Suspension techniques
- Two strips of fascia lata (Magnus 1936)
- Rhomboid technique (Tillett and Tillett 1965)
- Double rhomboid technique
- Crawford pentagon operation (Crawford 1956), modified Wright operation (Wright 1922)
- Fox procedure, trapezoid-pentagon
- Transconjunctival frontalis suspension
Materials
Autogenous fascia lata
(Figures 1 - 5)
- Recommended by Wright in 1922 and modified by Crawford (1956) and Fox (1957)
- Long considered the gold standard in frontalis suspension ptosis management
- Pros
- Material from self
- Biointegrated into body
- Low complication and recurrence rate (Wasserman et al, 2001)
- Cons
- Separate surgical harvest site with risk of infection and muscle prolapse
- Early pain on walking (67%), limping (38%), wound pain (57%), and cosmesis concerns on final wound healing (38%) (Wheatcroft et al, 1997)
- Patient must be at least 5 years old to have enough tissue to harvest
- Postoperative donor-site scarring
- Difficult to revise due to postoperative scarring
Figure 1. Frontalis suspension with autogenous fascia lata, closed technique. Surgical markings in eyelid and above brow. Courtesy Rona Z. Silkiss, MD, FACS.
Figure 2. Frontalis suspension with autogenous fascia lata, closed technique. A Wright fascial needle is used to pass the fascial lata strip through the lid. Courtesy Rona Z. Silkiss, MD, FACS.
Figure 3. Frontalis suspension with autogenous fascia lata, closed technique. The fascial lata strip is passed through the brow in a pentagonal pattern and tied through the central brow incision. Courtesy Rona Z. Silkiss, MD, FACS.
Figure 4. Preoperative photograph from bilateral frontalis suspension with autogenous fascia lata. Courtesy Rona Z. Silkiss, MD, FACS.
Figure 5. Postoperative photograph from bilateral frontalis suspension with autogenous fascia lata. Courtesy Rona Z. Silkiss, MD, FACS.
Nonautogenous lysophilized/banked fascia lata (Tutoplast)
- Pros
- Biointegration
- No need for second surgical site
- Cons
- Reported recurrence rate from 8% (Broughton et al, 1982) to 18% (Wasserman et al, 2001)
Silicone rod
(Figures 6, 7)
- Tillet and Tillet (1966) first described its use in frontalis suspension
- Pros
- Elastic
- Ease of adjustment and removal
- No second-site harvest
- Cons
- Early revision 4% (Morris et al, 2008)
- Complications:
- Infection (Morris et al, 2008) (Davies et al, 2013)
- Extrusion (Carter et al, 1995)
- Granuloma formation (Rizvi et al, 2014)
Figure 6. Frontalis suspension with silicone sling, open technique. Silicone sling is fixated to the tarsus. Courtesy Richard C. Allen, MD, PhD, FACS.
Figure 7. Frontalis suspension with silicone sling, open technique. Sling is passed superiorly in the postseptal plane through the suprabrow incision. Courtesy Richard C. Allen, MD, PhD, FACS.
Mersilene mesh (Ethicon, Somerville, NJ)
- Pros
- Provides a scaffold for fibrovascular ingrowth
- Becomes biointegrated
- Comparable outcomes to autogenous fascia lata (Salour et al., 2008)
- Cons
- High complication rate of 20% (extrusion, granuloma, and infection) (Mehta et al, 2004)
Supramid (nylon polyfilament cable suture)
- Pros
- Quick and easy (Betharia, 1985)
- Cons
- Sling fails over time (Liu, 1999) (Tannenbaum et al, 2014)
- Suggested as temporizing measure
Gore-Tex (polytetrafluoroethylene/PTFE)
- Originally used in vascular and abdominal surgery
- Inert, biocompatible, infection resistant, easily suturable and biointegrates by fibroblastic ingrowth (Wagner et al. 1984 and Karesh 1987)
- No need for second surgical site
- Reportedly low failure and complication rate (Steinkogler et al, 1992) (Kokubo et al, 2016)
Unilateral vs. bilateral surgery
- Unilateral surgery is generally preferred for simple unilateral poor levator function ptosis (Bernadini et al, 2007, 2013)
- The downside in congenital ptosis is that there is no drive to lift the ptotic brow, and amblyopia remains a risk.
- There can also be undesirable asymmetry because the brow frontalis lift on the ptotic side cannot match the levator lift on the other side.
- Bilateral surgery is sometimes advocated in unilateral congenital ptosis to improve symmetry
- Excision of the normal levator and bilateral frontalis suspension (Beard 1965)
- Can also be indicated for jaw winking ptosis (Cates and Tyers, 2008)
- Bilateral sling placement without excision of the normal contralateral levator (Callahan 1972)
- Equalizes palpebral fissure in primary gaze, downgaze (lid lag), and lagophthalmos with eyelid closure or blink
Open vs. closed technique
- Open
- Define eyelid crease
- Better symmetry (Bernardini et al. 2013)
- Slippage from tarsus
- Longer time in OR
- Closed
- Quick
- Good eyelid height and symmetry
- Lack of tarsal fixation