Anterior approach levator plication for congenital ptosis,absorpable versus non absorpable sutures

Introduction

Blepharoptosis, or ptosis is the condition in which the upper eyelid is lower than normal. This condition narrows the vertical dimension of the palpebral fissure. It may be congenital or acquired. Ptosis may either be unilateral or bilateral and can be seen either alone or in conjunction with other ocular or systemic conditions. ¹ Surgical correction is recommended not only for cosmetic reasons but also for prevention of visual deficits. Several types of surgeries can be used in the treatment of congenital ptosis; according to its severity and levator muscle action. A frontalis sling is the traditional surgery employed for treatment of severe ptosis with poor levator function, while levator muscle resection is reserved for ptosis with fair to good levator function. ² Levator resection can be used to treat mild to moderate ptosis with at least 4 mm of levator function. Another procedure for correcting mild to moderate ptosis with a similar degree of levator function is the levator plication technique. ³ The type of suture used for levator plication may affect the surgical outcome.

The aim of this study was to compare the efficacy of two different suture types, nonabsorbable polyester (Ethibond) versus absorbable polyglactin 910 (Vicryl) in levator plication for correction of congenital ptosis with good levator action.

Patients and methods

This prospective, comparative interventional randomized study included 42 patients (27 males, 15 females; age range, 7–39 years), who underwent levator plication for correction of congenital ptosis. A computer-generated randomization table divided patient into two equal groups (groups A and B), which included 21 patients each.

In group A, double-armed 5/0 polyester (Ethibond) suture was used, and in group B, double-armed 5/0 Coated Vicryl^® (polyglactin 910) suture was used. Patients with unilateral congenital ptosis with good levator action were included in this study.

Patients aged more than 6 years with unilateral congenital ptosis and good levator function (more than 10 mm) were included in this study. Exclusion criteria included patients less than 6 years old; and with bilateral ptosis, fair (5–7 mm) or poor (4 mm or less) levator action, poor Bell’s phenomenon, acquired ptosis, other associated developmental lid anomalies or a history of previous lid surgery.

The technique, likely post-treatment results and potential complications were explained to all patients. Written consent was obtained from all patients. Consent included permission to publish their photos. This research was approved by the Institutional Review Board of the Alpha Vision Center and was adherent to the ethical principles outlined in the Declaration of Helsinki as amended in 2013.

Surgical technique and follow-up

All surgeries were performed under general anesthesia. The upper eyelid crease was marked. A skin incision was made and dissection in the sub orbicularis space was performed until the orbital septum was visualized. The orbital septum was identified and opened. The levator aponeurosis was exposed and the levator was tented. Three horizontal mattress sutures were made with 5-0 Ethibond in group A (Figure 1), and with 5-0 Vicryl in group B; these sutures were passed through the levator at a level determined according to the levator function and severity of ptosis. Three lid crease-forming sutures were placed; and the rest of the skin was closed in an interrupted pattern with 6-0 polypropylene sutures. At the end of the surgery, a reverse Frost suture was performed, and a dressing was placed. Postoperatively, the patients received systemic antibiotics, systemic steroids to decrease postoperative edema rapidly, topical antibiotics and lubricant eye drops and ointment at bedtime. All patients were told to use immediate cold compresses after the eyelid surgery to decrease postoperative edema. Postoperative evaluations were performed on the first postoperative day and after 1, 2, and 4 weeks and then after 12 and 24 weeks. After the postoperative edema subsided, we considered that a postoperative MRD within 1 mm of the desired height was indicative of a successful surgery. After 1 week had passed and postoperative lid edema had subsided, we excluded both overcorrected and under corrected cases from both groups. After 1 week of follow-up and exclusion of over corrected and under corrected patients, there were 19 cases in group A and 17 cases in group B. We performed statistical analyses using these numbers.

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Figure 1.

(a) Three Ethibond mattress sutures passed through the levator and tarsus and (b) sutures were tightened and the levator was plicated.

All data were collected, tabulated and statistically analyzed using SPSS version 19. Continuous quantitative variables were expressed as the mean ± SD. Continuous data were checked for normality with the Kolmogorv-Smirnov test. An independent samples Student’s t-test was used to compare two groups of normally distributed quantitative continuous data.

A repeated measures ANOVA was used to assess quantitative data for different measurement times in the same group. Categorical data were compared using a Chi-squared test. All tests were two-sided and p-values <0.05 were considered statistically significant.

Results

A total of 42 patients, including 42 eyelids and 21 patients in each group, underwent levator plication surgery. A successful outcome was achieved in 19 patients in group A and in 17 in group B after the first week. The remaining patients, including two in group A and four in group B, underwent revision surgery. The mean preoperative MRD was 1.15 ± 0.97 mm in group A and 1.23 ± 0.86 mm in group B. The eyelid heights obtained by the end of the first postoperative week were nearly maintained until the end of follow-up at 6 months postoperatively in most patients in group A but not in group B (Figure 2).

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Figure 2.

Line graph showing MRD measurements at different times among the studied groups.

There was no significant difference between both groups regarding baseline characteristics such as age and sex.

The MRDs in postoperative week 1 and weeks 4, 12, and 24 are summarized in Table 1.

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Table 1.

Comparison of MRDs at different measurement times among the studied groups.

Variable	Group A (n = 19)	Group B (n = 17)	t-test	p-Value
Pre MRD
Mean ± SD	1.15 ± 0.97	1.23 ± 0.86	−0.262	0.793 (NS)
Range	0–2.5	0–2
MRD first week
Mean ± SD	4.05 ± 0.36	3.95 ± 0.34	0.00	1.00 (NS)
Range	3.5–4.5	3.5–4.5
MRD fourth week
Mean ± SD	3.78 ± 0.25	3.64 ± 0.29	1.543	0.129 (NS)
Range	3.5–4	3–4
MRD twelfth week
Mean ± SD	3.60 ± 0.42	2.55 ± 0.88	4.484	0.0002 (S)
Range	2.5–4	1–3.5
MRD twenty fourth week
Mean ± SD	3.60 ± 0.42	2.52 ± 0.85	4.746	0.0002 (S)
Range	2.5–4	1.5–4
p-Value#	<0.001 (HS)	<0.001 (HS)

There was no significant difference between both groups regarding MRD after 1 and 4 weeks of intervention. However, there was a significant difference between them regarding MRD at 12 and 24 weeks.

Comparing MRDs at different time points in group A, showed that there was no significant difference between them. MRD was found to be almost consistent at 1 and 24 weeks and it was the same at 12 and 24 weeks.

However, by comparing MRDs at different time points in group B, a significant difference was found between them (p-value < 0.05). MRD was found to decrease significantly at 12 weeks postoperatively compared to 1 and 4 weeks and it was consistent at 12 and 24 weeks with no significant difference between them (Figure 3).

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Figure 3.

(a) Preoperative, (b) 1 week postoperative, and (c) 24 weeks postoperative in group B.

In addition, by comparing the MRDs at 24 weeks with that preoperatively, a significant increase was found.

Regarding postoperative lid lag and lagophthalmos, they were prominent in both groups and there was no significant difference until the fourth week. After the fourth week both lid lag and lagophthalmos were significantly improved in group B but not in group A.

No serious complications were present in our study except for one case in group A, who developed an infection in the deep lid tissues. The patient was managed with systemic antibiotics and anti-inflammatory therapeutics. The wound was opened 6 weeks postoperatively and Ethibond sutures were removed using a surgical microscope.

There was no difference in the contour of the eyelids between the two groups.

Discussion

The correction of ptosis with an aponeurotic tuck has been described by many authors. Some authors had described that this method as providing beneficial results; however, others have reported a high rate of ptosis recurrence. ³ The purpose of surgical sutures is to approximate tissues, without producing excessive tension, while minimizing tissue injury and ischemia. Modern suture material should have good handling ability, predictable tensile strength, secure knot-tying, improved visibility, and healing and enhancement with an antibacterial agent to guard against infection. ⁴

In our study we used two types of sutures in levator plication for correction of congenital ptosis. MRDs were higher at the end of follow up in Ethibond group than in Vicryl group. In Ethibond group MRD was found to be almost consistent at 1 and 24 weeks and it was the same at 12 and 24 weeks, while in Vicryl group MRD was found to decrease significantly at 12 weeks postoperatively compared to 1 and 4 weeks and it was consistent at 12 and 24 weeks. One of the first authors who described tucking was Fox in 1979. He reported only nine patients on whom he had used three double-armed Dexon or Vicryl sutures. He noted that the levator tuck technique had uncertain and unpredictable results. Fox’s ⁵ disappointing results with this procedure are understandable because it was one of the earliest experiences reported. As the technique has gradually evolved and become refined, later reports have described much better results. Harris and Dortzbach ⁶ used three 5-0 chromic sutures but noted occasional prolapse of the superior fornix. Although, Fox, Harris and Dortzbach had disappointing results, success rate was 95% in the Older study, in which nonabsorbable Prolene sutures were used in 113 eyelids. ⁷

Liu reported that long-term results were excellent, as no change in the lid height was observed. Most of the patients in the Liu ⁸ study had acquired ptosis (approximately 90%) with levator action ranging from 11 to 17 mm; 6-0 nonabsorbable nylon sutures were used in this study. Johnson et al. ⁹ concluded that nonabsorbable silk sutures may be superior to absorbable polyglactin, because fewer surgical revisions were needed. Silk demonstrated superiority to polyglactin when a hang-back suture was employed. Berlin and Vestal ¹⁰ used 6-0 Vicryl suture and found a lower long-term success rate due to a drop in lid level clustered at the 2- to 4-month period postoperatively.

The results from the studies by Fox, Harris, Dortzback, Berlin and Vestal were consistent with our results for group B, in which we used absorbable sutures, and our findings for group A, in which we used nonabsorbable sutures, are in accordance with the results of both Liu and Older.

In the study by Kumar et al., ¹¹ with plication of the levator aponeurosis using absorbable sutures, the upper eyelid continued to fall after the fourth week until the final follow-up visit at 3 months. This drooping of the lid postoperatively was not observed in cases of levator resection. They attributed postoperative drooping of the upper eyelid to the cheese wiring of sutures through the tissue, the use of absorbable sutures, the loosening of knots with time postoperatively and the lack of a raw surface. We agree with Kumar regarding the secondary drooping of the upper eyelid with levator plication using absorbable sutures, but this postoperative drooping did not occur when we used nonabsorbable sutures in group A. They also mentioned that levator plication failed to correct the dystrophic muscle in congenital ptosis.

In a study by Anderson and Dixon, ¹² they found that tucking of the aponeurosis may provide temporary results: first, no raw surfaces were obtained, and second, the sutures were tied in a thin aponeurosis, resulting in cheese wiring of the sutures. Hussain ¹³ utilized three double-armed absorbable sutures for levator plication. He obtained good corrective results in 92% of the patients. A limitation of the Hussain study was the short follow-up period.

Hong et al. ³ reported successful outcomes (94.5%) in 241 of 255 patients using under through levator complex plication. They used 6-0 nonabsorbable nylon sutures in their new technique. They attributed good outcomes to a decrease in the likelihood of suture cheesewiring with their new technique. Yulish and Pikkel, ¹⁴ used (Ethibond) sutures for levator advancement blepharoptosis repair and reported that mean MRD measurements were almost constant for 1 year; or longer. They did not observe any significant complications; such as inflammation, granuloma formation or infection when using nonabsorbable Ethibond sutures in their study.Many surgeons find silk the easiest of all suture materials to work with. Bartley et al. ¹⁵ used 6-0 silk sutures in their study with good results for levator advancement. However, using silk sutures in levator advancement leads to some complications such as loss of strength due to gradual degradation in the follow up over several years, inflammation and allowing spaces for bacterial growth. Epithelial-lined suture tracks, erythema around sutures, and suture abscesses are also potential complications that may occur with the use of silk. Polypropylene (Prolene) is a synthetic nonabsorbable suture material; many surgeons use polypropylene 5-0 or 6-0 for suturing the levator aponeurosis to the tarsus. However, it can serve as a nidus for infection and has some stiffness, which may erode the skin and conjunctiva leading to extrusion of the suture’s ends. ¹⁴

Polyester (Ethibond) is a nonabsorbable suture that decreases the chance of recurrent ptosis due to good and durable knot security. Ethibond has good tensile strength and has demonstrated high efficacy in other surgical procedures such as in knee arthroplasty revision as it provides high fixation of the tibial tubercle osteotomy segment, with fewer complications compared with conventional fixation methods that uses wires and screws. ¹⁶ Polyglactin 910 is a synthetic absorbable suture that is used for suturing levator aponeurosis to the tarsus. However, the sutures weaken within a few weeks, which may explain the risk of ptosis recurrence. The weakness of surgical scars can have an effect 1–2 weeks after the operation. Absorbable sutures create more inflammation than nonabsorbable sutures and can lead to granuloma formation, but they are less prone to infection than permanent sutures. ¹⁷

In fact, we believe that the absence of a raw surface is a disadvantage in levator plication with absorbable sutures which can lead to postoperative drooping of the lid when lysis of the suture occurs, while this feature is a great advantage when nonabsorbable sutures are used due to the ease of reversibility or modifications with additional surgery due to preservation of tissue planes and decreased adhesions. We also noted that the postoperative stability of lid height was greater in patients with mild ptosis than in those with moderate and severe ptosis, which may be explained by a decrease in the likelihood of Cheese wiring of sutures due to the decreased force of tissue tearing in mild cases with narrow distance plication and vice versa in cases of severe ptosis. We also found that early postoperative lid rubbing decreased the postoperative lid height in group B.

The novelty of our study was its prospective nature with a focus on congenital ptosis with good levator function and comparison between nonabsorbable and absorbable suture used for levator plication.

Limitations of the current study include operation on only patients with good levator function without inclusion of those with fair or poor levator action, the small number of patients and the relatively short duration of postoperative follow up. Inconsistent outcomes for this method have been attributed to the lack of a raw surface for permanent adhesion during plication of the aponeurosis specially when using absorbable sutures. Non scraping of the anterior surface of levator muscle to create a row surface is another limitation in our study. We think that scraping the anterior surface of levator muscle may lead to consistent outcomes over long period of follow up when using absorbable sutures in this technique.

Conclusion

Using nonabsorbable Ethibond suture in levator plication was a safe and effective technique with durable consistent results. Levator plication has several advantages, including simplicity and ease of reversibility when adjusting the eyelid height.