Our Modification and Expertise with Ptosis Reversal

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Back story:

If congenital ptosis is not treated promptly, it might result in permanent visual impairments in addition to an asymmetric facial look. With a tolerable recurrence rate due to graft slippage, Crawford's technique of suspending the eyelid from the frontalis muscle with fascia lata is being utilized today to treat congenital ptosis. To eliminate this problem, this procedure has undergone numerous adjustments. In this study, we relate our experience with one such modification that has improved the results.

Methodology:

This retrospective analysis was carried out over 10 years at a private tertiary care hospital in Karachi. 26 patients in total met the requirements for inclusion. Under general anesthesia, a modified Crawford's operation was performed on each subject.

Statistics:

In this survey, there were 1.5 times as many men as women. 17 patients overall (or 65 percent) exhibited unilateral ptosis. 7 + 3 years old on average was the presentation age. All of our patients showed poor levator function (5 mm excursion), with a mean of 3 mm and a mean grade of ptosis of 4 1.6 mm. The average marginal reflex distance (MRD) before surgery was +1.8 0.6 mm. At the four-week follow-up in this study, the patients' average postoperative MRD was 4.2 mm, with a standard deviation of 0.7 mm.

Consequences:

Suturing the fascial sling to the tarsal plate ensures adequate anchorage and prevents recurrence, even though Crawford's method for correcting ptosis shows promising results.

Fundamentals:

Weak levator palpebrae superioris activity leads to an aesthetic and functional issue known as upper eyelid ptosis. Ptosis can be acquired if it develops more than a year after the birth or congenital if it exists from birth. The levator muscle performs poorly by nature when the ptosis is congenital [1]. The upper eyelid must therefore be raised using a different motor unit. The frontalis sling surgery is the gold standard in cases with impaired levator function, even though there are other ways to treat ptosis [2–5]. Tensor fascia lata (TFL) slings are credited with being developed by Payne [7] to correct ptosis.

Crawford treated congenital ptosis with suboptimal levator function in 1956 by suspending the frontalis and using fascia lata [8]. Crawford's method was a huge success since it produced positive results and decreased the incidence of recurring ptosis. Crawford's method has been applied for several years with a tolerable rate of sling slippage [9]. But Spoor and Kwitko [10] developed a method of directly fixing the tarsal plate with the frontalis sling in 1990. This method aids in defining the lid crease and modifying the lid contour.

In this paper, we discuss our experience adapting Crawford's technique to avoid early graft slippage and recurrence following surgery.

Components & Techniques:

In a private tertiary care hospital in Karachi, Pakistan, the Department of Plastic and Reconstructive Surgery undertook this retrospective study. The study lasted for ten years (2010-2020). We considered individuals with intact Bell's phenomenon who underwent surgery using Crawford's approach and were over the age of four years old and had inadequate levator muscle function. The study excluded patients who received secondary ptosis correction surgeries, exhibited jaw winking phenomena, or,  had preoperative amblyopia or conjunctivitis.

To obtain patient information, we looked at their age, gender, levator function, preoperative and postoperative degree of ptosis, lid crease height, lagophthalmos problems, recurrence time, signs of exposure keratitis, and satisfaction with the treatment.

Interventional Methodology:

Make three horizontal skin marks on the eyelid, one each on the medial, lateral, and lash lines (Figures 1 - 1 and 2). Here, the skin crease will develop. The mechanical advantage of the sling in elevating the lid will be lessened by a greater crease or insertion. Make two further vertical incisions just above the eyebrow, one slightly lateral to the mark for the lateral eyelid and the other somewhat medial to the mark for the medial eye. To complete an isosceles triangle, make a mark on the forehead that is above and between these two brow marks. To achieve symmetry, we prefer to mark and treat both eyelids simultaneously.

Insert stab wounds through each mark. To attach the tarsal plate to the frontalis muscle, we employ autologous fascia lata. Through creacreatingte two isosceles triangles, pulling one fascial strip from each eyelid incision (Figures 1–3) to the brow incisions (Figures 1–4 and 5), and then through the forehead incision (Figure 2).

Tends to result:

Throughout the study, we performed operations on 32 different patients, but only 26 of them met the requirements for inclusion. The male to female ratio of these 26 cases was 1:1.5, with 17 (65%) having unilateral ptosis and 9 (35%), having bilateral ptosis. 7 + 3 years old on average was the presentation age.

Weak levator function (5 mm excursion) was seen in all of our patients, with a mean excursion of 3 mm and a mean grade of ptosis of 4 1.6 mm. 21 (82%) of the patients had no lid crease at presentation, and the mean preoperative MRD was +1.8 0.6 mm and the mean distance between the lid creases was 3 mm. Both unilateral and bilateral cases had similar outcomes.

Under general anesthesia, our patients underwent a modified Crawford's operation, as previously mentioned. There were 25 patients overall or 95% of them, and none of them had any late or immediate issues other than postoperative lagophthalmos (Table 1). On the tenth postoperative day, one of our patients developed localized conjunctivitis, which was treated with topical medicines. There were no more signs of exposure conjunctivitis in the patient. At a mean follow-up of 20 months, none of our patients had recurred ptosis; nonetheless, two (7.6%) patients needed modest adjustments because they weren't content with the asymmetrical outcome despite good postoperative MRD. For an average follow-up period of four weeks, all patients were monitored every week. At the four-week checkup, our patients' mean postoperative MRD was 4.2 0.7 mm.

Forum:

Ptosis can be caused by a variety of acquired or congenital conditions [11], and when it occurs, it is only a symptom and not a diagnostic [6]. Therefore, ptosis necessitates a complete clinical assessment. The degree of levator function typically affects the surgical method chosen to correct ptosis. Ptosis is categorized into three groups based on MRD 1, which measures the distance between the upper lid edge and the corneal light reflex (typical MRD 1: 4-5 mm). Mild, moderate, and severe ptosis can all be attributed to unilateral ptosis depending on the MRD 1 difference between the two eyes [6]. The function of the levator might be poor (less than 5 mm), acceptable (6–9 mm), or good (10-15 mm).

Ptosis is surgically corrected using fascia lata slings and other tools. It is possible to collect fascia lata from autogenous sources or from donor material that has been lyophilized or exposed to radiation. Frontalis slings can also be made from silicone [15], marceline mesh [14], deep temporalis fascia grafts, and palmaris tendon grafts. Comparing fascia lata to silicone rods, which have the advantage of being elastic, fascia lata has good biocompatibility.

The advantage of a lid crease incision with tarsal fixation is that it creates a deep lid crease as well as a secure attachment to the tarsal plate. When present, lash ptosis is simple to treat using this method.

The lid structures are only slightly disturbed when using a supralash stab incision, and the levator insertion is unaffected [16]. Crawford's twin triangle technique provides the lid a nice shape. When adjusting the height of the operated lid with a frontalis sling, the degree of ptosis and the degree of the bell's phenomenon serve as guidance. The requirement to elevate the lids to a level just below the upper limbus is eliminated by poor levator and good bell's phenomenon. Patients with weak bell's phenomenon and postoperative lagophthalmos, on the other hand, are more likely to develop exposure keratopathy; as a result, their lids should only be elevated slightly to clear the visual axis. According to Young et al., lagophthalmos is an issue that comes with this procedure by nature.

Our study's primary drawback is that it was conducted in a single center. Additionally, only a few patients who met the requirements for the research underwent surgery. Future large-scale research projects of similar nature are required.

Implications:

Crawford's frontalis sling suspension treatment yields positive and long-lasting results. When the frontalis operates effectively, stitching the fascial sling to the tarsal plate ensures good anchoring and prevents relapse. Consequently, based on the findings of our investigation, we draw the conclusion that our alteration can result in more hopeful outcomes with less difficulty.