Frontalis Suspension

• The primary goal of frontalis suspension techniques in ptosis management is to improve visual function by elevating the eyelid.
• A secondary goal is to improve facial aesthetics and symmetry.

Indications

• Static ptosis with levator excursion less than 4 mm
• Congenital myopathic ptosis (levator maldevelopment) with high risk of occlusive amblyopia
• Blepharophimosis ptosis syndrome
• Marcus Gunn jaw-winking
• Occurs in 5% of congenital ptosis cases
• Congenital fibrosis of the extraocular muscles
• Double elevator palsy
• Myogenic ptosis
• Progressive external ophthalmoplegia with levator excursion less than 4 mm and reasonable Bell’s phenomenon (Lane and Collin 1987)
• Kearns Sayre syndrome (heart block, retinitis pigmentosa, abnormal retinal pigmentation)
• Oculopharyngeal dystrophy
• French-Canadian descent
• Myotonic dystrophy
• Stephens syndrome
• Congenital disorders (rare association)
• Abetalipoproteinemia
• Refsum disease
• Extraocular muscle fibrosis syndrome
• Moebius syndrome
• Progressive supranuclear palsy
• Endocrine exophthalmos
• Myasthenia gravis, occasionally, after maximal medical therapy
• Muscular dystrophy
• Traumatic ptosis with levator excursion less than 4mm
• Apraxia of eyelid opening (DeGroot, OPRS, 2000)

Contraindications

• Absolute: other ptosis types that require different management (Frueh 1980)
• Pseudoptosis
• Dermatochalasis
• Enophthalmos
• Hypotropia
• Globe malposition
• Small eye: phthisis bulbi, micro-ophthalmos, anophthalmos, enophthalmos and postenucleation
• Mechanical ptosis
• Excessive lid weight
• Eyelid tumor
• Restrictive ptosis due to conjunctival scarring
• Aponeurotic ptosis
• Myopathic ptosis with levator excursion greater than 4 mm
• Neurogenic ptosis
• Aberrant third nerve regeneration
• Myasthenia gravis amenable to medical therapy
• Horners syndrome
• Ophthalmic migraine
• Multiple sclerosis
• Weakness of the frontalis muscle
• Relative
• Neurogenic ptosis due to third nerve palsy
• Poor Bells phenomenon with risk of corneal exposure keratopathy
• Paralytic strabismus with high risk for postoperative diplopia
• Progressive external ophthalmoplegia with poor Bells phenomenon
• Risks of corneal exposure keratopathy due to ocular dysmotility
• Muscular dystrophy that is progressive and the cornea is at risk

History of ptosis

• Age of onset
• Progressive or static
• Variable
• Family history of ptosis
• Old photo evaluation for corroboration of history and time of disease onset

Clinical examination/preoperative assessment

• Complete eye exam with critical key components:
• Vision
• Pupil size and reflexes
• Extraocular motility
• Slit lamp examination looking for exposure keratopathy
• Funduscopic examination for retinal pigmentary changes
• Schirmer testing for dry eye
• Thorough eyelid evaluation
• Palpebral fissure (PF)
• Palpebral fissure on downgaze (dPF)
• Increased in static myopathic ptosis (congenital)
• Margin reflex distance 1 (MRD1)
• Margin crease distance (MCD)
• Margin fold distance (MFD)
• Levator excursion (LE) = levator function
• Lagophthalmos
• Presence of Bells phenomenon (absent, poor, fair, good)
• Synkinesis
• Aberrant innervation syndrome: Marin-Amat (III-VII miswiring)
• Marcus Gunn jaw-winking (III-V miswiring)
• Duane syndrome (change in PF in horizontal gaze (III-VI miswiring)
• Intact frontalis function is essential to the success of the procedure

• Eyelid crutch to prop open eyelid, worn on glasses frame
• Supramaximal blepharoplasty (Burnstine and Putterman 1999)
• Designed to remove the maximal amount of skin to allow for eyelid closure (when the brow is relaxed) and pupil clearance (when the eyebrow is elevated)
• Ideal for patients with the relative contraindications above, particularly those patients with a poor Bells phenomenon and decreased extraocular motility whose corneas are at risk
• Other ptosis repair techniques are generally used for patient with fair to normal levator function

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

Preoperative considerations

• Stop aspirin, nonsteroidal anti-inflammatories, and anticoagulants before surgery.
• Counsel patient on postoperative lagophthalmos and increased palpebral fissure on downgaze.

Postoperative instructions

• Lubricate the eye frequently due to postoperative lagophthalmos, lid lagophthalmos, and exposure concerns.
• Antibiotics to prevent postoperative wound infection, particularly with placement of nonautologous tissue
• Ice compresses to decrease swelling

Postoperative medications

• Cephalosporin
• Ocular lubricant: drops and ointment
• Antibiotic eye ointment
• Narcotic for postoperative pain

Management considerations

• Postoperative lagophthalmos guaranteed: Counsel patient beforehand.
• Increased palpebral fissure on downgaze (lid lag): Counsel patient beforehand.
• If ptosis is unilateral, result might be under-corrected. The drive to use brow is low.
  • Other choices
    • Bilateral frontalis suspension with preservation of normal levator
    • Destroy good levator on contralateral/normal side and perform bilateral frontalis suspension
• Exposure keratopathy risks high when
  • Patient is older
  • Bells phenomenon is compromised
  • Ocular motility is compromised (third nerve palsy)
• Frontalis suspension using autologous fascia lata in children under 3 years old
  • Autologous fascia lata is an eligible material in frontalis suspension in children under 3 years old, despite the traditional oculoplastic dogma that advises against.

• Hemorrhage
• Infection
• Eyelash loss
• Overcorrection
• Undercorrection
• Lagophthalmos (predictable)
• Increased palpebral fissure on downgaze (lid lag; predictable)
• Corneal exposure keratopathy
• Corneal stippling
• Corneal abrasion
• Corneal ulceration
• Eyelid margin defect
• Entropion
• Ectropion
• Contour abnormality with eyelid notching
• Margin crease and margin fold asymmetries

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