Disadvantages include granuloma formation, infection, and recurrent ptosis secondary to slippage. These narrow gauge materials are prone to cheesewiring through tissue. They may be considered a temporary measure. An alternative is polyfilament cable-type suture (Supramid Extra), which is inert, easily inserted, nonabsorbable, and reversible. Placing this material with a Wright fascia needle through the skin decreases theneedformultipleskinincisions.Disadvantages include fragility with trauma, short-term effect, and infection.

The use of polyester fiber (Mersilene polyester fiber mesh or suture) has had variable success in the past. Although it has good tensile strength, it provides a scaffold for fibrovascular ingrowth, and soft tissue complication rates can be as high as 20%. Infection, granuloma formation, and extrusion may occur despite meticulous surgical technique [12]. Cutting thinner strips of Mersilene mesh and soaking the sling in antibiotic solution may help reduce infection. Ends should be sutured together rather than knotted to reduce bulkiness and decrease the risk of granuloma formation. Burying the suture ends in a deep frontalis pocket with adequate wound closure may reduce extrusion rates.

Expanded polytetrafluoroethylene (ePTFE) has led to successful outcomes, yet is not without complication. It is inert, biocompatible, and resistant to breakdown by tissue enzymes. Although it can be used as patches or strips, ePTFE suture provides superior results for frontalis slings. Stability is provided by biointegration through fibrovascular ingrowth, thereby enhancing longevity of ptosis correction. The authors note that this biointegration is a major disadvantage if the sling needs to be revised or removed. Additionally, the rates of infection and granuloma formation are up to fourfold higher with ePTFE compared with other synthetic materials. This may be due to the inherent porous fibrous matrix of the material with potential for bacterial sequestration [13]. Extrusion rates are also higher with this material. Soaking the implant in antibiotic solution and meticulous wound closure may decrease the risk of infection and extrusion of ePTFE.

The silicone rod frontalis sling has been used with good success. It is readily available and well tolerated. Infection and extrusion rates are low. Unlike autogenous fascia lata, it can be used in children before 3 years of age. No harvesting is necessary, and the sling can be easily adjusted since there is no tissue incorporation into the silicone. Major disadvantages include sling migration, cheesewiring, infection, and exposure. Although in the past, silicone was thought of as a temporizing measure until the child was old enough to undergo ptosis repair with autogenous fascia lata, the authors have had good, long-term success using silicone, with some slings remaining for over 30 years without revision.

Silicone rods are especially advantageous in those at risk for corneal exposure, such as those with chronic progressive external ophthalmoplegia, myasthenia gravis, myotonic muscular dystrophy, congenital fibrosis, third nerve palsy, and a poor Bell’s phenomenon [14]. The elasticity of the silicone allows for better eyelid closure and less lagophthalmos compared to materials that are less flexible. The ease of adjustment through the original mid-forehead incision allows the lid height to be lowered if exposure keratopathy develops. The silicone rod is also particularly beneficial in those patients with progressive ptosis, such as chronic progressive external ophthalmoplegia, who may need adjustment as the disease process continues. Adjustment is critical in patients with variable ptosis, such as in myasthenia gravis. Because of lack of integration into surrounding tissues, the silicone sling is easily removed if no longer needed. In summary, silicone rods provide distinct advantages when compared with other surgical materials. The authors maintain that the silicone rod is an ideal suspensory material, suitable for all ages, and can be used in many conditions causing ptosis with poor levator function.

Techniques for Frontalis Suspension

The frontalis sling is placed in a similar fashion for all materials, with the exception of frontalis

muscle flap advancement. There are various configurations of the sling, including original descriptions by Crawford [15] and Fox [16], as well as more recent modifications [17–19].

Double Triangle or Rhomboid Frontalis Sling

A double triangle or rhomboid, described by Crawford, uses a double-loop configuration with two strands. This technique has been used primarily for autogenous fascia lata suspension. It provides good contour and stability, yet is not easily adjustable postoperatively [15, 20]. The authors do not use this technique with synthetic materials due to excessive bulk and a possible increase in the risk of infection.

The authors use a modified Crawford technique for autogenous fascia lata frontalis suspension, consisting of the following six steps:

1. A 4-0 silk traction suture is placed in the central upper lid margin. Six incisions are made using a #15 blade. Three equidistant incisions are placed 3 mm above the lash line of the lid (medial, central, and lateral) and carried down to the anterior tarsal surface (Fig. 23.4a). Two incisions are made at the superior brow hairs, just above the medial and lateral lid incisions, and carried down to periosteum. A similar forehead incision is made 1.5 cm above the superior brow hairs between the lateral and medial brow incisions. Tenotomy scissors are used to create a pocket superiorly beneath the frontalis muscle through the forehead incision.

2. A bone plate coated with ophthalmic ointment is placed beneath the upper lid for corneal protection. An empty Wright needle (Storz; St. Louis, MO, USA) is passed from the medial lid incision to the central lid incision. The fascia is passed into the eye of the Wright needle and drawn across the lid.

Fig. 23.4  Modified double triangle Crawford technique for frontalis suspension with fascia lata. (a) Demonstrates three lid incisions, two brow incisions, and a mid-fore- head incision. (b) Two strips of fascia lata are passed,

forming a medial and lateral triangle. The ends are pulled, thus tightening the slings, to adjust lid height and contour. (c) Closure of brow and mid-forehead incisions. (d) Postoperative appearance on day 1

The empty Wright needle is then passed from the medial brow incision, posterior to the septum, and through the medial lid incision. Care is taken to avoid a full-thickness pass through the lid. One end of the sling is then threaded through the needle and pulled superiorly, bringing the end through the brow incision. The empty Wright needle is then passed from the same medial brow incision through the central lid incision, threaded, and pulled gently superiorly through the medial brow incision where the end is retrieved (Fig. 23.4b). This configuration forms a medial triangle.

3. Similarly, a second sling is used to create a lateral triangle. An empty Wright needle is passed from the lateral lid incision to the central lid incision. The fascia is passed into the eye of the Wright needle and drawn across the lid. The empty needle is then passed from the lateral brow incision, posterior to the septum, through the lateral lid incision, taking care to avoid a full thickness pass through the lid. One end of the sling is then threaded through the needle and pulled superiorly, bringing the end through the brow incision. The empty Wright needle is then passed from the same lateral brow incision through the central lid incision, threaded, and pulled superiorly through the lateral brow incision where the end is retrieved.

4. The tension on each triangle is adjusted for predetermined height and contour. A knot is tied, and the ends are left long. The empty Wright needle is then passed from the mid-

forehead incision to the medial brow incision, threaded with the ends of the medial triangle, and pulled superiorly through the mid-fore- head incision. This is also performed for the ends of the lateral triangle.

5. The ends of each sling are tied with a single square knot, reinforced with a 6-0 Nylon suture, and buried superiorly in the pocket beneath frontalis muscle.

6. The brow and forehead incisions are closed using interrupted 6-0 chromic suture for subcutaneous tissue and 6-0 fast absorbing plain gut suture for skin (Fig. 23.4c, d). Antibiotic ophthalmic ointment is placed over the incisions and in the eyes. The patient is given IV antibiotics intraoperatively (Fig. 23.5a, b).

Single Pentagonal Frontalis Sling

Another technique is Fox’s single pentagonal loop using one strand. This single-loop technique has the advantage of straightforward adjustment [16]. Additionally, less foreign body material is utilized compared to that of the Crawford technique.

Although there have been many deviations from original descriptions, the authors prefer a modified pentagonal loop [20]. They use a 0.8-mm silicone rod with swedged-on needles (BD Visitec frontalis suspension set (Seiff); Franklin Lakes, NJ, USA). The needles can be used or removed per surgeon preference. The authors’ modified technique is outlined as follows:

1. A 4-0 silk traction suture is placed in the central upper lid margin. Five incisions are made using a #15 blade. Two incisions are placed 3 mm above the lash line of the lid, corresponding to the medial and lateral edge of the corneal limbus, and carried down to the anterior tarsal surface. Two incisions are made at the superior brow hairs, just above the lid incisions, and carried down to periosteum. A similar forehead incision is made 1.5 cm above the superior brow hairs between the lateral and medial brow incisions. Tenotomy scissors are used to create a pocket superiorly beneath the frontalis muscle through the forehead incision.

2. A bone plate coated with ophthalmic ointment is placed beneath the upper lid for corneal protection. An empty Wright needle is passed from the medial brow incision, posterior to the orbital septum, through the medial lid incision, taking care to avoid a full-thick-

ness pass through the lid. The sling end is threaded through the needle, and pulled superiorly through the brow incision, where the end is retrieved. The opposite sling end is then brought from the medial lid incision to the lateral lid incision above the tarsus in a similar fashion.

3. The empty Wright needle is passed from the lateral brow incision to the lateral lid incision, threaded, and pulled superiorly through the lateral brow incision (Fig. 23.6a). The empty Wright needle is then passed from the midforehead incision to the medial brow incision, threaded, and pulled superiorly through the mid-forehead incision where the end is retrieved. This is also performed to retrieve the end from lateral brow incision through the mid-forehead incision (Fig. 23.6b).

4. When using silicone rods, a 3-mm silicone sleeve is placed over a hemostat, and the silicone ends are brought through the sleeve in a

Fig. 23.6  Modified pentagonal Fox technique for frontalis suspension with silicone rod. (a) A silicone rod is threaded through the Wright needle before pulling the sling superiorly through the lateral brow incision. (b) Both ends of the silicone rod are brought

through the mid-forehead incision. (c) The ends are brought through a 3-mm silicone sleeve. The sling tension is adjusted to achieve the desired lid height and contour before securing the sleeve into position with a 6-0 Nylon suture

parallel fashion (Fig. 23.6c). (Some surgeons prefer to pass the ends through the sleeve in opposite directions). The authors do not routinely fixate to the tarsus. The lid height is adjusted, and a 5-0 Nylon suture is passed through the sleeve and then wrapped around the silicone sling ends to prevent slippage of the loop. Care should be taken to not cut the sleeve or slings with the needle or suture. When using other synthetic materials, the ends are knotted together several times. All ends are left 10–15 mm in length and buried in the superior pocket previously created beneath the frontalis muscle.

5. The brow and mid-forehead incisions are closed using interrupted 6-0 chromic suture for subcutaneous tissue and 6-0 fast absorbing plain gut suture for skin. Antibiotic ophthalmic ointment is placed over the incisions and in the eyes. The patient is given IV antibiotics intraoperatively (Fig. 23.7a, b).

Proper adjustment techniques vary for children and adults. When adjusting the lid height of a child intraoperatively, the surgeon should gently push the brow inferiorly to account for gravitational pull when the patient stands upright. With the brow in this position, the eyelid height should be set at the desired postoperative level. In the authors’ experience, this produces excellent postoperative results with good predictability.

In adults, the height of the lid should be set slightly lower than in children, and lagophthalmos should be minimized. Avoidance of over-

correction is important, especially in adults with myasthenia gravis and third nerve palsy. Such adults carry increased risk for corneal exposure (due to weak eyelid closure and/or poor Bell’s phenomenon) and diplopia secondary to impaired eye movement. Rather than positioning the lid for symmetry with the other side, the height should be set at an appropriate level above the pupil to prevent ocular surface issues. It is important to leave the silicone ends 10–15 mm in length from the sleeve to adjust the lid height in a graduated fashion, if needed.

Complications of frontalis sling placement include infection, granuloma formation, migration, and extrusion. The surgeon should be able to manage contour abnormalities, asymmetry, undercorrection, and overcorrection causing lagophthalmos. Passage of the sling too far inferiorly or anteriorly can cause eversion of the lid margin as the sling is tightened. Additionally, insufficient tarsus from prior surgery can lead to instability and unacceptable contour. Excess eyelid laxity can cause the sling to pull the eyelid away from the globe and create tear film abnormalities.

Frontalis suspension is the preferred method of ptosis repair in cases with poor levator function. Adjustable sling materials may have specific advantages in patients with progressive ptosis or who are at risk for corneal decompensation. In summary, excellent functional and aesthetic results can be obtained with frontalis slings when carefully placed with attention to surgical detail.