FRONTALIS SLING SURGERY

For patients with ptosis secondary to absent/ poor levator function, the traditional treatment is the frontalis sling surgery which links tarsus to frontalis muscle for obtaining better eyelid position in primary gaze. Conventional Fox pentagon is the most commonly performed technique all over the world and is done via a total of five incisions – two in the upper eyelid and three supra-brow incisions. This has the disadvantage of creating three post-surgical scars in a prominent location on the forehead, thus compromising the aesthetic outcome of surgery, even more so in bilateral surgeries.

In an attempt to enhance the aesthetic outcome of the surgery, I had described a modification to the conventional Fox pentagon and have been performing the same since 2007. In this supra-brow single stab incision technique, the pentagon shape is marked by using two curved non-toothed forceps placed at intended lid margin points and lifting the lid along the tentative vertical arms of the pentagon. Height and contour are assessed, and if contour is flat or peaked or undesirable with respect to location of greatest height of arch, the separation between margin points as well as angle of the arms connecting the margin points to the medial and lateral suprabrow points is adjusted until a desirable contour is achieved.

A single supra-brow stab incision of about 2.0-3.0mm is made at the superior tip of the pentagon about 2.0-4.0mm above the eyebrow up to the periosteum and the periosteum undermined. A sterile Seiff silicone suspension set consisting of a long silicone tube attached to needles of 6.3cm length on either end and passing through a silicone sleeve is taken. The sleeve is removed temporarily and the needle is passed in through the medial lid margin mark to pass in the epi-tarsal tissue horizontally and pierced out through the lateral lid margin mark.

With an eyelid plate for globe protection, the needle on either end is then sequentially reinserted through the skin puncture point (taking care not to inadvertently cut the sling) and advanced tangentially upwards dipping temporarily behind the septum just below the orbital rim and then further upwards to reach the upper, medial/lateral corner of the pentagon in the suprabrow region. Lid traction is then released and without externalising the needle, its direction is turned towards the central mark of the pentagon and guided in the same surgical plane to be externalised through the central suprabrow incision.

Lid height is adjusted according to required correction. The two ends are passed through the silicone sleeve and are further knotted together around a 6-0 silk stay suture. Excess length of sling is cut and sleeve with ends are buried below periosteum. The single suprabrow stab incision is closed with a silk suture.

As compared to traditional Fox pentagon, this technique in effect decreases the number of incisions to just one (the lid incisions being just needle punctures) and thus decreases intra-operative bleeding, oedema, ecchymosis and surgical time. Anchoring the sling at the orbital septum at the medial and lateral corners of the pentagon maintains a physiologically correct upward tangential pull and translates into a good lid contour.

The learning curve is smooth and the key is to release lid traction while changing direction at the upper medial and lateral corners of the pentagon as well as to slide the central brow incision toward the advancing tip of the needle to allow easy externalisation of the needle. Even in event of difficulty, surgery continues by simply creating a cut at the site of medial or lateral brow margins and externalising the needle similar to the conventional technique.

Postoperative results are consistent with respect to function and attained lid height and contour. Lid and brow oedema and scarring are less and therefore aesthetic appearance is better. This is especially important in dark-skinned races and in keloid or prominent scar formers. Though stab incisions may be created within the brow in an attempt to hide the scars, it might often result in damage to the hair follicles in the brow resulting in permanent hair loss and unsightly scarring.

Roman Shinder MD, director oculoplastics, SUNY Downstate Medical Center, NY, US comments: "This modified frontalis sling procedure allows for successful ptosis repair via a straightforward technique with a quick learning curve, superior cosmetic results and reduced operating time under general anaesthesia. It has been my surgical technique of choice for the past three years for poor levator function blepharoptosis, and I have been very happy with the functional and cosmetic postoperative results of this procedure. One of the main reasons I have adopted this surgical technique is the superior cosmetic appearance of the lid and brow. This is especially important given that most patients requiring frontalis suspension are children, and parents are very keen on obtaining a favourable cosmetic result for their children."

Rona Silkiss MD, chief, Division of Ophthalmic Plastic, Reconstructive and Orbital Surgery at California Pacific Medical Centre, California, US, adds: "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."

http://www.youtube.com/watch?v=PUT rjeQtQxc

* Dr Soosan Jacob is a senior consultant ophthalmologist at Dr Agarwal's Eye Hospital, Chennai, India and can be reached at: dr_soosanj@hotmail.com

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