Eye Ptosis Surgery Frontalis Sling Fixation
In this procedure, a surgeon attaches the upper eyelid to the frontalis muscle—the muscle just above the eyebrows—typically with the use of a small silicone rod that is passed through the eyelid, underneath the skin. Connecting the eyelid to the frontalis muscle with this rod allows the forehead muscles to elevate the eyelid.
Eye Ptosis Surgery Frontalis Sling Fixation
- avg. recovery
About the Procedure
Make 3 stab incisions in the brow down to the periosteum with a No 15 Bard-Parker knife. Make the lateral incision 0.5 cm above the orbital rim (at the upper border of the eyebrow) and 0.5 cm temporal to a line drawn perpendicularly above the lateral canthus. The second incision is made 0.5 cm above the orbital rim, perpendicular to the center of the lid, and the third incision is made 0.5 cm above the orbital rim and 0.5 cm nasal to a line drawn perpendicular to the inner canthus. Always make the lateral incision first because the brow is fairly vascular, and if the nasal and middle incisions are made first, the blood flows over the operative site, making the lateral incision difficult. Place a 4-0 black silk traction suture in the tarsus and pass the needle in and out of the gray line in the center of the lid. Place a Storz lid plate (#E2504), which has a knurled knob at the end, under the lid, and fasten the traction suture to the knob to put the lid on constant stretch. A protective contact lens or lid plate may also be used to protect the eye. Make 3 horizontal stab incisions, 2 mm long, in the upper lid 1 mm above the cilia line through the skin and pretarsal muscle to the tarsus. Place the temporal incision 3 mm from the medial canthus, the middle incision in the center of the lid, and the nasal incision 3 mm from the medial canthus. With the lid plate in place, insert an empty Wright needle into the middle brow incision to the depth of the periosteum. Pass it across the orbital rim without incorporating periosteal fibers of the linea alba. Direct the needle inferiorly and posteriorly to pass behind the orbital septum and then superficially into the lid anterior to the tarsal plate to emerge through the middle lid incision. Thread the fascia through the needle until the center of the strip is reached. Then withdraw the needle, pulling the doubled fascia through the middle incision and out the middle brow incision. Cilia must not be pulled into the tract with the fascia, since this increases the possibility of infection. Cut the double fascia at the needle, making 2 strips of equal length that are used to produce the double rhomboids. Insert the empty Wright needle into the temporal lid incision and pass it beneath the skin to the middle lid incision. Thread the end of one fascial strand through the needle and withdraw it toward the temporal lid incision. Direct the empty needle from the temporal brow incision downward and out through the temporal lid incision in the same fashion as it was placed through the central brow and lid incisions. The fascia is then drawn through the temporal brow incision. Pass the empty needle from the temporal brow incision to the middle brow incision, and thread the opposite end of the same fascial strand through the needle and pull it out through the temporal brow incision. This procedure produces a temporal rhomboid, and the tension on the 2 ends elevates the lateral half of the lid. The same steps are carried out in the same order to complete the medial rhomboid, using the second strip of fascia in the middle and nasal incisions of the brow and lid. By using the 2 strands of fascia in this fashion, the middle, temporal, and nasal portions of the lid can be controlled to produce a good lid contour that is slightly higher in the nasal third than in the temporal third. Both strands of fascia are pulled tightly enough to produce a good lid fold and to elevate the lid so it crosses the upper limbus with the eye in the primary position. If bilateral ptosis is present, perform the procedure on both lids during the same operation to produce symmetry. Grasp the ends of the fascia projecting from the nasal brow incision with small Halsted clamps, and place a single tie with the fascia pulled as tightly as necessary. As mentioned, tie the sling so that the upper lid crosses the globe at the upper limbus in the primary position at the time of operation. Some postoperative relaxation always occurs, usually 1-2 mm, which puts the lid at approximately the correct position. Suture the knot firmly with 4-0 chromic catgut suture or 5-0 Vicryl, using multiple passes to prevent slippage. However, the fascia is extremely slippery, and the ends must be fastened securely with suture material. The ends of the fascia are left long, projecting from the wound. Grasp the knot with the Halsted clamp and push it into the base of the incision so that it is well buried. Tie the fascia projecting from the temporal brow incision similarly. The temporal rhomboid usually is not tied quite as tightly as the nasal one in order to obtain proper lid contour. Examine the lids for symmetry. Grasp the tarsal plate with two Adson skin forceps and pull the lid down into the proper position to produce a good curve without any peaking. This pulling on the lid actually sets the fascia in the desired position. If any notching or irregularity of the lid is present, pull it out by grasping the tarsus firmly with Adson forceps and pulling the lid margin to its proper place to equalize the pull of the vertical components of the sling. When satisfied with the height of the lid, bury the projecting ends of the fascia by pulling them horizontally within the brow tract with the Wright needle from the nasal and temporal incisions toward the middle incision. In this procedure, the fascia should be inserted only slightly into the eye of the needle so it pulls free as the needle is drawn across the brow. If enough of the end of the fascia is left so that it projects from the middle wound, cut it off so that the buried portion lies deep and retracts into the incision. Close the brow skin incisions with 2-3 7-0 chromic catgut sutures placed very superficially. The lid incisions need not be closed. If the lid is picked up off the globe by elevating the brow, the fascia likely has not been placed behind the orbital septum superiorly. If this situation is detected, the fascia should be replaced prior to final suturing. At the end of the procedure, a Frost suture of 6-0 black silk is usually placed, allowing closure of the eye(s) by fastening the lower lid to the forehead with adhesive strips.
The goal of ptosis surgery is to elevate the eyelid for better vision and cosmetic appearance.
Limit activities for 1 week after surgery. Avoid rubbing eyes or doing anything that could irritate the eyes. Ptosis surgery lifts the eyelid leaving a larger surface area of the eye exposed and prone to dryness. This is especially true after frontalis sling fixation. The eyelid can become inflamed and may not be able to close completely. It is possible to develop new or worsening dry eye syndrome. Medications or other treatments may be recommended to keep the eyes properly lubricated.
It is recommended for people with ptosis who have poor muscle function.
Not Recommended For
Ptosis surgery is not recommended for patients with corneal sensitivity and severe dry eye syndrome. Although not a complete contraindication, patients with thyroid disease, Bell phenomenon, and poor eye muscle function may produce lagophthalmos.
Side effects from ptosis surgery may include prolonged bruising, edema, under-correction or over-correction of the ptosis, eyelid asymmetry and abnormal shape (i.e. peaking), and corneal foreign body sensation.