8.4 Surgical Technique of Brow Suspension

levator muscle and the aponeurosis. The tissue between the two incisions is removed completely, leaving the underlying conjunctiva intact. This will create a large gap of 6 mm in the levator complex and marked ptosis. The technique is also recommended to eliminate the synkinesis in Marcus Gunn ptosis [1].

risk (>30%) of degradation of the tissue [3]. Synthetic materials like silicone, polyester, nylon, polyethylene, PTFE (polytetrafluoroethylene), and polyglycolic acid are initially tolerated but carry a high risk (>30%) to be rejected after a period of 1/2 to 20 years [4, 5].

8.3.5The Lid-Lowering E ect and Eyelid Symmetry: Evolution of the Eyelid Level After Levator Recession

After the partial levator recession, the immediate postoperative eyelid level tends to be low and will rise in the following 2 weeks. If the lid has reached the desired level earlier, the patient is asked to massage his lid downward to prevent undercorrection.

8.3.6Undercorrection and Overcorrection

In partial recession, 80% of the patients finally reach a satisfactory eyelid level. Undercorrection (10%) and overcorrection (10%) are equally frequent. The undercorrected lid needs a repeated recession of the levator with a larger spacer tissue. Overcorrection (excessive recession) can be managed by ptosis surgery. The total recession surgery will usually create a marked ptosis without a tendency of undercorrection.

Summary for the Clinician

■The high levator recession is more effective and does not affect the skin crease position.

■A total recession creates a total ptosis and avoids the adjustment problems of the partial recession, but bilateral suspension will be necessary.

■Partial recessions carry a 20% risk of overor undercorrection, which will have to managed by secondary surgery.

8.4Surgical Technique of Brow Suspension

8.4.1Materials for Brow Suspension

8.4.1.1Nonautogenous Materials

Freeze-dried, irradiated allografts like dura mater, fascia lata, or fascia temporalis are effective initially for brow suspension. After a period of 3–6 months, there is a high

8.4.1.2 Autogenous Fascia Lata

Only the transplantation of autologous fascia lata can guarantee a lifelong integration without complications like extrusion, degradation, or dislocation. Autologous fascia lata can be harvested from the age of 1 to 2 years through a small incision [7].

8.4.2Our Technique of Harvesting Autogenous Fascia Lata

Many different techniques of fascia lata harvesting are recommended. To minimize donor site morbidity, the incision should not extend 20 mm. I recommend the combination of a 20-mm incision at the lower third of the limb and a second 3-mm stab incision at a higher location in the distance of the required extraction length of the fascia [6, 10]. The lower incision of 20 mm serves as an approach to split the required width of the fascia in an upward direction toward the stab incision. The higher stab incision serves to extract the fascia with a slim 3-mm grasper instrument, which is introduced downward to the lower incision to grasp and extract the lower edge of the fascia (Figs. 8.12–8.14).

Fig. 8.12 T he lower incision of 20 mm (right) serves as an approach to split the required width of the fascia in an upward direction toward the stab incision. The higher stab incision (left) serves to extract the fascia with a slim (diameter of 3 mm) grasper instrument, which is introduced down to the lower incision to grasp the lower edge of the fascia

8.4.3Mechanical Principals of Brow Suspension

When the fascia bands are passed through the tissue and tightened, the cutaneous and subcutaneous tissue can be compressed only to a certain limit depending on the tissue volume. The shortening effect depends primarily on the involved tissue volume and much less on the tension of the fascia. In some cases, the anterior lamella is excessively stretched and has to be shortened by a blepharoplasty to reduce the volume of the tissues involved in the suspension.

There are three sections of tissue connection in lid elevation: (1) frontalis muscle–brow; (2) brow–lid crease; (3) lid crease–lid margin. The first section above the brow usually shows good transmission of elevation and does not benefit from fascia implantation. The pretarsal and preseptal sections below the brow only show a loose connection dependent on the laxity of the anterior lamella. Oblique fascia implantation creates effective transmission with sufficient elasticity for sufficient lid closure (Fig. 8.15).

8.4.5Fascia Implantation

The fascia is split into 2 × 70 mm strips. The fascia needle is introduced into the stab incisions to emerge in the skin crease. Thus, the two bands of fascia are pulled up to the brow incisions through four separate tunnels in an oblique direction. The oblique direction of both loops (Crawford technique) provides better elasticity during lid closure than the single-loop technique (Fox pentagon). The loops are sutured in the center and the periphery to the upper third of tarsal plate [2]. The tightness is adjusted in the brow incision, where the ends of the loops are sutured together. We found that additional points of frontal fixation are not necessary. Further adjustment can be performed postoperatively by tightening or loosening the loops in the brow incision. Even after years, the effect of the suspension can be enhanced by shortening the preseptal anterior lid lamella inclusive of the integrated fascia, or it can be diminished by cutting the bands of fascia through a skin crease incision (Figs. 8.16–8.18).