Repair of· the Superior Sulcus Deformity Using Autogenous Costal Cartilage FRANCIS C. SUTULA, MD, OTTIE THOMAS, BFA

Abstract: Superior sulcus deformity is a late sequela of surgical anophthalmos. Many methods have been proposed to treat this difficult problem. A technique using autogenous costal cartilage that has re­sulted in satisfactory repair is presented. In addition to standard photo­graphs and exophthalmometry measurernents to follow these patients, a specific device to accurately measure orbital volume gain after opera­tion was fashioned. [Key words: costal cartilage, enophthalmos, superior sulcus deformity, surgical anophthalmos.] Ophthalmology 89:424-427, 1982

In addition to the visual and psychological difficul­ties associated with the loss of an eye, several other sequelae of surgical anophthalmos exist. These include socket secretions, socket contractions, entropion, ec­tropion, blepharoptosis, implant migration and extru­sion, and superior sulcus deformity. Superior sulcus deformity usually is a late sequela of acquired anophthalmos and is often associated with the triad of blepharoptosis, enophthalmos of the prosthesis, and a reduced upper eyelid crease.

Many methods for repair have been proposed. However, none has obtained universal acceptance. Results of repair of the superior sulcus deformity using autogenous costal cartilage are presented.

METHODS

The series consisted of six men, aged 35 to 58 years, having enucleations as a result of trauma. The range of

From the Department of Ophthalmology, Tufts University-New En­gland Medical Center and the Boston Veteran's Administration Medical Center, Boston, Massachusetts.

Presented at the Eighty-sixth Annual Meeting of the American Academy of Ophthalmology, Atlanta, Georgia, November 1-6, 1981

Reprint requests to Francis C. Sutula, MD, Department of Ophthal­mology, Tufts-New England Medical Center, Box 450,171 Harrison Avenue, Boston, MA 02111.

time from enucleation to repair of superior sulcus de­formity was 9 to 37 years, the average being 27 years.

Exophthalmometry measurements and photographs were performed before operation. Additionally, a custom eye cup was fashioned from an impression of the involved side (Fig 1). Volume gain before and after operation was obtained by measuring the amount of fluid necessary to fill the cup to a set mark (Fig 2).

The surgical technique commenced with appropriate preparation of the rib donor site, in addition to the preparation for the involved socket. Over the seventh rib cartilage an incision through skin, fascia, and rec­tus abdominis muscle was made. The perichondrium was then exposed and incised. A section of cartilage was freed from the overlying perichondrium and re­moved with a rib cutter. The section removed was up to 5 cm in length. Care was taken to avoid the inter­costal vessels, nerve, and posterior perichondrium. After the cartilage was removed, the perichondrium was closed separately, and a layered closure of the abdominal wound was then performed. The cartilage was prepared for insertion by dicing it into smaller pieces.

A transcutaneous incision through the lower eyelid crease permitted good exposure. The orbicularis oculi muscle fibers were separated to expose the orbital septum. The periosteum inferior to the inferior orbital rim was incised and reflected so that the subperiorbital space could be entered and followed posteriorly. The cartilage was inserted towards the apex of the orbit

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Fig 1. Custom eye cup.

with either forceps or chest tube. When using a chest tube, the cartilage pieces were pushed posteriorly with a trochar. The periosteum was closed followed by approximation of the orbicularis fibers and a subcu­ticular closure of the skin. The end point of cartilage placement was reached when a slight overcorrection of the superior sulcus defect was found at the time of surgery (Figs 3A, B).

RESULTS

Improvement was noted in five of the six patients. One patient suffered a chronic wound infection that required removal of the cartilage for its resolution. Exophthalmometry readings and orbital volume gains were significant.

CASE REPORT

Case 1. A 53-year-old man suffered a shrapnel injury to his right eye 27 years earlier. At the time of presentation he had 4 mm of enophthalmos of the prosthesis. At the time of surgery 4 cc of cartilage were inserted. This resulted in symmetrical ex ophthalmometry measurements at one year after operation. A volume gain of 3 cc was noted using the custom eye cup. Fourteen months after operation the patient continues to do well (Figs 4A, B)

Case 2. A 54-year-old man was involved in a motor vehicle accident 30 years ago. Before operation he had a deep supe­rior sulcus deformity and 5 mm of enophthalmos. Five cubic centimeters of cartilage were placed at the time of surgery. A 4 cc increase in volume gain was obtained with I mm of enophthalmos remaining by expohthalmometry (Figs SA, B)

Fig 2. Volume gain measurement taken using custom eye cup.

DISCUSSION

Several postulates have been proposed to account for the orbital changes in the superior sulcus defor­mity. These include volume deficiencies, relaxation of the orbital base, and disorganization of the remaining orbital contents. 1 There are several reasons that a vol­ume deficit exists. Based on an average anterior­posterior length of 24 mm,2 an adult globe has a vol­ume of 7 cc. Without an implant, this entire volume deficit remains. Placement of an 18 mm spherical im­plant replaces 3 cc. An ocular prosthesis replaces be­tween 2 and 3 cc. It is, therefore, common to begin with a deficit of 2 cc following enucleation with im­plantation.

More important is the role of atrophy of the orbital fat. Fatty atrophy occurs as a direct result of orbital injury as well as surgical manipulation. 1 Circulatory changes in the orbit resulting from the removal of the globe continue the atrophic proceSs. The weight of the implant and the prosthesis may add an element of pressure necrosis and contribute to long term atrophy. Laxity of the lower ~yelid due to the sustained weight of the prosthesis results in elongation of the eyelid, allowing the orbital contents to shift more anteriorly and downward. This increases the superior sulcus de­fect.

Lastly, without the support of the globe beneath it, the levator palpebrae superiorus may lose its normal curvelinear course and sag or invaginate. 1

Several remedies have been proposed for the supe­rior sulcus defect. 3.4 Synthetic materials such as acrylics, silastic, and proplast5 have been placed be­neath the orbicularis muscle of the upper eyelid. The resultant lumpy appearance has not been satisfactory. Since this defect is often characterized by blepharop­tosis and decreased excursion of the upper eyelid,

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OPHTHALMOLOGY. MAY 1982 • VOLUME 89 • NUMBER 5

Figs 3A, B. A, left, Preoperative appearance. B, right, immediate postoperative appearance.

Figs 4A, B. A, left , case I, preoperative appearance with right superior sulcus deformity. B, right, case 1, postoperative appearance.

Figs SA, B. A, left , case 2, preoperative appearance . B, right, case 2, postoperative appearance.

foreign material in this location adds to a mechanical disadvantage.

Glass beads6 have been introduced for volume gain, but reports of migration have limited its use. 7 Expand­able implants8 have been placed in the subperiosteal space but availability and certain technical problems have procluded universal acceptance.

Autogenous materials offer distinct advantages over synthetics. 9 ,lo Less inflammatory reaction and less

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tendency to migrate is observed because of better inte­gration of the implant material at the new site. Costal cartilage has long been used for reconstruction of bony contours of the face. Histologic evidence has shown that it resists resorption. 9 Recently, Costa and Gal­braithll reported good immediate results with costal cartilage implantation in the orbit.

In the technique presented, satisfying cosmetic re­sults coupled with objective evidence of volume gain

SUTULA AND THOMAS • SUPERIOR SULCUS DEFORMITY

more than one year after operation have been gained. Continuous monitoring of this data is necessary to evaluate more fully the long-term results of this or any other technique. However, the data suggests that the use of autogenous costal cartilage appears to be an­other option in the management of the difficult prob­lem of superior sulcus deformity.

REFERENCES

1. DeVoe AG. Experiences with the surgery oi the anophthalmic orbit. Am J Ophthalmol 1945; 28:1346-51.

2. Whitnall SE. Anatomy of the Human Orbit and Accessary Or­gans of Vision. London: Oxford University Press, 1932; 256.

3. Vistnes LM, Paris GL. Uses of RTV silicone in orbital recon­struction. Am J Ophthalmol 1977; 83:577-81.

4. Spivey BE, Allen L, Stewart WB. Surgical correction of superior sulcus deformity occurring after enucleation. Am J Ophthalmol 1976; 82:365-70.

5. Bello VM, Levine MR. Superior sulcus deformity. Arch Ophthalmol 1980; 98:2215-16.

6. Smith B, Obear M, Leone CR Jr. The correction of enophthal­mos associated with anophthalmos by glass bead implantation. Am J Ophthalmol 1967; 64:1088-93.

7. Soli DB. The anophthalmic socket. In: Soil DB, ed. Manage­ment of Complications in Ophthalmic Plastic Surgery. Birming­ham: Aesculapius Publishing, 1976; 324.

8. Soil DB. Correction of the superior lid sulcus with sub­periosteal implants. Arch Ophthalmol 1971; 85:188-90.

9. Peer LA Cartilage Grafting. Br J Plast Surg 1954; 7:250-62. 10. Peer LA The fate of living and dead cartilage transplanted in

humans. Surg Gynecol Obstet 1939; 68:603-10. 11. Coster OJ, Galbraith JEK. Diced cartilage grafts to correct

enophthalmos. Br J Ophthalmol 1980; 64:135-6.

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