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Nonhealing traumatic wound over frontalis silicone sling

Published:April 16, 2016DOI:https://doi.org/10.1016/j.jcjo.2016.01.008
      Silicone is a commonly used material for the frontalis sling procedure in cases of ptosis with poor levator function. It is particularly advantageous in young children who have underdeveloped tensor fascia lata. Extrusion of the silicone through surgical wounds is an infrequent but recognized complication. We describe a case of silicone sling exposure through a traumatic wound that evolved into a nonhealing ulcer.
      A 10-month-old boy was assessed for bilateral congenital blepharoptosis. He had previously been diagnosed with congenital cystic adenomatoid malformation of the lung and growth restriction (third percentile) and had undergone hypospadias repair. Levator function was poor (levator excursion <2 mm) and a bilateral frontalis sling was performed using polyester suture (Mersilene; Ethicon, Somerville, NJ, USA). Eleven months later, he required a repeat frontalis sling on the left slide and this was performed using a silicone sling (Seiff Frontalis Suspension Set; Beaver-Visitec International Ltd, Warwickshire, UK) passed in a pentagon configuration. The previously placed polyester suture was left in situ. The silicone ends were buried in a preperiosteal pocket created superior to the central brow incision by blunt dissection with Stevens scissors. The postoperative upper lid position and contour were excellent with a margin-reflex distance of 3 mm. During postoperative month 3, he fell and sustained a laceration to the left brow approximately 1 cm superior to the central brow incision site. This evolved into a nonhealing ulcer with exposed tips of the silicone sling (Fig. 1). He was brought to the operating room for repair. Pressure on the wound produced a small amount of discharge, which later grew methicillin-sensitive Staphylococcus aureus in culture. The wound was irrigated with bacitracin solution. The silicone sling ends were tucked into a preperiosteal pocket, without any trimming. Direct closure in 2 layers was performed with additional wound support provided by adhesive strips fixed with tincture of benzoin. Ophthalmic antibiotic ointment was applied after shedding of the adhesive strips. There was subsequent dehiscence over a couple weeks. The silicone sling was removed 6 months after insertion without difficulty. Exploration of the wound revealed pyogenic granuloma, which was excised. The wound was left to heal by secondary intention and closed by the first postoperative visit at 2 weeks. After the explant, the lid height and contour were unchanged after 1 year.
      Figure thumbnail gr1
      Fig. 1Traumatic brow wound with exposed silicone sling tips. The scar of the central brow wound used in pentagonal placement of the sling is visible 1 cm below.
      Silicone is a safe and effective material for the frontalis sling procedure.
      • Carter S.R.
      • Meecham W.J.
      • Seiff S.R.
      Silicone frontalis slings for the correction of blepharoptosis—indications and efficacy.
      • Lee M.J.
      • Oh J.Y.
      • Choung H.
      • et al.
      Frontalis sling operation using silicone rod compared with preserved fascia lata for congenital ptosis—a three-year follow-up study.
      It is inert and easy to work with and has become a popular choice.
      • Aakalu V.K.
      • Setabutr P.
      Current ptosis management: a national survey of ASOPRS members.
      Adjustability and elasticity are among the touted advantages. Removal is usually simple and, as demonstrated in our case, the fibrous connections between the eyelid and frontalis can be sufficient to maintain lid height and contour after explant. Complications are uncommon and limited to only the periocular area, because a remote harvest site is not required as in the traditional tensor fascia lata frontalis sling procedure popularized at our institution by Jack Crawford.
      • Crawford J.S.
      Repair of ptosis using frontalis muscle and fascia lata: a 20-year review.
      Extrusion of the silicone sling is an established infrequent complication. In the case described here, the unusual feature is that exposure did not occur at a surgical wound. The precise mechanism in our case cannot be established with certainty, but presumably the silicone tips prevented wound healing with secondary pyogenic granuloma formation and S. aureus colonization/infection. It is possible that the tissue overlying the silicone ends was more susceptible to laceration with trauma as a result of local inflammation or infection as a result of the foreign material. Despite mechanistic uncertainty, the case demonstrates an unusual event after frontalis silicone sling ptosis repair.

      Disclosure

      The authors have no proprietary or commercial interest in any materials discussed in this article.

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