Igal Leibovitch MD, Jean Paul Dray MD Tel-Aviv Medical Center ISRAEL

1. Long Term Results of Frontalis Suspension Using Autogenous Fascia Lata For Congenital Ptosis in Children Under 3 Years of age Igal Leibovitch MD, Jean Paul Dray MD Tel-Aviv Medical Center ISRAEL

2. Frontalis Suspension Surgery - Frontalis suspension is the procedure of choice for severe congenital ptosis with poor levator function - Operation is indicated when the eyelid blocks the visual axis causing amblyopia, or when an anomalous head posture is apparent

3. Autogenous Fascia Lata - 1909: Payr - 1922:Wright - 1956: Crawford - using it only in children older than 3 years - Difficulty in harvesting fascia - Insufficient amount of material - Post operative leg scarring

4. Autogenous Fascia Lata - Alternatives: Banked fascia lataSynthetic materials Second best - More local complications - Less favorable cosmetic results

5. Patients and Methods - A series of consecutive children, less than 3 years, with congenital ptosis who underwent frontalis suspension surgery using autogenous fascia lata as the sling material - Between January 1994 and December 2000

6. Patients and Methods - Upper eyelid margin position below the superior limbus (mm) (Severe = eyelid margin was 4 mm or more below superior limbus) - Levator muscle function less than 4 mm

7. Fascia Lata Harvesting Based on and modified from the technique described by Crawford Crawford JS, Repair of ptosis using frontalis muscle and fascia lata. Trans Am Acad Ophthalmol Otolaryngol 1956

8. Fascia Lata Harvesting – cont. - Identifying the anterior iliac crest (AIC) and the lateral condyle (LC) of the tibia - A 7 cm vertical incision starting in the upper quarter of the line connecting the AIC and LC, extending downwards to the knee

9. Fascia Lata Harvesting – cont. - Incision through skin, subcutaneous tissue and fat to the fascia lata

10. Fascia Lata Harvesting – cont. - Horizontal incision through the fascial fibers, two additional vertical cuts, parallel to the fascial fibers at the ends of the horizontal incision and extended toward the knee for 5-7 cm - Final fascia strip dimensions: 6 cm long, 2 cm wide, 1-2 mm thick

11. Fascia Lata Harvesting – cont. - Subcutaneous tissues closed with interrupted absorbable sutures - Polyglactin (Vicryl) 3-0 - Skin closed with Polydioxanone (PDS) 5-0 - An encircling pressure dressing

12. Frontalis Suspension Operation Operation based entirely on the technique described by Morax and Benia Morax S, Benia L. Suspension of the eyelid to the frontal muscle in the surgery of ptosis. Technic and indications. J Fr Ophthalmol 1986

13. Frontalis Suspension Operation– cont. - Eyelid crease incision and the entire tarsus is exposed after dissecting the preseptal and pretarsal orbicularis muscle - Three deep forehead skin incisions (lateral, medial and superior)

14. Frontalis Suspension Operation– cont. -A subcutaneous tract from the lower incisions to the eyelid incision and to the superior incision - The fascia lata strip is sutured in the middle to the tarsus

15. Frontalis Suspension Operation– cont. - The free ends are passed through the subcutaneous tracts and fixated to the frontalis muscle in the superior forehead incision

16. Results - Fourteen ptotic eyelids in 9 consecutive patients (4 girls, 5 boys) - Mean age of 15.3 months (6 mos to 2.5 yrs) - Mean follow up period of42 mos

17. Results - Surgical outcome was judged based on the criteria described by Manners (Eye 1994): Good: lid position within 1 mm below the superior limbus Moderate: lid position remained clear of the visual axis Poor: lid position obscures the visual axis

19. Pre Patient 1 Ptosis OU 18 months Post

20. Pre Patient 2 Post Ptosis OU 15 months

21. Pre Patient 9 Ptosis OS 24 months Post

22. Results – cont. - Fascia lata harvesting took about 20 minutes - Only one leg was needed to get the fascia - No recurrence of ptosis - No neurologic deficit or loss of leg function - No muscle herniation - Only one case of a hypertrophied leg scar

23. Discussion Alternatives: banked fascia lata and synthetic materials - Banked fascia lata: High ptosis recurrence rate -Wagner et al. (Ophthalmology 1984) - 8.3% - Wilson And Johnson (Ophthalmology 1991) - 50% after 9 years - Wasserman et al.(Arch Ophthalmol 2001) - 51.4%

24. Discussion – cont. Synthetic materials: (Prolene, Mersilene mesh, Gore-tex, Supramid) - High rate of recurrence - High rate of complications: Granuloma formation Infections Fascia extrusion

25. Discussion – cont. - Since Crawford’s publications, there were no other studies in which autogenous fascia lata was used in these young children -Naugle et al.(Ophthalmology 1997):good results in two children with congenital ptosis aged 3 years and one aged 2 years using the high leg incision

26. Discussion – cont. - Our study is the first, after many years, to report the feasibility of this technique in congenital ptosis in children less than 3 years old - Harvesting is easy and sufficient fascia was obtained, with no need to use more than one leg as the harvesting site - All children achieved satisfactory cosmetic and functional results

27. Discussion – cont. - The relatively higher site of fascia harvesting is advantageous: 1. Fewer cases of muscle herniations due to the deeper position of the fascia (Naugle, Ophthalmol 1997) 2. The fascia at this site is denser (Jordan & Anderson, Arch. Ophthalmol 1987) 3. The leg scar could be easily hidden even with shorts

28. Discussion – cont. - The harvesting of fascia latacan be quite easily performed, because of its constant and relatively superficial location - With training, inexperienced ophthalmologists can harvest the fascia effectively and safely

29. Conclusion - Although its long-term efficacy has to be further evaluated, frontalis suspension with autogenous fascia lata in children younger than 3 years appears to be a feasible, safe and effective treatment for congenital ptosis - Its use as a first option for sling surgery could reduce the post-operative complications, ptosis recurrence rate and the need for re-operations