LETTER TO
Comparison of Outcomes of Suprabrow Single-Stab and 3-Stab Incision Frontalis Sling Surgery To the Editor: read with interest about the article by Jacob et al1 on the comparison of outcomes of suprabrow single-stab (SBSS) and 3-stab incision frontalis sling surgery. This is one of the few randomized control trials comparing 2 different techniques of frontalis sling surgery. The authors conclude that SBSS is associated with a better aesthetic outcome with reduced bleeding, postoperative edema, and scarring. There are, however, a few areas that I would like to discuss. The authors have tried to mask the observers by sticking small bits of white Micropore tape on the traditional 3 suprabrow stab incision. These micropore tapes were then removed to assess the scar appearance. This means that the study group and control group will be unmasked by the observers in subsequent visits, which may lead to potential bias. A cosmetic score, which include lid crease height, lagophthalmos, vertical fissure height, multiple scars, and prominent suprabrow scar, was used to assess the outcome of the 2 surgical procedures. However, some important elements such as lid contour and/or any lid peaking was not included as an outcome measure. Also, the scar-related score accounts for a heavy proportion of the total cosmetic score (4 of 10 total score), and this may be a potential bias against the 3-stab incision procedure. The appearance of the suprabrow and forehead scars will be prominent in the early postoperative period, but these scars usually fade with time. However, the authors have not reported the trend off the cosmetic scores of the 2 groups with time. I am more interested to know the cosmetic score between the 2 groups at 1 year instead of the mean score at different periods. In my experience, a carefully placed suprabrow stab incision is cosmetically acceptable and will not lead to permanent hair loss.2,3 Infection and late recurrence are the 2 disadvantages of using exogenous material for frontalis sling surgery,4 and some surgeons prefer using autogenous tissue instead.3,5 The total length of the autogenous tissue harvested may be short in pediatric population, and techni-
I
Asia-Pacific Journal of Ophthalmology
&
THE
EDITOR
ques such as Crawford, double triangles, or double rhomboids may be required. I would like to seek the opinion whether SBSS can be applicable in such cases. Finally, I agree with the authors that SBSS is certainly associated with less operative time, less bleeding, and scarring, and it is an effective procedure in ptosis correction.
Hunter K.L. Yuen, MRCSEd(Ophth) Department of Ophthalmology & Visual Sciences The Chinese University of Hong Kong Hong Kong Eye Hospital, Kowloon and Hong Kong Eye Hospital, Hospital Authority Ophthalmic Services, Hong Kong SAR, China
AUTHOR DISCLOSURE INFORMATION The authors have no funding or conflicts of interest to declare.
REFERENCES 1. Jacob S, et al. Comparison of outcomes of suprabrow single-stab and 3-stab incision frontalis sling surgery. Asia Pac J Ophthalmol 2012;00:00Y00. 2. Chong KK, Fan DS, Lai CH, et al. Unilateral ptosis correction with mersilene mesh frontalis sling in infants: thirteen-year follow-up report. Eye (Lond). 2010;24:44Y49. 3. Wong CY, Fan DS, Ng JS, et al. Long-term results of autogenous palmaris longus frontalis sling in children with congenital ptosis. Eye (Lond). 2005;19:546Y548. 4. Ben Simon GJ, Macedo AA, Schwarcz RM, et al. Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material. Am J Ophthalmol. 2005;140:877Y885 5. Crawford JS. Repair of ptosis using frontalis muscles and fascia lata a 20-year review. Ophthalmic Surg. 1977;8:31Y40.
Author Reply To the Editor: he study was performed with informed consent and following all the guidelines for experimental investiga-
T
tions required by the institutional review board, of which all authors are affiliated. We appreciate Dr Yuen for his interest in our article and for his comments. As explained in the article, we masked the observers at each visit using the micropore tape, which was then removed before the cosmetic scar scoring. This made sure that the Micropore tape was removed after the other parameters were given scores to avoid potential bias. Also, we tried to include more objective parameters such as lid crease height, lagophthalmos, and vertical fissure height in our cosmetic scoring. The inclusion of other parameters such as lid contour and lid peaking would make the scoring more subjective and less quantifiable. However, in our experience, we found that the overall appearance of the lid including lid contour and lid peaking for the SBSS group was no different from the suprabrow-3-stab-incision group. As mentioned in our article, we found that the difference between the 2 groups is more due to the scar-related score, and a decrease in the difference in the frequency distribution of the cosmetic score was seen after removing the parameter of multiple scars and prominent eyebrow scar. In both children (P = 0.796) and adults (P = 1.000), there was no significant difference between the 2 groups after removal of the scar score. We agree that most scars do tend to fade with time, but in our experience, they do not disappear completely. In a surgery (frontalis sling) performed usually for improving cosmesis, we feel that a procedure that induces least amount of scarring with similar functional results would be preferable, especially when the degree of cosmetic awareness, expectations, and concern about scars is high among patients. Applicability in the pediatric scenario was possible, and our study included 6 children each in the study and the control groups. A Fox pentagon with the silicone sling was used in all the cases in both groups. We found good functional outcomes in both groups and better cosmetic scoring in the study group than in the control group. Difficulty in harvesting, insufficient material harvested, and postoperative leg scarring are disadvantages of autologous fascia lata; hence, we prefer avoiding its use. In comparison with other exogenous material, silicone has been found comparable with respect to recurrence and superior with respect
Volume 1, Number 3, May/June 2012
Copyright © 2012 by Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
185
Letters to the Editor
to granuloma formation, infection, elastic properties, and ease of adjustability.1 In a study by Lee et al2 comparing frontalis sling surgery using silicone rod with preserved fascia lata, also in pentagon configuration, the silicone rod was found to have better cosmetic results and lower recurrence rate as compared with preserved fascia lata up to 3 years after surgery for congenital ptosis. For these reasons, silicone is our preferred material for frontalis sling, and we have had a rewarding experience with this material. Several other authors have also successfully used silicone for frontalis sling surgery. 3Y5 Finally, we would like to thank Dr Yuen for his interest and his encouraging comments regarding the efficacy of our technique and its surgical and postoperative advantages.
186
Asia-Pacific Journal of Ophthalmology
Soosan Jacob, FRCS Amar Agarwal, FRCS Vidya Nair, MD Saraswathy Karnati, MS Dhivya Ashok Kumar, MD Gaurav Prakash, MD Dr Agarwal’s Eye Hospital and Eye Research Centre
AUTHOR DISCLOSURE INFORMATION The authors have no funding or conflicts of interest to declare.
REFERENCES 1. Lamont M, Tyers AG. Silicone sling allows adjustable ptosis correction in children and in
&
Volume 1, Number 3, May/June 2012
adults at risk of corneal exposure. Orbit. 2010;29:102Y105. 2. Lee MJ, Oh JY, Choung HK, et al. Frontalis sling operation using silicone rod compared with preserved fascia lata for congenital ptosis a three year follow up study. Ophthalmology. 2009;116: 123Y129. 3. Leone CJ, Shore JW, Van-Gemert JV. Silicone rod frontalis sling for the correction of blepharoptosis. Ophthalmic Surg. 1981;12:881Y887. 4. Carter S, Meecham WJ, Steiff SR. Silicone frontalis slings for the correction of blepharoptosis: indications and efficacy. Ophthalmology. 1996;103:623Y630. 5. Brun D, Hatt M. Ptosis operations with silicone suspension at the eyebrow. Klin Monatsbl Augenheilkd. 1991;199: 457Y460.
* 2012 Asia-Pacific Journal of Ophthalmology
Copyright © 2012 by Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
Comparison of Outcomes of Suprabrow Single-Stab and 3-Stab Incision Frontalis Sling Surgery To the Editor: read with interest about the article by Jacob et al1 on the comparison of outcomes of suprabrow single-stab (SBSS) and 3-stab incision frontalis sling surgery. This is one of the few randomized control trials comparing 2 different techniques of frontalis sling surgery. The authors conclude that SBSS is associated with a better aesthetic outcome with reduced bleeding, postoperative edema, and scarring. There are, however, a few areas that I would like to discuss. The authors have tried to mask the observers by sticking small bits of white Micropore tape on the traditional 3 suprabrow stab incision. These micropore tapes were then removed to assess the scar appearance. This means that the study group and control group will be unmasked by the observers in subsequent visits, which may lead to potential bias. A cosmetic score, which include lid crease height, lagophthalmos, vertical fissure height, multiple scars, and prominent suprabrow scar, was used to assess the outcome of the 2 surgical procedures. However, some important elements such as lid contour and/or any lid peaking was not included as an outcome measure. Also, the scar-related score accounts for a heavy proportion of the total cosmetic score (4 of 10 total score), and this may be a potential bias against the 3-stab incision procedure. The appearance of the suprabrow and forehead scars will be prominent in the early postoperative period, but these scars usually fade with time. However, the authors have not reported the trend off the cosmetic scores of the 2 groups with time. I am more interested to know the cosmetic score between the 2 groups at 1 year instead of the mean score at different periods. In my experience, a carefully placed suprabrow stab incision is cosmetically acceptable and will not lead to permanent hair loss.2,3 Infection and late recurrence are the 2 disadvantages of using exogenous material for frontalis sling surgery,4 and some surgeons prefer using autogenous tissue instead.3,5 The total length of the autogenous tissue harvested may be short in pediatric population, and techni-
I
Asia-Pacific Journal of Ophthalmology
&
THE
EDITOR
ques such as Crawford, double triangles, or double rhomboids may be required. I would like to seek the opinion whether SBSS can be applicable in such cases. Finally, I agree with the authors that SBSS is certainly associated with less operative time, less bleeding, and scarring, and it is an effective procedure in ptosis correction.
Hunter K.L. Yuen, MRCSEd(Ophth) Department of Ophthalmology & Visual Sciences The Chinese University of Hong Kong Hong Kong Eye Hospital, Kowloon and Hong Kong Eye Hospital, Hospital Authority Ophthalmic Services, Hong Kong SAR, China
AUTHOR DISCLOSURE INFORMATION The authors have no funding or conflicts of interest to declare.
REFERENCES 1. Jacob S, et al. Comparison of outcomes of suprabrow single-stab and 3-stab incision frontalis sling surgery. Asia Pac J Ophthalmol 2012;00:00Y00. 2. Chong KK, Fan DS, Lai CH, et al. Unilateral ptosis correction with mersilene mesh frontalis sling in infants: thirteen-year follow-up report. Eye (Lond). 2010;24:44Y49. 3. Wong CY, Fan DS, Ng JS, et al. Long-term results of autogenous palmaris longus frontalis sling in children with congenital ptosis. Eye (Lond). 2005;19:546Y548. 4. Ben Simon GJ, Macedo AA, Schwarcz RM, et al. Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material. Am J Ophthalmol. 2005;140:877Y885 5. Crawford JS. Repair of ptosis using frontalis muscles and fascia lata a 20-year review. Ophthalmic Surg. 1977;8:31Y40.
Author Reply To the Editor: he study was performed with informed consent and following all the guidelines for experimental investiga-
T
tions required by the institutional review board, of which all authors are affiliated. We appreciate Dr Yuen for his interest in our article and for his comments. As explained in the article, we masked the observers at each visit using the micropore tape, which was then removed before the cosmetic scar scoring. This made sure that the Micropore tape was removed after the other parameters were given scores to avoid potential bias. Also, we tried to include more objective parameters such as lid crease height, lagophthalmos, and vertical fissure height in our cosmetic scoring. The inclusion of other parameters such as lid contour and lid peaking would make the scoring more subjective and less quantifiable. However, in our experience, we found that the overall appearance of the lid including lid contour and lid peaking for the SBSS group was no different from the suprabrow-3-stab-incision group. As mentioned in our article, we found that the difference between the 2 groups is more due to the scar-related score, and a decrease in the difference in the frequency distribution of the cosmetic score was seen after removing the parameter of multiple scars and prominent eyebrow scar. In both children (P = 0.796) and adults (P = 1.000), there was no significant difference between the 2 groups after removal of the scar score. We agree that most scars do tend to fade with time, but in our experience, they do not disappear completely. In a surgery (frontalis sling) performed usually for improving cosmesis, we feel that a procedure that induces least amount of scarring with similar functional results would be preferable, especially when the degree of cosmetic awareness, expectations, and concern about scars is high among patients. Applicability in the pediatric scenario was possible, and our study included 6 children each in the study and the control groups. A Fox pentagon with the silicone sling was used in all the cases in both groups. We found good functional outcomes in both groups and better cosmetic scoring in the study group than in the control group. Difficulty in harvesting, insufficient material harvested, and postoperative leg scarring are disadvantages of autologous fascia lata; hence, we prefer avoiding its use. In comparison with other exogenous material, silicone has been found comparable with respect to recurrence and superior with respect
Volume 1, Number 3, May/June 2012
Copyright © 2012 by Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
185
Letters to the Editor
to granuloma formation, infection, elastic properties, and ease of adjustability.1 In a study by Lee et al2 comparing frontalis sling surgery using silicone rod with preserved fascia lata, also in pentagon configuration, the silicone rod was found to have better cosmetic results and lower recurrence rate as compared with preserved fascia lata up to 3 years after surgery for congenital ptosis. For these reasons, silicone is our preferred material for frontalis sling, and we have had a rewarding experience with this material. Several other authors have also successfully used silicone for frontalis sling surgery. 3Y5 Finally, we would like to thank Dr Yuen for his interest and his encouraging comments regarding the efficacy of our technique and its surgical and postoperative advantages.
186
Asia-Pacific Journal of Ophthalmology
Soosan Jacob, FRCS Amar Agarwal, FRCS Vidya Nair, MD Saraswathy Karnati, MS Dhivya Ashok Kumar, MD Gaurav Prakash, MD Dr Agarwal’s Eye Hospital and Eye Research Centre
AUTHOR DISCLOSURE INFORMATION The authors have no funding or conflicts of interest to declare.
REFERENCES 1. Lamont M, Tyers AG. Silicone sling allows adjustable ptosis correction in children and in
&
Volume 1, Number 3, May/June 2012
adults at risk of corneal exposure. Orbit. 2010;29:102Y105. 2. Lee MJ, Oh JY, Choung HK, et al. Frontalis sling operation using silicone rod compared with preserved fascia lata for congenital ptosis a three year follow up study. Ophthalmology. 2009;116: 123Y129. 3. Leone CJ, Shore JW, Van-Gemert JV. Silicone rod frontalis sling for the correction of blepharoptosis. Ophthalmic Surg. 1981;12:881Y887. 4. Carter S, Meecham WJ, Steiff SR. Silicone frontalis slings for the correction of blepharoptosis: indications and efficacy. Ophthalmology. 1996;103:623Y630. 5. Brun D, Hatt M. Ptosis operations with silicone suspension at the eyebrow. Klin Monatsbl Augenheilkd. 1991;199: 457Y460.
* 2012 Asia-Pacific Journal of Ophthalmology
Copyright © 2012 by Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
