi, Sameh S Mandour, Sara A Nage
Departement of Ophthalmology, Faculty of Medicine, Menoufiya University, Shebin el kom, Menoufia, Egypt
|Date of Submission||17-Aug-2016|
|Date of Acceptance||04-Oct-2016|
|Date of Web Publication||25-Sep-2017|
Sara A Nage
Department of Ophthalmology, Faculty of Medicine, Menoufia University, Shebin el kom, Menoufia, 32511
Source of Support: None, Conflict of Interest: None
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.
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 group I (20 eyelids), the upper-eyelid tarsus was suspended to the frontalis muscle using autogenous fascia lata. In group II (20 eyelids), the upper-eyelid tarsus was suspended to the frontalis muscle using a ribbon of 0.3 mm Gore-tex sheet. In group III (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.
At 12 months postoperatively (end of the follow-up period), there was no statistically significant difference between group I and group II regarding eyelid level. Fascia lata-related complications were detected in three eyelids of group I. Gore-tex-related complications were detected in five eyelids of group II. Prolene-related complications were detected in eight eyelids of group III. There was no statistically significant difference in complications between the three groups. The recurrence rate was 5% (one of 20 eyelids) in group I, 10% (two of 20 eyelids) in group II, and 40% (eight of 20 eyelids) in group III. The difference in recurrence rates was statistically nonsignificant.
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|| |
Frontalis sling operation is the classic procedure adopted for treatment of upper-eyelid ptosis with poor levator function . 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 . 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 .
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|| |
This is a prospective randomized study conducted on 60 eyelids of 40 patients 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 4 mm excursion on looking up from a downward gaze). Exclusion criteria included presence of recurrent ptosis, having levator muscle function of more than 4 mm, or history of previous upper-eyelid surgery. Patients were randomly enrolled into three groups. Group I included 20 eyelids of 13 patients who underwent frontalis suspension using autogenous fascia lata. Group II included 20 eyelids of 15 patients who underwent frontalis suspension using Gore-tex sheet. Group III included 20 eyelids of 12 patients 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 1 mm or more than the immediate stable postoperative level.
As for group I, surgery was performed under general anesthesia in all patients older than 3 years because of the need to retrieve the fascia lata. The upper eyelid was infiltrated with 2% lidocaine with 1:100 000 epinephrine.
An autogenous fascia lata strip of about 13 cm long and 3 mm 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 ~10 mm apart were marked 3 mm 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 group II, surgery was performed under general anesthesia in all children. The upper eyelid was infiltrated with 2% lidocaine with 1:100 000 epinephrine. Crease incision was marked and made, followed by dissection of the orbicularis muscle to expose the tarsus. A single suprabrow incision was made, centered between the medial and lateral limbus. A ribbon of 25 × 6 mm was cut from the Gore-tex sheet, measuring 0.3 mm in thickness. The ribbon was cut at one end along its long axis for 15 mm 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 group III, surgery was performed under general anesthesia in all patients The upper eyelid was infiltrated with 2% lidocaine with 1:100 000 epinephrine. The same technique was performed in group III using prolene suture as in the fascia lata group.
Statistical analysis was performed using SPSS, version 16 (IBM corporation, Somers, New York, 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|| |
In group I the mean age was 9.07 ± 3.4 years (range: 4–15 years); seven (53.8%) cases were male and six (46.2%) cases were female. In group II the mean age was 8.4 ± 4.1 years (range: 3–16 years); eight (53.3%) cases were male and seven (46.7%) cases were female. In group III the mean age was 7.08 ± 3.89 years (range: 3–14 years); five (41.7%) cases were male and seven (58.3%) cases were female [Table 1]. One month postoperatively, the mean MRDI was 3.61 ± 0.5 mm in group I, 3.33 ± 0.61 mm in group II, and 3.33 ± 0.61 mm in group III, with no statistically significant difference between the three groups (P = 0.685). At 12 months postoperatively, the mean MRDI was 3.46 ± 0.5 mm in group I, 3.06 ± 0.7 mm in group II, and 2.6 ± 0.65 in group III, 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) [Table 2],[Table 3],[Table 4].
|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 group III had undercorrection, which required revision in the first postoperative week. Undercorrection did not occur in groups I and II.
One eyelid each had overcorrection in groups I, II, and III (5%). Gore-tex-related complications were detected in three eyelids of group II (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 group III (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 group I. Donor site complications in group I were in the form of herniation of vastus lateralis muscle in 1 case. There was significant difference in complications between the three groups [Table 5].
The recurrence rate was 5% (one of 20 eyelids) in group I, 10% (two of 20 eyelids) in group II, and 40% (eight of 20) in group III. The difference between groups I and II was statistically nonsignificant (P = 0.648). The difference between groups I and III was statistically significant (P = 0.008). The difference between groups I and II was statistically noninsignificant (P = 0.648). The difference between groups II and III was statistically significant (P = 0.028).
| Discussion|| |
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 . 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 .
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 . 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 group I 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 group II. For example, infection occurred in two (10%) eyelids and was treated with intensive systemic antibiotics. Overcorrection and hematoma occurred in one each (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 et al. , 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 1 month. 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 . 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 .
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 group III, there were three (15%) eyelids complicated 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 1 month. 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 et al. 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 , infection.
The recurrent ptosis rate of autogenous fascia lata has been reported to be as low as 5%; the complication rate of fascia lata was 5%; the complication was due to overcorrection in one eyelid after 6 months 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 2 weeks); 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.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]