Autogenous palmaris longus tendon as frontalis suspension material for ptosis correction in children

Surgical results of retroauricular fascia graft in frontalis suspension surgery: A case series study

Frontalis suspension surgery is commonly used for the repair of congenital ptosis and involutional blepharoptosis with poor levator function. Grafts for this procedure have been developed using a variety of different materials, each with advantages and disadvantages. The retroauricular fascia graft might be beneficial in this surgery. This article reports the surgical results of blepharoptosis, who were treated with the retroauricular fascia, which is a new autologous graft for the frontalis suspension technique. This case series study targeted patients with ptosis who underwent frontalis suspension surgery with the retroauricular fascia graft at Wakayama Medical University in Japan between May 2016 and May 2023. Patients with insufficient follow-up (<6 months) were excluded from the study. Eligible patients were categorized into one of the following three assessment groups: "good" (improvement of palpebral fissure height without laterality, Margin reflex distance-1 gap between right and left side <0.5 mm), "fair" (improvement of palpebral fissure height with laterality), or "poor" (poor improvement of palpebral fissure height). Thirty-five eyes in 25 patients were treated with the retroauricular fascia graft. The mean postoperative follow-up was 27 months. Eight patients were classified as good (32%), 15 as fair (60%), and two as poor (8%). Two patients (8%) had postoperative lagophthalmos. No patients had eyelash inversion, tarsal deformity, or recurrence of ptosis. Scars along the edge of the hairline were inconspicuous and there were no hypertrophic scars. Functional reconstruction of the eyelids using the retroauricular fascia graft technique is described here for the first time. This grafting technique may be a useful alternative for frontalis suspension surgery because it can be harvested with easy access and without leaving conspicuous scars.

Double Rhomboid Suture Technique for Congenital Ptosis

PURPOSE

Congenital ptosis is a troubling eye condition for pediatric ophthalmologists. There are many considerations to contemplate when deciding when to operate and which technique to use.

METHODS

A retrospective chart review of 69 pediatric patients treated for congenital ptosis using a double rhomboid frontalis sling with a nylon suture at a single tertiary care center.

RESULTS

For patients with more than 6 months of follow-up, there were 38 patients with 46 primary surgeries (22 [58%] males and 16 [42%] females). The average age at the first surgery was 39.34 ± 33.18 months. There was a mean follow-up time of 51.87 ± 53.79 months. There were 7 children who needed one revision and 1 child who needed a second revision, equaling a 23.9% rate of revision. Patients who had surgery before the age of 3 years had a statistically significant likelihood of needing a second surgery (chi-square test = 7.246, P = .007, 95% confidence interval = 0.027 to 0.687). It was also statistically significant (P < .05) that, throughout childhood, older patients were less likely to need a revision.

CONCLUSIONS

A double rhomboid frontalis sling using a nylon suture is an effective technique to treat congenital ptosis. This technique is easy to master and has a low cost compared to techniques involving autografts and allografts. It is also important to advise the family of the likelihood of a second surgery if there is a need to operate at a young age. [J Pediatr Ophthalmol Strabismus. 2018;55(2):117-121.].

Prevalence of Absence of Palmaris Longus and Its Association with Gender, Hand Dominance and Absence of FDS Tendon to Little Finger Among Malay Population

BACKGROUND

Palmaris Longus is being widely used in reconstructive, plastic and cosmetic surgeries due to its long tendon. It is the most readily available source for tendon grafting. The objective of this study was to determine the prevalence of absence of Palmaris Longus and its association with gender, hand dominance and absence of FDS (flexor digitorum superficialis) tendon to little finger among Malay population.

METHODS

An analytical cross sectional study design was used and a self-administered proforma was distributed for data collection. 1239 Malay secondary school children in Putrajaya were tested for absence of Palmaris Longus using Schaffer's test. 4 additional tests namely Thompson's test, Mishra's test I, Mishra's test II and Pushpakumar's 'two-finger sign' method were used to confirm its absence in respondents with negative Schaffer's test. Function of Flexor Digitorum Superficialis tendon to little finger was determined by flexing PIP of little finger while hyperextend the other fingers.

RESULTS

The prevalence of absence of Palmaris Longus was 11.7%. Left side absence of Palmaris Longus was much common. There was a significant association between absence of Palmaris Longus with gender in which female had higher prevalence of absence of Palmaris Longus than male.

CONCLUSIONS

In conclusion, the prevalence of absence of Palmaris Longus in Malay population was lower than Indian but higher than Chinese population. Females had higher prevalence of absence of Palmaris Longus and no association can be found with hand dominance and absence of Flexor Digitorum Superficialis tendon to little finger.

Congenital absence of the palmaris longus muscle: A meta-analysis comparing cadaveric and functional studies

The aim of our paper was to provide comprehensive data on the prevalence of absence of palmaris longus muscle (PLM) and its anatomical characteristics and conduct two separate meta-analyses comparing cadaveric and functional studies while identifying variation among different ethnic groups. An extensive search was conducted through the major electronic databases to identify eligible articles. Data extracted included prevalence of absence of PLM among subjects, ethnicity, laterality, side, and gender. Our main findings revealed that the absence of PLM is more frequently reported in functional studies. Moreover, functional tests likely overestimated the absence of PLM and recommend future studies to assess the validity of functional tests and use an imaging assessment prior to excluding the use of a palmaris longus tendon graft in patients in whom a function test identified the absence of PLM.

A Modified One-Stage Early Correction of Blepharophimosis Syndrome Using Tutopatch Slings

PURPOSE

To investigate the efficacy of a one-stage early correction of blepharophimosis-ptosis-epicanthus inversus syndrome (BPES), using bovine pericardium derived membrane (TUTOPATCH(®)) for the frontalis suspension.

METHODS

We prospectively studied 12 eyes from 6 patients (median age 14 months) affected by BPES with severe ptosis. All patients were submitted to a one-stage early correction of ptosis (frontalis suspension with TUTOPACH(®)) and telecanthus and epicanthus inversus. Upper margin reflex distance (MRD), nasal inner intercanthal distance (IICD), horizontal fissure length (HFL), and IICD/HFL ratio were evaluated using photographs.

RESULTS

The Wilcoxon signed-rank test showed a statistically significant difference between pre- and post-operative MRD, IICD, HFL, and the IICD/HFL ratio.

CONCLUSION

An early TUTOPATCH-assisted frontalis suspension, together with the correction of telecanthus and epicanthus inversus, is an effective procedure for BPES cases with severe ptosis.

Modified supramid brow suspension in paediatric ptosis

PURPOSE

To understand the safety and complication profile of the modified supramid brow suspension surgery in the paediatric ptosis.

DESIGN

Retrospective interventional case series.

METHODS

Review of medical notes of 32 patients who underwent supramid brow suspension surgery of the upper lid. Surgery was performed by a single surgeon at Great Ormond Street Hospital, London during 2007-2012. Complication rates were analysed.

RESULTS

Forty-six eyes of 32 patients underwent upper eye lid brow suspension surgery; 18 cases were unilateral and 14 bilateral. Mean follow-up period is 28 months after the surgery. Post-operative granulomatous reaction was noted in 6 eyes (13%) and prolonged exposure keratopathy in 2 eyes (4.3%). There were no cases of suture infection or exposure. No recurrence of ptosis was observed in any of the operated cases. Pupillary axis clearance was achieved in all eyes.

CONCLUSION

Modified brow suspension surgery using supramid for upper eyelid ptosis is a safe and clinically useful procedure with low complication rate.

Free transplantation of autogenous palmaris longus tendon in the repair of cicatricial ectropion of lower eyelid

Treatment of cicatricial lower eyelid ectropion is often difficult and requires surgical intervention. Numerous techniques have been developed over the years to treat the cicatricial lower eyelid ectropion. This article describes an effective surgical technique using the free transplantation of autogenous palmaris longus tendon in the repair of cicatricial lower eyelid ectropion. The operation was performed with the patient under local anaesthesia. After the contracture of the lower eyelid skin or conjunctiva had been thoroughly released, a palmaris longus tendon graft was obtained through small transverse incisions along the non-dominant forearm. The graft is suspended between the medial canthal ligament and lateral orbital rim with proper tension. Then a local skin flap was transferred to cover the wound at the lower eyelid. In this study, 15 patients were treated using autogenous palmaris longus tendon between December 2008 and October 2012. At the 9-18 months of follow-up assessment, there were no major complications reported with any of the cases, and all have achieved good function and satisfactory appearance of the lower eyelid. However, five patients (33%) still had lagophthalmos, but it was in remission. In conclusion, free transplantation of autogenous palmaris longus tendon in the repair of cicatricial ectropion of the lower eyelid is an effective procedure for cicatricial ectropion, the functional and cosmetic results were satisfactory, the recurrence rate is low. Especially for the moderate and severe ectropion this method is a good choice.

An alternative frontalis suspension technique: triband suspension--a modified Garcia's procedure

Blepharoptosis surgery is one of the most common oculoplastic procedures, and the aim is to clear the visual axis. Many surgical techniques for the correction of ptosis have been described and performed, but the operative approach is based on the extent of eyelid excursion, the amount of levator function, and the degree of ptosis.In this study, the frontalis sling procedure with triband suspension was performed on 32 eyelids of 23 patients. All the patients had visual loss because of blepharoptosis with only 0 to 3 mm of measurable levator function. Postoperatively, the palpebral fissure was increased in all the patients. The purpose of this study was to report the use of a modified frontalis sling procedure for congenital ptosis patients with minimal to no levator function. In conclusion, this modified frontalis sling technique if used maximizes the frontalis muscle, creating sufficient eyelid elevation, with stable effect over time.

Palmaris longus tendon as an autogenous expander for Brown's syndrome: a novel technique

INTRODUCTION

The palmaris longus tendon (PLT) is one of the most commonly used donor tendons in orthopedic and reconstructive surgery. We present a new surgical technique using this autogenous tissue for lengthening the superior oblique tendon in cases of moderate to severe Brown syndrome.

METHODS

Four children with Brown syndrome were selected, and consent was obtained. Preoperative motility assessment and intraoperative forced duction tests confirmed the diagnosis. PLT harvesting was performed under general anesthesia. Follow-up ranged from 12 to 21 months.

RESULTS

Preoperatively all patients demonstrated hypotropia of 16Delta to 30Delta with an abnormal head posture. Postoperatively all patients showed an improvement in hypotropia to <3Delta, with complete resolution of abnormal head posture. Improvement of elevation in adduction did not match that of the vertical deviation, but all patients had less restriction of elevation in adduction after surgery. No patients developed any of the complications encountered with a silicone expander (eg, extrusion, tendon-related inflammation, foreign body sensation, or consecutive superior oblique palsy), and none needed further surgery. Wrist function was completely normal in all patients postoperatively.

CONCLUSIONS

PLT is an autogenous tissue that allowed for controlled weakening of the superior oblique tendon, with minimal complications observed in four patients. More studies comparing PLT tendon expansion with other published methods are warranted.

The Long-Term Results of Frontalis Suspension Using Autogenous Fascia Lata in Children with Congenital Ptosis under 3 Years Old

Purpose. To describe the long-term results of frontalis suspension using autogenous fascia lata in children with congenital ptosis under 3 years old. Methods. Forty three-eyes of 35 patients were enrolled in the study. Frontalis suspension using autogenous fascia lata was performed in all patients. The postoperative eyelid level, ptosis recurrence, visual acuity, and cosmetic results were evaluated. Results. The mean age of the patients was 16.8 ± 9 months (7-36 months). The mean follow-up time was 52.8 ± 15 months (14-95 months). All patients had good (ptosis <2 mm) or moderate (2-3 mm ptosis) eyelid level after the operation. All patients achieved satisfactory cosmetic results. Succesfull harvesting was performed in all cases and no additional materials or surgical manipulation were needed during the surgery. Conclusion. Frontalis suspension using autogenous fascia lata can be used in children under 3 years old without harvesting problems. Surgical experience and good knowledge of anatomy are important factors for successful results after the surgery.

Unilateral ptosis correction with mersilene mesh frontalis sling in infants: thirteen-year follow-up report

PURPOSE

To assess surgical, visual, refractive, and aesthetic outcomes 13 years after mersilene mesh frontalis sling (MMFS) operation for severe unilateral congenital ptosis performed in 10 infants before 1 year of age.

METHODS

Longitudinal follow-up of an interventional case series by structured ocular examinations, external photographs, and questionnaire-based interviews.

RESULTS

Mean age at surgery was 6.9+/-2.7 months. After a mean follow-up of 13.0+/-0.6 years, one patient (10%) had recurrent ptosis with the upper lid 2 mm below the superior limbus at 3 months postoperatively. Best-corrected visual acuities were within two Snellen lines between the two eyes in all patients. Astigmatic errors were 1.20+/-1.00 D and 1.10+/-1.70 D between operated and unoperated eyes. Four patients had 2 mm lid lag on down-gaze and one of them had 2 mm lagophthalmos. Mean satisfaction scores (scale of 1 to 100) for lid position, cosmesis, function, and to the procedure were 83.3+/-11.8, 77.0+/-22.9, 89.4+/-5.5, and 86.8+/-6.3, respectively. No case of overcorrection, sling extrusion, stitch granuloma, or exposure keratopathy was noted.

CONCLUSIONS

In view of the low recurrence rate (10%) and absence of serious complication or need for revision after 13 years, the use of MMFS seems effective and feasible in infants less than 1 year old. Achieving compatible long-term stability, satisfactory aesthetic, and visual outcomes, MMFS may offer an alternative to delaying operations for autogenous fascia lata harvesting in infants requiring early ptosis correction.

Stability of silicone band frontalis suspension for the treatment of severe unilateral upper eyelid ptosis in infants

PURPOSE

To address the efficacy, safety, and stability of frontalis suspension of the upper eyelid with a silicone band for the treatment of severe congenital ptosis in infants.

METHODS

Data from 22 pediatric patients undergoing unilateral frontalis suspension with silicone band were retrospectively reviewed with a follow-up ranging from 18 to 30 months. The margin-reflex distance (MRD) and the corneal staining had been evaluated at each pre- and postoperative visit. Data were analyzed by analysis of variance and t test for paired data.

RESULTS

MRD was absent before surgery in all cases: it ranged from -1 mm to -4 mm (-2.4+/-0.8 mm). Immediately after surgery, it increased to 2.9+/-0.3 mm, and then progressively reduced by 0.6 mm within the first 3 months (p=0.001); a further reduction of 0.2 mm, occurring between 3 and 12 months after surgery, was not statistically significant. After the 12-month visit, no changes in MRD were found at follow-up for any patient. Corneal staining, which was present in five patients over the first 2 postoperative weeks, recovered without sequelae. Complications occurred in three eyes: overcorrection and corneal ulcer in one case requiring removal of the silicone band, one granuloma, and one extrusion of the silicone band from the upper frontal incision.

CONCLUSIONS

During the study period, the frontalis suspension with a silicone band was an effective and safe procedure. MRD values were stable between month 3 and the end of follow-up, although this series does not preclude the possible occurrence of blepharoptosis at longer time intervals.

Broad fascia fixation enhances frontalis suspension

PURPOSE

To report the use of a modified frontalis suspension procedure for congenital ptosis patients with minimal to no levator function.

METHODS

Retrospective, non-comparative case series of frontalis suspension by 2 surgeons over a 21-year period.

RESULTS

Frontalis suspension with broad fascia fixation was performed on 48 eyelids of 25 patients. All patients had visual obscuration due to blepharoptosis with only 0 mm to 2 mm of measurable levator function. Age ranged from 3 to 13 years. Minimum length of follow-up was 6 months (range, 6-174 months). The palpebral fissure was increased in all patients, improving their head position and unmasking their visual axis in primary gaze. Postoperatively, all patients developed transient exposure symptoms. There were no migrations, extrusions, infections, or granulomas. All patients achieved a satisfactory postoperative result based on eyelid position, function, and contour.

CONCLUSIONS

This modified frontalis suspension procedure maximizes frontalis muscle recruitment, creating powerful eyelid elevation with stable effect over time. The technique minimizes other procedures' pitfalls and advances in cosmesis are achieved with enhanced eyelid crease formation and adjustable eyelid contour.

A randomized clinical trial of two methods of fascia lata suspension in congenital ptosis

PURPOSE

To compare the results of 2 methods of upper eyelid sling placement with autogenous fascia lata in the treatment of congenital ptosis.

METHODS

In a randomized clinical trial, patients with congenital upper eyelid ptosis and poor levator function (<4 mm) were randomly assigned to either of 2 methods of upper eyelid sling placement: group A, bitriangular fascia sling (modified Crawford method), and group B, monotriangular fascia sling (modified Fox method).

RESULTS

This study included 30 upper eyelids (15 eyelids in each surgical group) of 19 patients (8 unilateral and 11 bilateral cases) with congenital ptosis. Mean increase in eyelid fissure height was 2.7 +/- 2.3 mm in group A and 3.4 +/- 2.2 mm in group B. Change in eyelid fissure in both groups was significant (p < 0.001, paired t test) but the intergroup difference was not (p = 0.4, independent sample t test). Early complications such as corneal epithelial defects and entropion and late complications such as undercorrection were comparable in the 2 groups. No patient experienced recurrent ptosis requiring reoperation in either group.

CONCLUSIONS

The monotriangular method of upper eyelid fascia sling placement can be used instead of the more popular bitriangular method. Advantages include less need for fascial tissue, less periocular scar formation, and a shorter period of anesthesia.

Correction of Blepharophimosis with Silicone Implant Suspensor

BACKGROUND

Blepharophimosis is a rare autosomal-dominant syndrome involving the periorbital region. It is characterized mainly by eyelid ptosis, palpebral phimosis, telecanthus, and epicanthus inversus.

METHODS

Ten patients ranging in age from 2 to 22 years who presented with blepharophimosis were retrospectively studied over the past 14 years; they had an average follow-up of 7 years and 5 months. They were treated at the Division of Plastic Surgery of the Faculty of Medicine, University of São Paulo. Eight patients presented with the complete form, including epicanthus, telecanthus, and severe palpebral ptosis, and two presented with the incomplete form. The epicanthi and telecanthi were corrected with Mustardé's technique, and the ptosis was treated by frontalis suspension with a soft, preformed silicone device called the silicone implant suspensor.

RESULTS

The results were classified as good, fair, and poor, according to the postoperative position of the upper eyelid in relation to the scleral limbus, medial canthus position, and residual epicanthal fold. The results were assessed as good in seven cases and fair in three.

CONCLUSIONS

The silicone eyelid suspensor was effective in improving the patients' difficult condition. It was a better alternative than the use of fascia lata, because it permitted an easier readjustment of the eyelid margin and it offered the possibility of creating a well-defined palpebral fold, which is usually absent in this group. The results were maintained with long-term follow-up. The silicone suspensor was safe and long-term results were good in both children and adults.

Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material

PURPOSE

To compare two sling designs (single loop or double pentagon) and a variety of suture material that was used in frontalis suspension surgery for correction of upper eyelid ptosis.

DESIGN

Retrospective, nonrandomized, comparative interventional case series.

METHODS

Medical record review of 99 patients (164 surgeries) who underwent frontalis suspension surgery for upper eyelid ptosis was conducted at the Jules Stein Eye Institute in 1996 to 2002. Functional and cosmetic success, margin reflex distance (MRD) and lagophthalmos were evaluated.

RESULTS

MRD increased an average of 1.1 mm after the operation (P < .001). Ptosis recurrence was noticed in 42 cases (26%); polytetrafluoroethylene achieved the lowest recurrence rate (15%), although not statistically significant. No difference in functional success, ptosis recurrence, or change in MRD was noticed between single loop and double pentagon design. A better cosmetic outcome was noted in cases in which nylon suture was used. Complications included four cases (2.4%) of over-correction, three cases (1.8%) of suture infection (all in polytetrafluoroethylene), two cases of pyogenic granuloma (1.2%), and two cases (1.2%) of suture exposure.

CONCLUSION

Frontalis suspension for upper eyelid ptosis resulted in 26% ptosis recurrence after a mean of 12 months from first surgery. Polytetrafluoroethylene showed the lowest incidence of ptosis recurrence. No statistically significant difference was found between different suture materials or loop shape that was used in the surgical technique. A better cosmetic outcome, as graded by different observers, was noted in cases in which a nylon sling was used.

The role of palmaris muscle tendon in mitral valve annulus reconstruction: a novel technique for mitral valve repair

BACKGROUND

Autogenous tissue for heart valve repair is limited to pericardium and fascia lata. Prosthetic annuloplasty rings have limitations and are expensive. No previous cadaveric study has documented autotransplantation of forearm tendons for mitral valve repair. The purposes of this anatomical study were (1) to determine the feasibility of using tendons for annular reconstruction during mitral valve repair (band or ring shape) and (2) to compare the metric dimensions and gross morphology with those of prosthetic rings.

METHODS

The palmaris tendon (PM) (n = 7) was harvested from forearms of human cadavers and prepared in the dissecting room. The tendon was incorporated along the valve annulus. Surgery consisted of mitral valve annuloplasty performed with an undersized and a complete tendon.

RESULTS

On gross handling PM tissue was morphologically resilient. Preparation and use of PM for annuloplasty were feasible. Anatomical reconstruction of the annulus with autogenous tissue using this tendon also was feasible. The annulus behaved as a flexible ring that allowed for improved atrioventricular continuity. Complete (n = 7) and partial (n = 7) annuloplasty rings were constructed. Metric dimensions were similar to those of prosthetic rings.

CONCLUSION

PM is a suitable novel autogenous tissue that can be harvested together with the radial artery and has direct relevance in ischemic mitral valve regurgitation. These tendons can be easily utilized to achieve results similar to those of pericardial reconstruction and prosthetic annuloplasty rings. The tissue is readily available from the patient, and no extra cost is incurred. Further chemical studies in the human subjects are warranted.

Long-term results of autogenous palmaris longus frontalis sling in children with congenital ptosis

PURPOSE

To investigate the long-term outcome of using autogenous palmaris longus tendon (PLT) sling for correcting congenital ptosis in children.

METHODS

This is an observational case series involving 15 eyelids of 14 consecutive children with congenital ptosis who underwent frontalis suspension surgery using PLT in a university teaching hospital.

RESULTS

One child had bilateral ptosis and the other children had unilateral ptosis. The age of patients at the time of surgery ranged from 2 to 7 years, with an average of 4.7 years. At a mean follow-up of 92 months (range, 80-104 months), all eyelids were successfully corrected with good lid height. No recurrence or other postoperative complications were encountered except one patient who developed a small skin fold over the PLT harvest site.

CONCLUSION

Long-term lid position is remarkably stable after surgical correction using PLT. PLT sling appears to be a safe and effective treatment for children with congenital ptosis requiring frontalis sling operation. It could be a good alternative to autogenous fascia lata, and further studies, to compare these two sling materials seem warranted.

[Correction of congenital blepharoptosis by transposition of the frontal muscle]

Congential ptosis (CP) represents a significant reconstructive problem. Numerous studies have not yet provided full and satisfactory results. In this study, we have presented our experience in the surgical treatment of 108 patients by the use of Son Ye Guang's modified method--frontal muscle transposition. A total of 108 patients with CP were surgically treated at the Clinic for Plastic Surgery and Burns of the Military Medical Academy in the period 1991-2000. Unilateral ptosis was operated in 85 patients, and bilateral in 23 patients. CP was more frequently found in males (58.34%) than in females (41.66%). The youngest patient was only 5.5 years old, and the oldest was 42, the average age was 21.3 years. All patients were operated on by the same surgeon, and were monitored monthly during the first six months, and then twice a year for the next 3 years. Postoperative results were evaluated after 6 months: the action of raising the eyelids was compared to the full amplitude of movement of the eye on the healthy side. The closure of the eyelids and the symmetry of the palpebral fissure in a steady horizontal view was also assessed. The action of the opening as well as closure of the eyelids in full amplitude was obtained in all operated patients. Assymetry of the palpebral fissure in a steady horizontal view up to 1 mm did not require additional correction. In 9 cases, assymetry of the palpebral fissure greater than 1 mm was subsequently corrected. The advantages of this surgical method compared to the other, previously described techniques, were emphasized in the conclusion. The main advantage was the elimination of postoperative lagophthalmos, which represented the problem in all previously used methods.

Congenital and acquired blepharoptosis

Blepharoptosis is a relatively common condition that is frequently encountered by the ophthalmic surgeon. Treatment remains somewhat unpredictable, and the choice of one of the various surgical options depends on the cause of the ptosis and the amount of levator function. Recent contributions to the literature on the classification and management of ptosis are reviewed here.