ACTA 0 P H T H A L M 0 L O G I C A

68 (1990) 487-490

The correction of ptosis with adjustable suture technique Nurettin Akyoll and Cahit H. UnluCerCi2 Department of Ophthalmology1(Head:N. Akyol), Faculty of Medicine, Karadeniz Technical University,Trabzon and Department of Ophthalmology*(Head: H. C. UnluCerqi),Haseki Hospital, Istanbul, Turkey

Abstract. We discuss here the results of a simple technique for the correction of ptosis, performed by us as an alternative to other techniques. The basic principal of this technique is to suspend the ptotic upper eyelid to the frontalis muscle by 3/0 silk sutures passed above the tarsus using a peritoneal needle and to adjust the rima palpebrarum in the post-operative period. This method is simple and easy to perform with few complications. Key words: ptosis - suspension - adjustable suture. Indications for suspensory operations are: levator function less than 4 mm; unsuccessful levator resection operations; and some cases of Marcus-Gunn phenomenon (Fnedenwald 8c Guyton 1943; Crawford 1956; Fox 1966; Beard 1976). For a successful operation, the eyes should be able to close during sleeping, and there should be no diplopia, no hypertropia and no notch remaining on the lid. The eyelashes should not be directed inward. There must be normal blinking, and the upper eyelid should move synchronically with the eye movements (Beard 1976; King & Wadsworth 1981; Charles & Leone 1982; Collin 1988). Many reports have described suspension procedures in which the eyelid height can be adjusted post-operatively (Argamaso 1974; Mustarde 1975; Carlson &Jampolsky 1979).We describe herein an adjustable eyebrow suspension technique with 310 silk suture, which allows post-operative alteration of the eyelid position and formation of eyelid fold.

Material and Methods Fourteen patients were operated with the adjustable suture technique. Ten were males and 4 females. Seven of them were bilateral. Distribution

of the patients is given in Table 1. The children were operated under conditionswith general anesthesia and the others with local anesthesia. Levator resection had been applied previously to the 2nd, 3rd, 4th 13th and 14th cases (Table 2). Since the results were unsatisfactory, they were operated using the new technique and an obvious improvement was obtained. Case 5 had an accident and ocular trauma. The globe was perforated. For this reason we preferred to wait for 1 year before the operation. Technique of the operation: see Fig. 1. First, two stab incisions were made through the skin 2 m m above the upper eyelid margin and about 2cm apart placed symmetrically about 7mm from the nasal and lateral canthi, respectively (A). Two more incisions were made 2 m m above the upper border of the brow, on 7 m m from the nasal termination and the other approximately 3cm lateral to the first. A 3/0 silk suture starting from the temporal side was passed through the incisions with the peritoneal needle in a rhomboid shape (B and C). The needle which is 8 to 10cm in length is easily passed through the eyelid tissues without any damage because of its sharpness and fineness. The suture was passed through the suprabrow incisions above the frontal periosteum, and through the lid margin incision under the orbicularis oculi muscle. After pulling up the lid in the desired position the ends of the sutures were tied with a bow knot and after inserting a piece of surgical glove between the ends they were retied. Before applying a light dressing, skin incisions were closed with 487

Table 1. Distribution of patients.

Sex

I

Patient No.

I

1

1

Unilateral Bilateral I

I

there is a possibility of adjustment of the rima palpebrarum relative to the other eye, local anesthesia should be preferred. Bilateral cases were operated in a separate session. We have obtained appreciable results in 14 cases (Table 2). In the post-operative period, between the 3rd and 7th days, if the rima palpebrarum was normal and there was no notching the suture was cut and buried under the wound. No post-operative adjustment was made for 5 cases having normal rima palpebrarum and no notching. There was an over correction in 5 cases and under correction in 11 cases. In these cases, the sutures were loosened under sterile conditions and after the rima was adjusted to the desired level, they were tied and buried again. In the post-operative period, the upper eyelid fold was formed more or less in all of the patients. Post-operative complications consisted of a diplopia in one instance (this was the patient with exotropia),upper lid notching in two instances, and lagophthalmos in one instance. If the sutures are passed under the orbicularis muscle notching does not occur. The patients were followed-upfor a long period post-operatively.No suture reaction was observed and rima palpebrarum and eyelid fold remained unchanged.

I (~Es) I

Male Female

10 4

6" 1

4 3

6-23 12-25

Total

14

7

7

6-25

* One was traumatic (6 years old), the others were congenital.

5/0 silk sutures (D). In the post-operative period between the 3rd and 7th days, if there were no notching, lagophthalmos, etc, and if the rima palpebrarum was normal the suture was cut and buried under the skin. But if the correction was not at the desired level, the suture was untied and was pulled up or loosened until the lid was in the desired position, and was cut and buried again.

Results Adjustable suture technique can be performed easily both under local or general anesthesia.Since

B

C

D

rr@+

Fig. 1. Operation procedure of the adjustable suture technique (see text).

488

Table 2. Features of the cases.

Rima palpebrarum

Patient Features

Preoperative Post-operative (mm) (mm)

No.

Age

Sex

Eye

1

21

M

Right

Right ambliopi, left normal

R 3 L 9.5

R: 9

2

15

M

Both

Bilateral optic atrophy, residue of levator resection

R: 3.5 L: 3.5

R 7.5 L 7

3

15

M

Both

Residue of levator resection

R 3 L 3.5

R: 8.5 L 9

4

6

M

Both

Residue of levator resection

R 3.5 L 3.5

R 8 L 7.5

5

6

M

Right

R: 4

R. 8.5

Complication

Notching on the left lid

L 9 6

12

F

Left

7

18

M

Right

8

22

F

Both

Left exotropia

R 9 L 3.5

-

L 9.5

Diplopia

R 4 L 9.5

R 9.5

Notching

R: 4

R. 10

L 4

L

Slight lagophthalmos

10

9

17

M

Right

R 3 L 9

R: 9

10

23

M

Both

R 3.5 L: 3

R 9 L 8.5

R. 9 L 3

L9

R 4 L. 3

R 9 L 8.5

R: 3 L: 3.5

R 9.5

11

18

M

Left

12

19

F

Both

13

25

F

Both

14

10

M

Left

Residue of levator resection Residue of levator resection

Discussion Suspension technique for ptosis is not a complicated operation (Friedenwald & Guyton 1943; Beard 1976).However, the result is not always perfect; the eyelid elevation may be insufficient or too much. In addition, lagophthalmos (in sleeping), abnormal curvature of the eyelid margin, ectropion may occur (Beard 1976; King & Wadsworth 1981; Charles & Leone 1982). Some of these com-

R 9.5 L 4

-

L 9

L 8.5

plications can be prevented by adjustable suture technique. Adjustable surgical techniques which are used in ptosis are not new (Snyder & Norton 1961;Argamaso 1974; Mustard6 1975; Argamaso & Lewin 1976). In the techniques using fascia lata, postoperative eyelid contour notching was reported (Beard 1976). Carlson and Jampolsky had showed, in two cases, that this complication may be 489

prevented by using 410 silk suture with adjustable procedure (Carlson & Jampolsky 1979). We applied adjustable suture technique on 14 cases post-operatively. Our results were satisfactory. In the present technique, if the suture is placed parallel to the lid margin, a normal lid fold is usually formed. This is achieved by the sharpness and the fineness of the needle which we have been using since 1981 (Akyol & hliicerci 1985). Such lid folds may not be seen frequently in the other techniques using frontalis muscle, and also, these lid folds are generally better than those obtained with operations utilizing the levator. Being adjustable in the post-operative period may be evaluated as a superiority. Thus, complications like over or under corrections may be prevented by this technique. The technique gives good results in selected cases and in those with moderate levator function or in those who had an unsuccesful ptosis operation previously. Since it is simple and easy to perform with few complications, the present technique seems to be a preferable method.

Beard C (1976): Ptosis, p 170 and 251 (2nd ed). CV Mosby, St. Louis. Carlson M R &Jampolsky A (1979):Adjustable eyelid and eyebrow suspension for blepharoptosis. Am J Ophthalmol88: 109-112. Charles R & LeoneJ (1982): Plastic surgery. In:Spaeth G L (ed). Ophthalmic Surgery, p 579. WB Saunders CO,~ Philadelphia. Collin R J 0 (1988):New concepts in the management of ptosis. Eye 2: 185-188. Crawford J S (1956): Repair o f ptosis using frontalis muscle and fascia lata. Trans Am Acad Ophthalmol Otolaryngol 60: 672. Fox S A (1966): Congenital ptosis 2 frontalis sling. J Pediatr Ophthalmol Strabismus 3: 25. Friedenwald J S & Guyton J S (1943): A simple ptosis operation utilization of frontalis by means of single rhomboid-shaped suture. Am J Ophthalmol 31: 411414. KingJ H & WadsworthJ A C (1981):An Atlas of Ophthalmic surgery p 161 (3rd ed): J P Lippincott, Philadelphia. Mustarde J D (1975):Problems and possibilities in ptosis surgery. Plast Reconstr Surg 56: 381-388. Snyder C C & Norton W W (1961): Eyelid ptosis. Plast Reconstr Surg 27: 586.

References Akyol N & UnliiqerGi H C (1985):The correction of ptosis with adjustable Friedenwald-Guyton technique. Haseki Tip Biilteni (Text in Turkish; Summary in English) 22: 280-287. Argamaso R B (1974): An adjustable fascia lata sling for the correction of blepharoptosis. Br J Plast Surg 27: 274. Argamaso R B & Lewin M L (1976): Fascia lata sling in blepharoptosis. Enhancement of result by postoperative adjustment.J Pediatr Ophthalmol Strabismus 13: 51.

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Received on December ZOth, 1989. Author’s address: Nurettin Akyol, Assistant Professor, Department of Ophthalmology, Faculty of Medicine, Karadeniz Technical University, 61080 Trabzon, Turkey.

The correction of ptosis with adjustable suture technique.

We discuss here the results of a simple technique for the correction of ptosis, performed by us as an alternative to other techniques. The basic princ...
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