Comparison Of The Curative Effect Of Two Kinds Of Frontalis Operative Procedures On Severe Blepharoptosis

Objective:Congenital ptosis is common clinical ophthalmological congenital malformation.The upper eyelid covers part or all of the visual axis, so patients tend to use excessive construction of the frontalis or look up to replace. It induces the forehead stripe to increase , eyebrows high vertical and to change the neck muscles or the cervical spine. Especially in severe congenital blepharoptosis, it not only impedes the appearance , can also causes form deprivation amblyopia.Ptosis brings great harm to the development of children's vision and mental growth.Surgery is the only way to deal it. At present ,there are so many operation type to correct severe congenital ptosis,including:(1) Enhancing the strength of levator palpebrae superioris muscle,for example to shorten palpabralis.(2)turning to frontalis:frontalis suspension surgery may use several different sling materials.Materials include autogenous or allograft fascia lata ,silk,biological materials and fish line and so on.It creates a linkage between the frontalis muscle and the tarsus of the upper eyelid.The use of intermediary objects as supplementary material has obvious advantages in frontalis suspension surgery.It is simple, no obvious scars and small disturbance for vulnerable tissue of children.There is no effect to redo another procedure if any reaction shows up.However, the influences of the surgery will be contacted with the materials.It increases chances of re-admission surgery when there is infection, suture loosening, exclusion and so on.Frontalis suspension surgery using frontalis direct does not appear the problems above,for it turns to the frontal muscle flap with blood supply and innervation.It takes a certain postoperative efficacy. Based on the foregoing analysis, the editor considers that the surgery using frontlis is the best way to treat the severe congenital ptosis.Classic rectangular frontalis muscle flap was used more than others in surgery produre currently.A lot of clinician have proposed modified frontalis muscle flap in recent years.They trim it into various shapes in the surgery.Such as fan-shaped flap, trapezoidal valve, 3 valve, etc.We glided the frontalis directly fixed on the tarsus of the upper eyelid to suspend. This method has only one double eyelid incision.For no incision on the frontalis ,it decreases the injury on frontalis itself and makes less bleeding.Considering the low injury probability of Temporal branch of facial nerve and supraorbital neurovascular bundle,less postoperative bleeding and simple to operate,we chose it to contrast with classic frontalis flap basing on the merits above.To compare the long-time curative effects and complications of the two surgical techniques on severe congenital ptosis,it provides the basis for selecting the suitable procedure.Methods:1 We chose the cases that the downward ofupper eyelid≥4mm, MS of musculus levator palpebrae superioris<4mm and MS of frontalis>7mm.2 Group:A total of 33 patients(41eyes) with severe congenital ptosis who underwent frontalis muscle suspension surgery were allocate to two groups:Ⅰ. simplified frontalis muscle flap suspension surgery group.Ⅱ. orectangular frontalis muscle flap suspension surgery group;3 Operative method:(1) simplified frontalis muscle flap suspension: isolating tissue in the orbicularis oculi muscle and orbital separation up to the supraorbital margin and separating the frontalis and periosteum to 1cm above the eyebrow.Making a transverse incison from the junction of the frontalis and oculi muscle and separating the skin and the oculi muscle to 1cm above the eyebrow,so the frontalis can be exposed clearly and its width is the same as the palpebral fissure. It will be separated a direct drop-down flap. (2) orectangular frontalis muscle flap suspension:making two incisions on both side of the free margin of the frontalis,then it becomes a frontalis flap of 20mm.Fixing the frontalis flap on the upper 1/3 of the tarsus at 3 points of the middle ,the inside and the outside.In the procedure,adjusting the height and radian is significant.The height is 9mm when patients look ahead,and the palpebral margin is 1mm above the limbus of cornea.Cut the extra frontalis flap for pathology.Suturing the incision to double eyelid without trichiasis and enstrophe.Making Frost suture on the lower eyelid skin,and fill erythromycin eye ointment in the conjunctival sac.Fixing the suture on the forhead to protect the cornea.The eye is given pressure bandaging.4 observation index the clinical effects and complications were observed and evaluated according to the standards as follows:(1)position of upper lid rim after ptosis correction (2)the upper lid height(3) arc of upper palpebral rim (4)eyelid closure (5)phenomenon of lagophthalmos in down-gaze (6)double-fold crease(7) entropion and trichiasis (8)incident of exposure keratitis.5 Follow-up time:6~12moths.Results:1 Efficacy of postoperative ptosis1.1 efficacy of 1 month after the surgery:Comparing two surgical groups,the difference was not statistically significant (P>0.05).GroupⅠ(simplified frontalis muscle flap suspension surgery group ):16cases(22eyes),20eyes were excellently corrented,1eye was wasundercorrection,and 1eye was over correction.GroupⅡ(orectangular frontalis muscle flap suspension surgery group):17(19eyes),16eyes were excellently corrented, ,and 3eyes was over correction with none was undercorrection.1.2 efficacy of 6 months after the surgery: Comparing two surgical groups,the difference was not statistically significant (P>0.05).GroupⅠ(simplified frontalis muscle flap suspension surgery ):16cases(22eyes),18eyes were excellently corrented,3eyes were corrected,and 1eye was partly corrected.GroupⅡ(orectangular frontalis muscle flap suspension surgery):17(19eyes),17eyes were excellently corrented,and 2eyes were partly corrected.2 Regression of postoperative ptosis2.1 1 week after the surgery:the regression of the two groups is 0.45±.0671mm,0.95±0.705mm respectively.2.2 1 month after the surgery: the regression of the two groups is 0.36±0.658mm,0.89±0.737mm respectively.2.3 3 months after the surgery: the regression of the two groups is 0.32±0.477 mm,0.79±0.631 mm.2.4 6 months after the surgery: the regression of the two groups is 0.27±0.456mm,0.74±0.562mm.Comparing the two groups,the difference of the regression of 1 week,1 month,3months,6months after the surgery is statistically significant(P<0.05).3 Complications3.1 the complications of postoperative 1month: Comparing two surgical groups,the difference was statistically significant (P<0.05).(1)Exposure keratitis:1 eye in groupⅠ,3 eyes in groupⅡ;(2) margin incisure:1 eye in groupⅠ,2 eyes in groupⅡ;(3) margin angulated deformity:none in groupⅠ,1 eye;(4) palpebral fissure asymmetry: groupⅠhad 1 eye,Ⅱhad 2 eyes;(5)double-fold crease of upper eyelid were obviously in the two groups;(6)eyelid closure were observed in the two groups;(7)entropion and trichiasis did not appear;(8)both the two groups have lagophthalmos in down-gaze.3.2 the complications after the surgery: Comparing two surgical groups,the difference was not statistically significant (P>0.05). (1)Exposure keratitis:none of the two groups; (2) margin incisure:1 eye in groupⅠ,1 eye in groupⅡ; (3) margin angulated deformity:none in groupⅠ,1 eye in groupⅡ; (4) Eyelid closure were satisfied in most cases except 1 case in groupⅠand 2 cases in groupⅡhad a 1 ~ 2mm dysraphism of the palpebral fissure;(5) Lagophthalmos in down-gaze appeared in both groups;(6)double-fold crease of upper eyelid:GroupⅠhas 10 cases of double eyelid folds appearde shallow,1 case disappeared;Ⅱgroup of 7 cases of double eyelid folds shallow,2 cases of disappearance;(7) entropion and trichiasis did not appear;(8) Symmetry of the upper lid height was satisfied in all the cases.4 The average of the height of palpebral fissure of 33 patients is 3.56±0.867mm preoperative, 8.12±0.781mm of 6 months after the surgery,and the difference was statistically significant (P<0.01).The difference of eyes closure is not statistically significant(P>0.05). Conclusion:1 The general of the efficacy of simplified frontalis muscle flap suspension is better than rectangular frontalis muscle flap suspension.2 Comparing the two operation type, the simplified frontalis muscle flap suspension cause fewer complications and less repression.3 Simplified frontalis muscle flap suspension is valuable of extension for its simplicity and stable.