|Year : 2016 | Volume
| Issue : 2 | Page : 102-107
Evaluation of expanded polytetrafluoroethylene (Gore-Tex) suture in frontalis suspension in severe congenital upper-eyelid blepharoptosis
Mohammed O.A. El-Sayed MD , Waleed M Mahran, Ahmed T.S. Saif
Department of Ophthalmology, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
|Date of Submission||30-May-2015|
|Date of Acceptance||27-Apr-2016|
|Date of Web Publication||30-Aug-2016|
Mohammed O.A. El-Sayed
Department of Ophthalmology, Faculty of Medicine, Beni-Suef University, Beni-Suef 13511
Source of Support: None, Conflict of Interest: None
The aim of the study was to evaluate the efficacy and complications of a new expanded polytetrafluoroethylene (Gore-Tex) suture in frontalis suspension in severe congenital upper-eyelid blepharoptosis with poor levator function (4 mm or less) wherein fascia lata is difficult to harvest in young children.
Patients and methods
In a retrospective study, frontalis suspension was performed in patients with severe congenital ptosis in whom the levator function was 4 mm or less. The procedure was performed in 62 eyes of 40 patients between February 2010 and March 2013. The mean follow-up duration was 12 ± 2 months. Forty patients were included in this study, 26 girls and 14 boys, with an average age of 2.8 ± 0.1 years. Frontalis suspension was performed with the open approach using a single pentagon suture (Fox procedure).
The average margin reflex distance was −0.55 mm preoperatively, which improved to +2.2 mm at 6 months postoperatively (P < 0.009) and then decreased to +1.55 mm 1 year postoperatively (P = 0.005). Six eyes (10%) showed complete recurrence. Twenty-two eyes (35%) experienced partial recurrence. The average period of recurrence was 6.56 months. Postoperative complications such as suture granuloma, infection, exposure, lagophthalmus, and overcorrection occurred in a few patients.
The use of the new version of Gore-Tex suture as a suspensory material in frontalis suspension in severe congenital upper-eyelid blepharoptosis is safe and effective and can be recommended for clinical use.
Keywords: congential ptosis, fascia lata, Gore-Tex
|How to cite this article:|
El-Sayed MO, Mahran WM, Saif AT. Evaluation of expanded polytetrafluoroethylene (Gore-Tex) suture in frontalis suspension in severe congenital upper-eyelid blepharoptosis. Delta J Ophthalmol 2016;17:102-7
|How to cite this URL:|
El-Sayed MO, Mahran WM, Saif AT. Evaluation of expanded polytetrafluoroethylene (Gore-Tex) suture in frontalis suspension in severe congenital upper-eyelid blepharoptosis. Delta J Ophthalmol [serial online] 2016 [cited 2022 May 22];17:102-7. Available from: http://www.djo.eg.net/text.asp?2016/17/2/102/189470
| Introduction|| |
Frontalis suspension is the treatment of choice for patients with severe congenital ptosis with poor levator muscle function (4 mm or less). Different sling materials are available for frontalis suspension but autogenous fascia lata is the best. Crawford suggested that autogenous fascia lata should be used only in patients over 4 years because inadequate material is harvested from younger patients. In severe congenital ptosis in which the upper eyelid is completely covering the pupil or there is severe abnormal head position the possibility of amblyopia or neck torticolis is high, hence the importance of using an alternative to fascia lata in such cases .
Many synthetic materials are used for frontalis suspension – for example, the banked fascia lata. Although the success rate of sling surgery with the banked fascia lata is high in short follow-up (∼90%), the long-term success rate decreases to ∼50%. The initial success can be attributed to the fact that the banked fascia may be replaced by fibrous tissue, which may provide a permanent effect. However, premature absorption occasionally occurs before the permanent bond forms, resulting in recurrence .
Another synthetic suture used as a suspensory material is the monofilament polypropylene suture. However, the postoperative ptosis recurrence rate is high (12.5–55.6%). Polypropylene sutures are mainly used as a temporary suspension material to prevent amblyopia in young children who are candidates for 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 lack of interference with future use of autogenous fascia lata. Similarly, the nylon monofilament suture (Supramid) has a high recurrence rate of ptosis (25–69.2%) .
One of the most popular materials used for frontalis suspension is the silicone rod. The most valuable advantage of the silicone rod is its elasticity, which allows complete eyelid closure and appropriate upper-eyelid height. The silicone rod may, therefore, be most appropriate for patients with poor Bell's phenomenon. However, this material does not integrate with the fibrovascular tissue, and may therefore slip, resulting in recurrence of ptosis. The reported recurrence rate with the silicone rod sling is 50% .
Integrated materials like mersilene mesh were tried as a suspensory material as they act as a permanent scaffold, supporting fibrovascular ingrowth and thereby reducing the risk of slippage and providing a long-lasting upper-eyelid lift. Although the reported recurrence rate is relatively low (0–12.5%), it causes soft-tissue complications such as extrusion, infection, and granuloma formation .
Recently, Gore-Tex suture, which is a unique microporous nonabsorbable monofilament made of expanded polytetrafluoroethylene (ePTFE), was used as a suspensory material. This unique material offers the benefits of both monofilament and multifilament sutures, with excellent material properties. Polytetrafluorethylene material is, chemically, one of the teflon derivatives. The first generation of Gore-Tex suture was commercially available as a plate with 10 × 5 × 0.2 cm thickness with a large pore size of up to 50 μm. A high rate of infection, granuloma and extrusion occurred because of the relatively large pores that led to the entry of a lot of microorganisms .
The second generation of Gore-Tex was made of ePTFE wherein the polytetrafluoroethylene material was heated to 300°C, as a result of which its fibrils are linked together by knots that delimit the pore size to 17–20 μm and hence decrease the rate of infection and granuloma formation and extrusion. The micropores are too small to allow infiltration into fibrovascular tissues; therefore, it can be easily removed or manipulated to adjust the eyelid height. The fibrovascular tissue is strong enough to maintain a sufficient upper-eyelid height and contour .
Many surgical approaches are used for frontalis suspension, either with the open technique (where the suspensory material is fixed directly to the tarsus through lid crease incision) or with the closed technique (where the suspensory material is threaded under the skin of the lid and deep layers of the brow). Many suture designs were used for the suspensory material – for example, single triangle, double triangle, single rhomboid (Friedenwald–Guyton procedure), double rhomboid (Iliff procedure) double trapezoid (Wright procedure), single pentagon (Fox procedure), and double pentagon configurations (Crawford procedure) .
This study was conducted to evaluate the efficacy and complications of ePTFE (Gore-Tex) suture in frontalis suspension in severe congenital upper-eyelid belpharoptosis with poor levator function (4 mm or less).
| Patients and methods|| |
This is a retrospective study in which frontalis suspension was performed for patients with severe congenital ptosis in whom levator function was 4 mm or less. This study included 62 eyes of 40 patients who were operated upon between February 2010 and March 2013. The mean follow-up duration was 12 ± 2 months. The data retrieved included personal data such as age, sex, family history, and maternal history. The clinical evaluation included levator function, degree of ptosis, margin reflex distance (MRD), extraocular motility, Bell's phenomena, Marcus Gunn syndrome, belpharophimosis, presence of abnormal head position, and nystagmus. The postoperative data included follow-up time, postoperative lid position, recurrence time, and related complications [Table 1]. The IRB approved the study and an informed consent was signed by the patients parent before inclusion in this study.
All surgeries were performed by a single surgeon (M.E.) after an informed consent form had been signed by the patients’ parents. Frontalis suspension was performed with the open technique by a single pentagon suture (Fox procedure). All surgeries were performed under general anesthesia. A lid crease incision was marked 4–5 mm above the lash line after infiltration with saline mixed with epinephrine in a ratio of 1: 200 000 for the purpose of hydrodissection and hemostasis [Figure 1]a). Dissection through the orbicularis muscle was done to expose the tarsus. The ePTFE was anchored directly to the middle third of the tarsus by three 5–0 polyster (Ethibond, Ethicon Co., Somerville, NJ 08876, USA) sutures on a spatulated needle corresponding approximately in width to the horizontal iris diameter in the primary position. The middle suture was just nasal to the center of the pupil and the two other sutures corresponded to the nasal and lateral limbus [Figure 1]b). Three suprabrow stab incisions were made; the peripheral two stab incisions were made 0.5 cm above the brow medial and lateral to the vertical line drawn from the medial and lateral ends of the ePTFE suture, and the central suprabrow incision was made 1–1.5 cm above the center of the brow. The two ends of the ePTFE were passed from the tarsus to the corresponding suprabrow incisions through a deep pretarsal passage using a Wright needle. The two ends of the ePTFE were brought together in the submuscular plane to the central brow incision, which created a pentagonal sling. The ePTFE was tied carefully as a square knot and adjusted to achieve the desired eyelid elevation (usually at the level of the upper limbus) and contour. The square knot was sutured to the deep submusclar layer by a 5/0 ethibond suture to prevent downward migration of the Gore-Tex suture [Figure 1]c). The brow incisions and the eyelid incisions were sutured with 7–0 vicryl except the central brow incision, which was closed in two planes, the deeper one with 5–0 vicryl and the superficial plane with 7–0 vicryl. The eyelid crease incision was closed with interrupted sutures using the traditional technique of artificial crease formation [Figure 1]d). Frost suture may be used if Bell's phenomenon is inadequate.
|Figure 1 (a) Upper-eyelid crease incision. (b) Fixation of Gore-Tex suture to the tarsal plate. (c) Single pentagonal suture (Fox procedure). (d) Lid crease closure with a 7/0 vicryl suture.|
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The mean follow-up period was 12 ± 2 months.
Total recurrence was defined as upper eyelid completely covering the pupil with the MRD +0.1 or less. Partial recurrence was defined as any degree of ptosis that did not cover the pupil or any upper eyelid asymmetry in unilateral cases.
Data were analyzed using SPSS, version 16.0 (SPSS Inc., Chicago, Illinois, USA) by the χ2-method. A P value less than 0.05 was considered statistically significant.
| Results|| |
Sixty-two eyes of 40 patients were included in this study, 26 girls and 14 boys. The minimum age was 18 months and the maximum age was 2.5 years (30 months), with a mean age of 1.8 ± 0.1 years. The procedure was performed bilaterally in 22 patients and unilaterally in 18 patients (10 in the right eye and eight in the left eye). Four eyes had Marcus Gunn phenomena and five had belpharophimosis syndrome [Table 2].
The average MRD was −0.55 mm preoperatively, which improved to +2.2 mm at 6 months postoperatively (P < 0.009) and then decreased to +1.55 mm 1 year postoperatively (P = 0.005). Twenty-two eyes experienced partial recurrence (35%). The average period of recurrence was 6.56 months. Six eyes showed complete recurrence (10%) [Table 3].
[Table 4] illustrates the postoperative complications. Two eyes (3.5%) showed suture granuloma at the middle suprabrow incision [Figure 2], which responded well to a combination of antibiotic and steroid ointment with no need for surgical removal. Two eyes (3.5%) showed suture exposure at the middle suprabrow incision and/or at the skin crease incision within an average time of 2 months postoperatively [Figure 3]. Reoperation was carried out under a complete umbrella of broad-spectrum antibiotics with closure of the wound at two different layers; that is, the orbicularis was sutured with 6/0 vicryl and the skin sutured separately with 7/0 vicryl suture. Only one case (2%) had infection, which was treated with iodine sterilization of the skin of the upper eyelid, topical antibiotic ointment, and systemic antibiotic. Reoperation was done after skin infection was controlled and removal of the Gore-Tex material over the tarsal plate and skin suturing with interrupted 7/0 vicryl. One eye (2%) had overcorrection where the upper eyelid returned to normal position without massage or surgical intervention 8 weeks after the operation. During this period only lubricants were used.
All patients showed different degrees of lagophthalmos, but no corneal complications occurred and none of them needed surgical correction. No lid notching persisted 4 weeks after surgery.
[Figure 4]a illustrates a successful case of unilateral ptosis repair in a 3-year-old child with left severe unilateral ptosis with levator function of 3 mm and MRD +2 mm with nystagmus. [Figure 4]b shows postoperative result after 1 year with a MRD of 3.3 mm.
| Discussion|| |
Frontalis suspension is a surgical procedure that is performed to address congenital ptosis with poor levator function of less than 4 mm. It creates a linkage between the frontalis muscle and the tarsus of the upper eyelid, which allows for a better eyelid position in primary gaze .
Frontalis suspension surgery may use several surgical techniques and different sling materials. Materials include autogenous or banked fascia lata and alloplastic materials such as polypropylene suture, nylon suture silicone rod, mersilene mesh, and finally ePTFE (Gore-Tex). Autogenous fascia lata is considered more effective with comparably low rates of recurrent ptosis and infection, but it is not well developed until preschool age (4–5 years). Therefore, in cases of severe congenital ptosis, in which autogenous facia lata was difficult to harvest and there was a high risk for amblyopia or abnormal head position or nystagmus, other suspensory materials may be used instead of fascia lata .
This study was performed to evaluate Gore-Tex material as a suspensory material in cases of severe congenital ptosis.
This is a retrospective study in which frontalis suspension had been performed for patients with severe congenital ptosis in whom levator function had been 4 mm or less. The study included 62 eyes of 40 patients. Gore-Tex suture was anchored directly to the upper tarsal plate (open technique) and frontalis suspension was in the form of a single pentagon suture (Fox procedure).The mean follow-up duration had been 12 ± 2 months.
The average MRD was −0.55 mm preoperatively, which improved to +2.2 mm at 6 months postoperatively and then decreased to +1.55 mm 1 year postoperatively. Six eyes (10%) showed complete recurrence, whereas 22 eyes (35%) experienced partial recurrence. The average period of recurrence was 6.56 months. Two eyes (3.5%) showed exposure of the Gore-Tex material at the tarsal Plate 2 months after surgery. Only one case showed infection and was treated by removal of the Gore-Tex material over the tarsus after topical and systemic antibiotics.
Two eyes (3.5%) showed suture granuloma at the middle suprabrow incision and responded well to a combination of antibiotic and steroid ointment with no need for surgical removal.
One eye 2% showed overcorrection when the upper eyelid returned to normal position without massage or surgical intervention 8 weeks after the operation; during this period only lubricants were used.
All patients showed different degrees of lagophthalmos but no corneal complications occurred and none of them needed surgical correction.
Takaashi et al. conducted a study to evaluate Gore-Tex material for congenital ptosis. This study included 27 eyes from 20 patients with an average age of 45 (5–85) years and an average follow-up period of 18 months. The average MRD was -0.45 mm preoperatively, which improved to +1.89 mm after surgery, but after 1 year it was +1.6 mm. Ten eyes (37%) showed partial recurrence: seven eyes out of 10 in the younger age group and three eyes in elderly patients. One case showed exposure, but no cases of suture granuloma or infection were reported. The preoperative and postoperative results in the form of recurrence rates and MRD are comparable to those of the present study, whereas the rates of infection and suture granuloma were higher in our study. This can be attributed to the difference in age groups between the two studies.
Nakauchi et al. had performed a study in 2013 to evaluate the recurrence rate and complications of Gore-Tex sheet in young children. He sutured one end of the Gore-Tex strips with 7–0 prolene at one-half to one-third the height of the tarsal plate, whereas the other end of the sheet was sutured to the frontalis muscle using 7–0 prolene. The partial recurrence rate in their study was 27%. The recurrence rate in our study was higher than that of this study because of the different surgical techniques as frontalis sling was performed by means of the direct suture procedure.
Ben Simon et al. carried out a study on 99 eyes with severe ptosis to compare and evaluate different suspensory materials for frontalis suspension procedure. They found that the recurrence rate for Gore-Tex was 15% compared with 40–70% in silicone rods and nylon suture, whereas the fascia lata showed the least recurrence (5%). Pyogenic granuloma and suture infection were 4% with Gore-Tex suture, which is higher than that with other materials but statistically nonsignificant compared with other materials (e.g. infection was 2% in fascia lata patients). Overcorrection occurred in 2.4% of Gore-Tex patients. Extrusion occurred in 5% of cases. These results are comparable to our study results.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]