Plastic Surgery Unit, Royal Infirmary, Glasgow

Transcription

1 THE TREATMENT OF PTOSIS AND EPICANTHAL FOLDS 1 By J. C. MUSXARD~, F.R.C.S. Plastic Surgery Unit, Royal Infirmary, Glasgow THE treatment of ptosis of the upper lid falls into the province of both the plastic surgeon and the ophthalmic surgeon, and I am bound to say that, with some notable exceptions, it is often better carried out by the latter rather than by the former. This is largely due, I am sure, to the ophthalmic surgeon's greater familiarity with the structures around the eye, and with his better appreciation of the detailed anatomy and physiology of the levator muscle. Ptosis may be congenital or acquired : the latter condition arising, for instance, as a result of neurological disease either locally in the third nerve or in the central nervous system, or it may be the result of trauma--as in avulsion or section of the levator muscle. It may on occasion be due to the presence of local disease such as neurofibroma or cavernous hremangioma, or it may rarely be a manifestation of hysteria ; and, of course, it may be part of the clinical picture in myasthenia gravis. It is not proposed to deal here with these acquired conditions in any detail, and I shall make only the rather broad observation that those cases amenable to surgery nearly all require a sling type of correction, using fascia lata if direct repair of the levator muscle is impossible. Congenital ptosis, on the other hand, is a very different problem, and it is worth recalling that Berke has stated that there are over eighty different operations for dealing with ptosis. There are, however, three main lines of attack : z. Operations utilising the upward movement of the superior rectus muscle to raise the lid. 2. Sling operations designed to hitch up the lid either to the supra-orbital ridge or to frontalis muscle. 3. Operations involving shortening of the levator muscle or its aponeurosis. The first group need not concern us greatly for, apart from its being properly within the province of the ophthalmic surgeon, the advisability of linking the superior rectus to the levator, either by direct attachment as in Motais' operation or by a suture of fascia lata as in the Dicky, is open to question. Amongst several disadvantages are lagophthalmos with a constant lack of closure of the palpebral opening, failure of the cornea to roll up under the lid during sleep, and imbalance of the ocular muscles with production of diplopia. The second group of techniques embraces a wide variety of operations including Hess stitches intended to cause subcutaneous scarring of the skin of the upper lid, utilisation of the orbicularis muscle and orbital fascia to hitch up the lid to the frontalis, as in the Reese operation, and the use of fascia lata similarly to hitch 1 Since this paper was read before the British Association of Plastic Surgeons the writer has on two occasions substituted medium-thickness silk thread instead of fascia lata in the technique for correction of ptosis by hitching the upper lid to the frontalis muscle with completely satisfactory results. 252

2 THE TREATMENT OF PTOSIS AND EPICANTHAL FOLDS 253 the lid to the frontalis muscle, a procedure first described by Wright and later elaborated by Lexer and others. The only technique of this group of which I have any considerable experience is the use of fascia lata strips and I shall say more about this prese~htly. This brings us to the third group of operations for correction of ptosis : shortening of the levator muscle itself. Without doubt more cases are treated to-day by one or other modification of the techniques described by Everbusch and by Blaskovics for shortening of the muscle than by any other technique. In one case the approach is made to the aponeurosis of the levator muscle via an incision in the skin of the lid, and in the other the approach is from the conjunctival surface. The first technique, that of Everbusch, has several disadvantages, chiefly owing to the tendency to eversion of the upper lid, unless a large amount of the tarsal plate is excised, and the fact that a scar--albeit a fine one--is left on the skin surface. The Blaskovics technique, on the other hand, has neither of these disadvantages, at least in my experience, although Stallard states that the sharp upper edge of the cut tarsal plate may tend to tilt backwards on to the cornea if not affixed to the levator tendon and he advises special buried sutures to prevent this, and it is this Blaskovics' form of treatment that I would like to consider. I am not proposing to describe the actual technique of the operation-- accounts of which or of variations of which may be found in considerable detail in the literature--but rather to collate several points which I have found to be helpful in my own moderate experience over a period of years. It used to be widely held that resection and advancement of the levator muscle was worth considering only in cases in which some definite evidence of levator action could be elicited--but opinion to-day is changing. Matthews (I949), who has had more experience of this work than most, states : "For congenital ptosis, shortening and advancement of the levator muscle is the most satisfactory method of correction, even if no action of the muscle can be detected pre-operatively." Scott (1952) has re-endorsed this maxim and added that "if the superior rectus is not paralysed, then one should undoubtedly do a resection and advancement of the levator," thus emphasising the necessity for the eye being able to roll upwards beneath the lid in sleep. A consideration of the anatomy of the eye (Fig. I) at this point may be helpful. The levator muscle, it will be seen, splits into three main layers: a small slip becoming inserted into the conjunctiva of the upper fornix, a large main slip going forward as an aponeurosis over the upper edge of the tarsal plate to be inserted into the skin of the lid and the lower third of the anterior surface of the tarsal plate, and a third slip finding attachment to the upper edge of the tarsus itself. This last slip is composed of unstriped muscle fibres and is one of the muscles of Miiller. Many people, including myself, have on occasions found the levator aponeurosis and muscle to be abnormally thin in cases of ptosis but this is not agreed by all, and Matthews records that it is often surprising how bulky it is. Scott, discussing this point, suggests that those surgeons who have found the aponeurosis thin and friable have mistakenly dissected out and resected only Mtiller's muscle and may have failed to advance the aponeurosis along with it. My own opinion is that this does not accord with the facts in all cases. The point, however, which Scott makes--that the central slip of muscle, which may be of a more reddish colour than the aponeurosis, should be identified as well as the 3 E

3 254 BRITISH JOURNAL OF PLASTIC SURGERY aponeurosis itself so that the latter can be resected with certainty along with it-- is of paramount importance, and its neglect will certainly result in cases showing a disappointing lack of improvement. One other point about the exposure of the levator aponeurosis to which I should like to draw attention is the need for carrying the dissection well out towards each canthus in order to divide the lateral horns running out on each side to become attached to the canthal ligaments. Unless this is carried out assiduously the aponeurosis is difficult to free easily and draw forward for resection. APONEU ~O~ S OF LEVATOR. FORVC~,D CONTINUATION OF / I:ASCtAL 5HEATH OF LEVATOR. ORBITAL FAT. FA$CIAL SHEATH OF LENATOR. L EVATOR MUSCLE. ATTACNHENT TO O~BITAL S~.I=q'UM ~ U P P E R ~'0RNIX. MULLEF~ PIUSC L E MUt. LE RfS HUSCLE. PRIMARY INSERTION OF k EVATOR. FIG. I Anatomy of the human eye. (After Whitnall.) (Reproduced by courtesy of the "British Journal of OphthMmoiogy.") The question of how much or how little aponeurosis one should resect may puzzle some as there are almost as many formulm for achieving the correct elevation of the lids as there are for achieving the correct position of the nipples in mammaplasties. In practice, most surgeons resect from IO to 15 mm. of aponeurosis and muscle and about 2 to 3 mm. of tarsal plate, according to the degree of ptosis, and the results are, in the circumstances, remarkably uniform. Stallard (1957) considers it important to conserve as much of the tarsal plate as possible, partly because it is moulded so excellently to the shape of the cornea and party because the uncut upper edge is soft and fine and not square and sharp. In most instances the operation is performed between the ages of 2 and 3 years, or even earlier if the ptosis is severe and the child has begun to show evidence ofpostural deformity. In severe cases it may be impossible to achieve a completely satisfactory result in one operation, because although a greater resection of levator will achieve a greater elevation, the lids may not close adequately during sleep, and despite the fact that the cornea may be covered severe conjunctivitis may result. If operation is not carried out until adult life less satisfactory results are achieved on the whole, but if the ptosis is not too severe (Fig. 2) quite a reasonable improvement can be expected.

4 THE TREATMENT OF PTOSIS AND EPICANTHAL FOLDS 255 In Blaskovics' description of the operation he advised the insertion of mattress sutures between the upper fornix and the skin to create a fold in the eyelid skin and to re-form the fornix. Spaeth, however, in his book on ophthalmic surgery, suggested tying the sutures over silk or other material on the skin surface to obviate cutting into the skin of the lid. For my own part, I used to insert three such sutures and tie them over a single length of fine rubber tubing, as I still do with the main sutures, but I find that they are not always necessary, and it has been suggested by Matthews that they may be a contributory cause of partial failure due to small areas of muscle ischa:mia and fibrous replacement resulting from, mattress sutures inserted so close to the cut end of the muscle. A B FIG. 2 Ptosis with moderate epicanthal folds. A, Before operation. t3, After Blaskovics' operation and the writer's operation for epicanthal folds. Post-operatively some surgeons make a point of lifting the lower lid to meet the upper by means of a suture in the lid margin, thus allowing for relaxation of the levator. Others, including Blaskovics himself, advise fixing the upper lid down to the cheek. Nowadays I do neither but carefully close the lids digitally and cover them with a Vaseline-smeared eye pad. This is left on for four days and the eye then left completely uncovered. The mattressed muscle sutures are removed in twelve days, and it is explained to the patient's parents that the full effect of the operation will take two to three months to be seen. They should also be warned to note whether there is any considerable failure of the lids to close at night and if this is the case to insert liquid paraffin or other oily drops when the child goes to bed. Turning now to those cases in which a levator resection is not applicable-- cases of total paralysis of the third nerve and the majority of cases of acquired ptosis--the method of choice in my hands is the Lexer type of operation--the use of fascia lata slings from the lid margin to the frontalis muscle. Such a procedure gives a certain amount of movement to the lid and allows of closure of the eye at rest. The technique which I follow for introducing the fascial strip--which is inserted in the form of a W--is to make five small incisions (Fig. 3) and then introduce a fine trocar and cannula backwards along each track to be followed. The trocar is removed and the fascia, on a long straight needle, can be threaded

5 256 BRITISH JOURNAL OF PLASTIC SURGERY through the cannula which is then withdrawn. The tension of the fascia is adjusted to suit the needs of the case and the fascial knots in the frontalis are secured by a silk whip-stitch. Thus in congenital absence of the eye (Fig. 4) the eyelid can be brought into almost normal position at the time of operation as there is no cornea to be covered. In total third nerve paralysis, on the other hand, a balance must be struck between full opening and retention of the ability to cover the cornea at rest. Matthews has used a static sling and passed the fascial strips through small holes drilled in the supraorbital ridge instead of threading them into the frontalis, i ~ on the grounds that the necessity for elevating the eyebrows in order to raise the lids gives rise to an undesirable grimace. I have not considered this grimace to be so unpleasant myself and indeed I have observed... that most patients with severe ptosis of some years' standing have developed a reflex arching of the eyebrows in an attempt to raise the lids, and they tend to continue Fro. 3 this grimace--if one cares to call it such--whatever else Technique of introducing may be done to relieve them of their disability. fascia lata strip into upper Finally, we come to the epicanthal folds. Here, as eyelid, using trocar, plastic surgeons, we are on very much more familiar ground, for basically the treatment of these folds should be a simple one of rearrangement of tissues to take away that which hath and give it to that which A ]3 FIG. 4 Fascia lata sling to frontalis in congenital absence of eye. A, Before operation. ]3, After construction of socket and elevation of lid. hath not. Unfortunately it is not quite as simple as that and here again the long list of names associated with the correction of these folds bears eloquent witness to this melancholy fact. Many normal children show a slight degree of bilateral epicanthal fold at birth, but this gradually disappears with forward growth of the nasal bones. Rarely

6 THE TREATMENT OF PTOSIS AND EPICANTHAL FOLDS 257 the folds may be excessive and permanent, and such permanent folds are frequently met with as an accompaniment of congenital ptosis. The folds may be dealt with by division and insertion of a small Wolfe graft or by some form of modified Z-plasty, either single or double. The first procedure Xr A B FIG. 5 Correction of epicanthal folds. A, Blair's technique. B, Spaeth's technique. (After Spaeth.) FIG. 6 Fig. &--Writer's technique for correction of epicanthal folds. A, Horizontal incision carried as far medially as site of new canthus. Vertical incisions midway between X and X'. Length of incisions approximately to scale of diagram. B, Flaps well undermined. C, The suture transfixing the canthal ligament at X and the medial end of the horizontal incision should pick up the deeper tissue at X'--if possible the periosteum--and not simply skin. is disappointing, as a new fold invariably tends to arise at the site of one or other of the vertical scars around the graft, and indeed this fault--the development of a secondary fold along the line of a scar which is in any degree near-vertical as FIG. 7 Pre-operative and post-operative appearances, with writer's technique. it crosses the canthus--is the bugbear of the standard types of correction whether it be a single Z or akin to the technique of Blair (Fig. 5, A) or Spaeth (Fig. 5, B). A basic point which none of these techniques appears to take very much into account is that in any case of pronounced epicanthal fold the length of the

7 258 BRITISH JOURNAL OF PLASTIC SURGERY palpebral fissure is considerably shorter than normal and the medial canthi themselves are displaced laterally apart from being overlapped by the fold. In order to achieve both an advantageous rearrangement of the tissue comprising the fold and a medial displacement of the canthus itself, I evolved, by much trial and error, a simple technique which has so far proved extremely efficacious (Figs. 6 and 7). It will be seen that not only do the rather rectangular flaps effectively dispose of the fold but the canthus is drawn medially by a considerable amount--even to the extent of appearing over-corrected to begin with. Most important of all, the only vertical scars crossing the line of the canthus are close to the lid margin itself by reason of the paramarginal situation of the lateral limbs of the two Z's, and thus no secondary fold can develop at a later stage as so often happens with other techniques. REFERENCES MATTHEWS, D. N. (1949). Trans. ophthal. Soc. U.K., 59, 583. SCOTT, G. I. (1952). Brit..7. Ophthal., 36, 362. STALLARD, H. B. (1957). Trans. ophthal. Soc. U.K., 77, 5Ol.