Congenital Myogenic Ptosis

Frontalis Suspension

Frontalis suspension is used to manage myogenic ptosis, neuromuscular diseases, and cases in which linkage between the muscle and the eyelid is abnormal, such as Marcus Gunn jawwinking phenomenon or third nerve palsy with aberrant regeneration. Autogenous fascia has been shown to result in lower ptosis recurrence and complication rate compared with banked fascia and therefore is considered the material of choice [7]. Historically, fascia lata from the thigh has been the gold standard for fixation. Recurrence rates after frontalis suspension vary and are reported to be between 0 and 100%.

Polytetrafluoroethylene (PTFE) and autogenous fascia have demonstrated the lowest recurrence rate [8], which is reported to be between 4 and 20%, while nylon or silicone has reported recurrence rates between 40 and 100%.

It is believed that the suture material serves only as a temporary skeleton for scar formation, and therefore no difference is anticipated between different suture materials as long as they remain in good position during the inflammation and scarring process. However, better cosmetic outcome was noted in cases in which a nylon sling was used [8]. Several suture designs such as single loop or double pentagon configurations are used for frontalis suspension surgery with no clinically significant difference between them [8].

Many investigators believe that eventually all cases of congenital ptosis that are treated with frontalis suspension will recur. This is evident from the higher recurrence rate (ranging from 4 to 100%) published in studies with longer fol- low-up periods (Table 28.1), regardless of the type of sling used. Success of frontalis suspension with lyophilized human fascia lata decreases from 90% at 2–3 years after surgery to 50% at 8 and 9 years [9]. In cases of congenital ptosis, parents and children should realize that the ptosis recurrence rate is high after surgery and that the patient is likely to need additional surgeries.

Despite the fact that autogenous fascia has better biocompatibility than alloplastic materials, similar functional and cosmetic outcomes and incidence of ptosis recurrence may be achieved with alloplastic materials [9]. Rates of common complications associated with frontalis suspension including early postoperative exposure keratopathy, inflammation or pyogenic granuloma, eyebrow scars, suture infection with preseptal cellulitis, and suture exposure vary with different sling materials. Higher rates of complications are associated with nylon monofilament and PTFE.

Frontalis suspension is the preferred option for poor levator function cases, although levator resection is often employed [18]. Both methods were found to be effective [19] in cases of poor levator function (2–4 mm). Levator function was reported to be the best predictor of surgical outcome in these cases [18].

A relatively new procedure termed “Incisionless frontalis suspension” utilizes a nylon monofilament suture for frontalis suspension [20]. The nylon suture is passed in a circling fashion via puncture wounds without making eyebrow incisions. Two puncture sites, approximately 10 mm apart, are marked 3 mm above the lash line centered over the area of desired maximal eyelid elevation. Another two puncture sites are marked above the eyebrow approximately in line with the lateral and medial canthi. This minimally invasive surgery is scarless and can be performed with little trauma to the orbicularis oculi muscle. In comparison to the results of frontalis suspension using allogenic (banked) material, which is not permanent and may be associated with late failures, this technique is a simple, safe, and temporary measure in elevating the eyelid for visual development until the child is old enough for definitive surgery using autologous tissues.

Levator Resection

More aggressive lifts are achievable with levator resection compared to levator advancement, so it is preferred in cases with decreased levator function [2].