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Saai Eye Hospital

PTOSIS: Frontalis Sling

What is a PTOSIS: Frontalis Sling?

This surgery is performed for congenital ptosis and is especially useful in instances where the levator function is very poor. In this procedure, the eyelid is coupled to the frontalis muscle using either a fascial sling or a sling made of synthetic material. By recruiting the frontalis muscle to raise the eyelids, this procedure relieves the dysfunctional levator from contributing to eyelid elevation.

There are a number of materials that can be used to sling the frontalis to the eyelid; each has its own indications.

Sling Materials:

1. Silicone: Silicone is another synthetic alternative to the fascia that also does not require a donor site and can be used in patients of any age. Unlike Supramid, silicone is not associated with frequent recurrence of ptosis and is often used as a permanent solution for congenital ptosis. The other advantage is that the material is elastic and can be adjusted, both intraoperatively and post-operatively, if the eyelid height needs to be altered over time.

2. Fascia Lata: Fascia lata, the deep fascia of the thigh, is one of the most commonly used materials for frontalis sling. Fascia lata can either be harvested from the patient (autogenous fascia lata) or be provided by a tissue bank (allogenic fascia lata)

3. Supramid: is a synthetic alternative to fascia lata. Its advantage is that it does not require a donor site and can be used in children of any age. Supramid has, however, been associated with recurrences of ptosis and is not thought to be a reliable permanent solution for congenital ptosis.



Why one might need a PTOSIS: Frontalis Sling?

Surgery is the only best treatment for drooping eyelids. Your surgeon tightens levator muscles to lift eyelids, giving you improved vision and appearance.

In severe cases where weakened levator muscles are involved, your surgeon attaches the eyelid under the eyebrow. This allows the forehead muscles to substitute for levator muscles in lifting the eyelid.



What is the risks involved in PTOSIS: Frontalis Sling?

After surgery, the eyelids may not appear symmetrical, even though the lids are higher than before the surgery. In Very rare Conditions, eyelid movement may be lost.

It is important to choose your Oculoplastic surgeon carefully since poorly done surgery could result in an undesirable appearance or in dry eyes from lifted eyelids not closing completely.

Before agreeing to ptosis surgery, ask how many procedures your surgeon has done. Also ask to see before-and-after photos of previous patients, and ask if you can talk to any of them about the experience.



What is the symptoms & signs of PTOSIS: Frontalis Sling??

SYMPTOMS

  • Drooping of one or both eyelids
  • Not associated with other ocular or systemic disorders
  • No variation in eyelid position with jaw movement or ocular motility

SIGNS

  • Unilateral or bilateral ptosis
  • Poor levator function
  • Poor eyelid crease
  • Amblyopia/irregular astigmatism

 



How the surgery has to be planned?

The decision to perform unilateral or bilateral surgery in cases of severe unilateral ptosis should be discussed with the patient and patient’s family if underage. A bilateral suspension procedure for severe unilateral congenital ptosis may optimize symmetry (especially if there is a poor elevation of the brow on the ptotic side). However, if there is enough unilateral brow elevation, a unilateral sling may be considered.

The use of autogenous FL (can be obtained from the leg of patients older than 3-5 years) is considered the gold standard treatment in congenital ptosis associated with poor levator function. However, FL harvesting can be technically difficult and leaves a scar. In some cases, an insufficient amount of FL may be harvested necessitating the use of alternative autogenous or alloplastic synthetic materials such as:
  • Preserved (tissue bank) fascia lata
  • Nonabsorbable suture material (e.g., 2-0 Prolene, Nylon (Supramid) or Mersilene)
  • Silicone bands
  • Silicone rods
  • Silastic (silicone elastomer)
  • ePTFE (expanded Poly Tetra Fluoro Ethylene)
  • Gore-Tex
  • Autogenous materials used less frequently include palmaris longus tendon and temporalis fascia.

Synthetic materials may be preferred in children younger than 3 years or for patients who do not want an additional harvesting operation.



What is the Procedure for Ptosis: Frontalis Sling?

The frontalis sling operation includes:

  • Patient preparation
  • Decision regarding open or closed approach
  • Skin incision markings
  • Decision to suture the sling to tarsus or not
  • Passing the suture to the brow
  • Skin crease closure
  • Adjustment of height and contour
  • Closure of forehead incisions

Procedure

  • The operation is usually performed under general anaesthesia in children but can be performed under local anaesthesia with sedation in adults.
  • A 50:50 mixture of 2% xylocaine with 1:100,000 epinephrine, 0.5% Marcaine with 1:200,000 epinephrine and hyaluronidase is injected in the area of the upper eyelid and suprabrow area.
  • A marking pen is used to mark the intended skin incisions. These incisions maybe 3 to 5 small stab incisions or incorporate a blepharoplasty incision. Once the incisions have been marked, a 5-0 or 6-0 silk traction suture is placed, and the lid placed on downward tension.
  • If blepharoplasty is to be performed, a #15 Bard-Parker blade is used to incise the skin and the cutting mode of cautery used to excise skin. The orbital septum may be incised and some preaponeurotic fat trimmed according to the plan outlined prior to surgery.
  • In this open technique, an orbicular muscle flap at the anterior inferior one-third of tarsus is raised and the anterior surface of the tarsus revealed. The sling material is then sutured to the tarsus using a 6-0 vicryl suture. The sling material is then passed under the orbital septum near the arcus marginalis and out the of the brow incisions using either the needles attached to the silicone sling or a Wright needle.
  • The skin crease is created by suturing skin to orbicularis to sling and then orbicularis and skin using skin crease-forming sutures. The sling is externalized at the central subrabrow incision, tightened, cut and buried ensuring appropriate height and contour of the eyelid margin. The brow incisions are closed.
  • If blepharoplasty is not performed the sling is placed sequentially through each of the three or five stab incisions in the fashion of a trapezoid. The ends are externalized at the superior most aspect, tied and cut. The ends are buried, and the incisions closed.
  • In this supra-brow single stab incision technique, the internal pentagon shape is delineated by using two curved non-toothed forceps placed at the intended lid margin points to lift the lid along the tentative vertical arms of the pentagon.
  • Height and contour are assessed, and if the contour is flat or peaked or undesirable with respect to the location of the greatest height of arch, the separation between margin points as well as the angle of the arms connecting the margin points to the medial and lateral suprabrow points is adjusted until a desirable contour is achieved. This technique provides for a consistent lid crease and contour with a single small supra/adjacent brow incision and is an elegant refinement of a classic procedure. It allows the single suprabrow incision to be almost invisible. This provides an aesthetic advantage over the conventional three stab supra-brow or forehead incision. 
  • This technique is ideal for pediatric congenital ptosis and less easily used in adult ptosis where the larger lid lengths makes passing of the sling in a subcutaneous trapezoidal configuration more challenging.


NEXT STEP

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  • The name of the test or procedure
  • The reason you are having the test or procedure
  • What results to expect and what they mean
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  • What the possible side effects or complications are
  • When and where you are to have the test or procedure
  • Who will do the test or procedure and what that person’s qualifications are
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  • Any alternative tests or procedures to think about
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