Frontalis Suspension Procedure Research Articles

Combination of Dermal fat Grafting and Frontalis Suspension Using Polytetrafluoroethylene Sheet for Blepharoptosis With a Deep Sulcus.

The frontalis suspension procedure is a common surgical method for patients with severe blepharoptosis. While frontalis suspension is a very effective method, the transplant material may be visualized after surgery in patients with a deep sulcus and severe blepharoptosis. To prevent this complication, we performed a combination of dermal fat grafting and frontalis suspension using a polytetrafluoroethylene sheet in 5 patients (6 eyelids). We followed-up the patients for at least 6 months postoperatively (mean: 6.8 months) and observed no transplant material visualization or occurrence of infection. The mean pre- and postoperative margin reflex distance-1 was -3.75 (-5 to -2) and 2.10 (1-3), respectively. Bulky upper eyelids were observed 6 months postoperatively in 1 patient (2 eyelids). None of the patients underwent reoperation. In conclusion, the combination of frontalis suspension using a polytetrafluoroethylene sheet and dermal fat grafting for severe blepharoptosis and a deep upper eyelid sulcus was effective in preventing visualization of the transplant material.

Eyebrow Elevation as a Prognostic Factor for Success of Frontalis Suspension in Severe Congenital Ptosis.

PurposeThe study aims at evaluating eyebrow elevation as a prognostic factor for frontalis sling procedure success in patients suffering from severe congenital ptosis with poor levator function.Patients and MethodsThis is a retrospective study that included 66 eyelids of 57 patients selected from a surgical log database between January 2016 and June 2019. All of them underwent frontalis suspension surgery for treating severe congenital myogenic ptosis with poor levator function. Based on the absence or presence of brow elevation, patients were divided into two groups: 1 and 2, respectively. The latter was further subdivided into subgroup A with unilateral brow elevation and subgroup B with bilateral brow elevation. All included cases completed 6 months of follow-up after surgery. Postoperative functional outcomes in the form of margin reflex distance (MRD1) and palpebral aperture (PA) were recorded and correlated to preoperative brow elevation status.ResultsBoth principal groups showed improvement of MRD1 and PA compared to the preoperative values. There was no statistically significant difference between both groups for the tested parameters in the 1st postoperative week. By the 6th postoperative month, MRD1 and PA showed statistically significant higher values in group 2 compared to group 1 (p<0.001). However, the difference between subgroups A and B was statistically insignificant for the same parameters.ConclusionEyebrow elevation is significantly associated with the success of frontalis suspension procedure. Hence, brow position evaluation should be included in the preoperative assessment of patients undergoing frontalis suspension for congenital ptosis.

Symmetry of Upper Eyelid Contour After Unilateral Blepharoptosis Repair With a Single-strip Frontalis Suspension Technique.

To analyze the upper eyelid contour of patients with unilateral congenital ptosis who underwent single-strip frontalis suspension. The authors compared the upper eyelid shape of the right and left eyes of 10 patients who underwent unilateral frontalis suspension with a single strip of autogenous fascia. At a mean postoperative time of 10.1 ± 4.01 months, the image J software was used to measure the ratio between the nasal and temporal areas of the upper half of the palpebral fissure. The midpupil upper eyelid distance (MRD1) was also measured on the photos with the same software. The nonparametric Wilcoxon signed-rank test was used to compare the data. Postoperative MRD1 ranged from 2.5 to 4.7 mm (median = 3.8) on the affected side. The MRD1 for nonoperated eyelid ranged from 1.8 to 5.0 mm (median = 3.5). On the operated side, the temporal areas ranged from 50.3 to 85.7 mm (median 65.2) and nasal areas ranged from 41.5 to 72.3 (the median was 60.1). In the contralateral, nonoperated palpebral fissures, the temporal areas ranged from 42.7 to 94.3 mm (median = 54.5) and the nasal areas ranged from 36.8 to 86.1 mm (median 52.3). The T/N ratio distributions were almost identical between groups, ranging from 0.9 to 1.2 (median = 1.1) in the operated eyes and from 0.9 to 1.3 (median = 1.1) in the fellow eyes. In autogenous fascia frontalis suspension procedures, the upper eyelid contour of the ptotic eyelids can be adequately normalized with a single area of traction on the tarsal plate.

The Value of the Frontalis Suspension Procedure as a Repeat Intervention in Congenital Blepharoptosis.

To evaluate the therapeutic benefits of frontalis suspension as a repeat intervention in congenital blepharoptosis. Pediatric patients diagnosed as having congenital ptosis who had at least 2 years of postoperative follow-up were included in this retrospective study. A successful outcome was defined as a postoperative margin-reflex distance of 3 mm or greater. The chi-square, Student's t, and Mann-Whitney U tests were used in comparisons. Eighty-four eyes of 77 patients with a follow-up period of 8.4 ± 0.7 years were included. The initial surgery was levator resection in 29 (34.5%) eyes and frontalis suspension in 55 (65.5%) eyes. Frontalis suspension was performed for all repeat interventions (n = 20). Surgical success was achieved in 61.9% of patients with single surgery (75.9% for levator resection vs 54.5% for frontalis suspension; P = .06) and in 77.4% of patients following repeated surgeries (93.1% vs 69.1% for patients who initially underwent levator resection vs frontalis suspension, respectively; P = .012). A higher success rate was associated with better preoperative levator function (P = .01) and a higher margin-reflex distance (P = .004), and was inversely proportional to ptosis severity (P = .04). Frontalis suspension as a repeat intervention for congenital blepharoptosis is associated with a further increase in long-term anatomic success rates and should be considered when initial procedures fail or remain inadequate. [J Pediatr Ophthalmol Strabismus. 2017;54(5):320-323.].

Therapeutic Algorithm for Congenital Ptosis Repair with Levator Resection and Frontalis Suspension: Results and Literature Review

ABSTRACTBackground: Several treatments have been described for the treatment of congenital ptosis, but there are few studies that analyze the effectiveness of a therapeutic approach rather than a single technique. Aims: In this study, we aim to evaluate the effectiveness of our therapeutic algorithm, which relies on levator muscle resection and frontalis suspension with silicone rods, polytetrafluoroethylene (PTFE), or autologous fascia lata. Methods: We retrospectively analyzed all patients affected by congenital ptosis who underwent corrective surgery at a single department between January 1998 and January 2016. Results: A total of 116 procedures were performed in 86 patients, accounting for 35 levator resections, 67 frontalis suspensions, and 14 revisions. A satisfactory result was observed in 65 cases after one procedure (75.6%). Complications occurred in 13 cases after primary surgery (15.1%). Ptosis relapse was observed in 25 cases after primary procedure (21.5%). Frontalis suspension displayed a higher number of complications than levator resection (22.2% vs 3.1%, p=0.02). Conclusion: Our therapeutic algorithm was effective in 75.6% after one procedure. Frontalis suspension procedures encountered a higher rate of complication than levator resection. Fascia lata should be preferred to silicon rods whenever possible due to the lower recurrence rate. These issues confirm the therapeutic algorithm, although larger prospective studies are necessary to validate our approach.

Frontalis suspension with an expanded polytetrafluoroethylene sheet for congenital ptosis repair

Congenital ptosis with poor levator function is most often repaired with a frontalis suspension procedure. Autogenous fascia lata grafting is generally effective, with low rates of infection and granuloma formation. However, contraction of the grafted fascia lata may cause eyelash inversion, tarsal deformity, and/or lagophthalmos. Conversely, several synthetic suspensory materials have been used for frontalis suspension, among which polytetrafluoroethylene has been reported to be comparable to the fascia lata. However, in some studies using polytetrafluoroethylene strips or sutures, complications such as infection and granuloma formation were a significant problem. This study evaluated the outcomes of frontalis suspension with an expanded polytetrafluoroethylene sheet for congenital ptosis repair in 97 patients (130 eyelids). No ptosis recurrence was reported in an average follow-up of 31.6 months (range: 6-102 months). Six of the 130 eyelids (4.6%) had complications. Based on these results, frontalis suspension with an expanded polytetrafluoroethylene sheet for congenital ptosis repair can be considered safe and effective and be recommended for clinical use.

Silicone Rod Exposure After Frontalis Suspension Procedure For Blepharoptosis

Silicone Rod Exposure After Frontalis Suspension Procedure For Blepharoptosis

Intra-eyebrow frontalis suspension using inverted Y-shaped short autogenous fascia lata for blepharoptosis with poor levator function

Frontalis suspension using autogenous fascia lata is a common procedure for blepharoptosis with poor levator function. However, donor-site morbidity associated with fascia lata harvest cannot be ignored. In conventional procedures, the required length of the fascia lata is usually >5-12cm with a lateral thigh skin incision of approximately 5cm or more. The present study introduces a new frontalis suspension procedure in which the required size (length and width) of the fascia lata and length of lateral thigh incision is much smaller. The harvested fascia lata is tailored to an inverted Y shape and the separated caudal legs are fixed to the tarsus while the cephalic end is grafted inside the eyebrow through a suborbital septum tunnel. In the present study, 11 patients who underwent the new procedure with a minimum of 6 months of follow-up were evaluated. The average length and width of the harvested fascia lata in unilateral ptosis cases were 2.85 and 0.89cm, respectively. The average length of the lateral thigh incision was 1.25cm. The margin reflex distance improved in all cases at 6 months postoperatively. The cosmetic result was graded as good to excellent in most of the patients. Trichiasis, widened donor scar, and eyebrow notch were noted as complications. The present method is a good alternative for the treatment of blepharoptosis with poor levator function. It potentially reduces donor-site morbidity as compared with conventional frontalis muscle suspension procedures using autogenous fascia lata.

Comparison of Mersilene Mesh and Autogenous Fascia Lata in Correction of Congenital Blepharoptosis: A Randomized Clinical Trial

To asses the functional results and complications of Mersilene mesh as an alternative to autogenous fascia lata in the management of low function ptosis. In a randomized clinical trial, 31 eyelids with poor levator function were operated on. In 16 eyelids Mersilene mesh (Group A) and in 15 eyelids autogenous fascia lata were used for frontalis suspension procedure (Group B). Nine patients with congenital unilateral and 11 patients with bilateral ptosis underwent sling procedure. There were no differences between the two groups with regards to functional (lid fissure height stability) and cosmetic (lid margin contour) results. Eyelid fissure increase was 4.00-/+1.46 mm in Group A and 3.13-/+1.72 mm in Group B. Change in eyelid fissure in both groups was significant (p=0.00, paired t-test), but intergroup difference was not significant (p=0.141, independent sample t-test). Follow-up for Group A was 14.2 (range 6-26) months and for Group B was 15.1 (range 9-29) months. Dermatochalasis was seen more in Group B (B/A = 10/2) and extrusion of Mersilene mesh was seen in two cases of Group A and none of Group B. Early complications such as corneal epithelial defects and entropion and late complications such as undercorrection were comparable in the two groups. Mersilene mesh with long-term functional results and low rate of complications is a suitable alternative to autogenous fascia lata as a suspensory material in ptosis surgery.

Removal and plastic reconstructive surgery of orbital neurofibroma

To investigate the safety and efficacy of surgical management of orbital neurofibroma (NF). Twenty-six patients with orbitotemporal NF underwent tumor resection. And then 12 of the 26 patients that were of Jackson group I, underwent blepharoplasty surgery, including lid plastic and reconstructive surgery, lateral canthal reattachment and ptosis surgery. Ten patients of group II underwent blepharoplasty combined with orbital reconstruction. And 4 patients of group III underwent blepharoplasty surgery, orbital reconstruction, and hydroxyapatite orbital implanting. The functionally useless eyes of 2 patients were retained for cosmetic appearance. There was no recrudescence after neurofibroma resection. 10 patients had their vision acuity improved. All patients obtained satisfying results after eyelid and orbital plastic surgery. 2 patients relapsed into ptosis that was cured with further frontalis suspension procedure with autogenous fascia lata. Neurofibroma removal surgery is a safe and effective treatment method for NF patients. The periorbital appearance and visual acuity of patients with orbitotemporal NF can be significantly improved through oculoplastic surgery.

Broad Fascia Fixation Enhances Frontalis Suspension

To report the use of a modified frontalis suspension procedure for congenital ptosis patients with minimal to no levator function. Retrospective, non-comparative case series of frontalis suspension by 2 surgeons over a 21-year period. Frontalis suspension with broad fascia fixation was performed on 48 eyelids of 25 patients. All patients had visual obscuration due to blepharoptosis with only 0 mm to 2 mm of measurable levator function. Age ranged from 3 to 13 years. Minimum length of follow-up was 6 months (range, 6-174 months). The palpebral fissure was increased in all patients, improving their head position and unmasking their visual axis in primary gaze. Postoperatively, all patients developed transient exposure symptoms. There were no migrations, extrusions, infections, or granulomas. All patients achieved a satisfactory postoperative result based on eyelid position, function, and contour. This modified frontalis suspension procedure maximizes frontalis muscle recruitment, creating powerful eyelid elevation with stable effect over time. The technique minimizes other procedures' pitfalls and advances in cosmesis are achieved with enhanced eyelid crease formation and adjustable eyelid contour.

The Search for an Ideal Surgical Procedure for Pediatric Congenital Ptosis With Poor to Absent Levator Muscle Function Continues

&lt;h4&gt;EXCERPT&lt;/h4&gt; &lt;p&gt;The surgical management of severe congenital blepharoptosis in pediatric patients continues to evolve. Results are often less than ideal regardless of the procedure used. This accounts for the numerous reports of proposed improved techniques and modifications of frontalis suspension and maximal levator muscle resection surgical procedures. A recent improvement in the frontalis suspension procedure is the incorporation of tarsal fixation of the suspensory material. This procedure includes an eyelid crease incision with dissection to the tarsus. This technique may preclude slippage of the suspensory material and recurrence of the ptosis. Although this increases surgical time, the improved long-term results make the extra time invested well worth it.&lt;/p&gt;

Comparison of Silastic and Banked Fascia Lata in Pediatric Frontalis Suspension

To compare the use of Silastic and banked fascia lata in pediatric frontalis suspension surgery for functional success, ptosis recurrence, and infection and granuloma rates. This retrospective study analyzed the medical records of 72 patients who underwent 131 frontalis suspension operations using either Silastic or banked fascia lata during the past 12 years at Children's Hospital at Westmead, Sydney, Australia. Functional success rates for primary frontalis suspension procedures were not significantly different for banked fascia lata and Silastic (60% versus 67.2%, respectively; P = .4666). Infection and granuloma rates also were not significantly different (7.1% for banked fascia lata versus 15.2% for Silastic; P = .1381). There was, however, a statistically significant difference between the two materials in ptosis recurrence (35.3% for banked fascia lata versus 13% for Silastic; P = .0062). Silastic was significantly better than banked fascia lata in terms of ptosis recurrence. Both materials were comparable in terms of functional success after one procedure and in infection and granuloma rates. Given the conflicting evidence presented in the literature, large prospective studies are needed to compare the use of the most common synthetic materials with banked fascia lata in pediatric frontalis suspension.

Resultados y complicaciones del politetrafluoroetileno expandido en la cirugía de ptosis palpebral por suspensión al frontal: Estudio de 59 casos

To evaluate the functional results and complications of the use of expanded polytetrafluoroethylene (ePTFE) in frontalis suspension surgery for the treatment of moderate-severe palpebral ptosis (> 3 mm) with poor or absent levator muscle function. Retrospective study of 59 frontalis suspension procedures performed between 1992 and 2003 on 38 patients with palpebral ptosis (21 bilateral). Seventeen (44.7%) cases were women and 21 (55.3%) men. The mean age was 51.7 S.D. 27.6 years (range, 2 to 87). The surgical techniques used were performed by a Wright fascia needle. The etiology, ptosis grade, levator function, Bell's phenomenon and frontalis compensation were studied. After a median follow-up time of 35.9 S.D. 18.5 months (range, 6 to 72), we observed that the functional results were good in 55 cases (93.2%). Infection with preseptal cellulitis appeared in 1 case (1.7%) and required removal of the material, and in 2 cases (3.4%) there were foreign body granulomas that were resolved by excision. Two cases (3.4%) had to be reoperated due to recurrence. The ePTFE, in our experience, is a good material with excellent functional results and relatively few complications in the surgical treatment of eyelid ptosis for frontalis suspension. Other synthetic materials or fascia lata may be used, but all carry the risk of potential infection, extrusion, granuloma formation or recurrence.

Autologous Pedal Extensor Tendon for Frontalis Suspension in the Correction of Blepharoptosis with Poor Levator Function

Introduction:Blepharoptosis with poor levator function is commonly repaired with a frontalis suspension procedure. A variety of suspension materials have been used, including autologous fascia lata, banked fascia lata, Supramid, Gortex, silicone, and Mersilene. Autologous materials offer the advantage of less rejection and granuloma formation, and lower rates of ptosis recurrence. Autologous fascia lata, although commonly used, has been associated with hemorrhage, scar problems, pain, and muscle herniation over the harvest site. Additionally, sufficiently long autogenous fascia is sometimes not readily available. We describe the use of autologous pedal extensor (extensor digitorum longus) tendon for frontalis suspension.Materials and Methods:In a retrospective study, the authors evaluate 19 frontalis sling suspension surgeries using pedal extensor tendon in 17 consecutive patients with ptosis with poor levator function. The method of harvesting the pedal extensor tendon is described in detail.Results:Of 19 ptotic eyelids, 18 were successfully corrected with good final lid position. One eyelid was undercorrected. No recurrence of ptosis was encountered. No wound infection, eyelid contour abnormality, or ptosis overcorrection occurred. One eye developed exposure keratopathy that resolved with conservative treatment. There were no major complications associated with the pedal extensor tendon donor site.Discussion:Frontalis suspension with an autogenous pedal extensor tendon appears to be cosmetically sound and an effective treatment for ptosis with poor levator function. Its use as an alternative material to fascia lata for frontalis sling surgery can be considered.

Use of orbicularis oculi muscle flap for undercorrected blepharoptosis with previous levator muscle resection.

Based on the detailed anatomy, the orbicularis oculi muscle and the orbital septum are the continuation of the frontalis muscle and its fascia. Therefore, the shortened orbicularis oculi muscle and orbital septum would transmit the frontalis muscle action more effectively. The superior-based orbicularis oculi muscle and orbital septum flap, as a single flap, were advanced and attached to the tarsal plate for the correction of blepharoptosis. Six patients with undercorrected blepharoptosis were included in this study. Each patient had undergone more than two levator resection procedures by ophthalmologists or plastic surgeons. Conventionally, the frontalis suspension procedure was the next choice in these cases. The shortened orbicularis oculi muscle and orbital septum flap was used in these cases. Postoperative results were satisfactory after 3-year follow-up.

Frontalis suspension with "expanded polytetrafluoroethylene (ePTFE) strips" in congenital ptosis

The Frontalis Suspension Technique is indicated in cases with minimal or no levator function. At the beginning sutures were used as sling material and after further modifications suture material was replaced by autologous or homologous fascia lata. In the last years ePTFE has proved to be a very suitable sling material. Since ePTFE is very biocompatible, it was used for this modified frontalis suspension technique. The anterior tarsal surface is exposed and a small tunnel is created between the skin incision and the second incision superior to the brow. An 0.3 mm thin ePTFE strip is induced into the tunnel and connects the upper lid with the frontalis muscle. The ePTFE Soft Tissue Patch must be exactly adapted to the tarsus and has to be deeply sutured to the frontalis muscle below the brow incision. Since 1994 17 modified frontalis suspension procedures have been performed on 14 patients. The functional and cosmetic result were good in nearly all patients. No implant had to be removed during the follow up period. The new technique of frontalis suspension using a ePTFE strip guarantees a regular upper lid lifting by the axial and direct connection of the anterior tarsal surface with the frontalis muscle.

Ptosis surgery using Mersilene mesh suspensory material.

Frontalis suspension procedure using a Mersilene mesh sling was performed on 23 ptotic eyelids of 22 patients (age range 3 to 35 years) with poor or absent levator function. The surgical technique used was a modified Fox's method. The mean palpebral fissure height was 3.1 mm preoperatively and increased to 8.0 mm after the operation. No serious complication was seen postoperatively and during an average follow-up of 25 months. In one case with a cosmetically inadequate result, the upper third of the initially implanted Mersilene mesh was removed during reoperation and histological examination of the specimen revealed fibrovascular tissue invasion through the mesh fibres. Mersilene mesh appears to be an effective and safe alternative sling material for brow suspension surgery, giving good permanent results for cases in which autogenous fascia lata was inappropriate.

Gore-Tex soft-tissue patch frontalis suspension technique in congenital ptosis and in blepharophimosis-ptosis syndrome.

The frontalis suspension technique is the surgical method of choice in ptosis patients with a levator function of 2 mm or less. This type of ptosis is found unilaterally or bilaterally in isolated congenital ptosis and mostly bilaterally in blepharophimosis-ptosis patients. The frontalis suspension technique is frequently used in children being operated on because of congenital ptosis, where the excision of the fasciae latae can be avoided so as not to risk scarring the donor area. Since the new heterologous material polytetrafluoroethylene (Gore-Tex soft-tissue patch) has been available (1986), it has been used on our ptosis patients with minimal levator function instead of the formerly much used fasciae latae. Thirty-seven frontalis suspension procedures have been performed in 26 patients, of whom 6 were children who suffered from bilateral blepharophimosis-ptosis syndrome. All ptosis procedures were performed as Fox pentagons, and in the combined cases, the medial canthoplasty was carried out as a bilateral one-stage procedure. The postoperative healing was free of complications. Three years postoperatively one patient did exhibit rejection of one of the two implanted Gore-Tex slings. In all other patients, the functional and cosmetic results were satisfying, and high biocompatibility of the Gore-Tex soft-tissue patch material could be shown.

Transconjunctival Frontalis Suspension (TCFS)

We have devised a frontalis suspension technique originally described in an article entitled, "Transconjunctival frontalis suspension for blepharoptosis" (Trans Am Acad Ophthal Otolaryngol 83:684-92), by Swan and Tongue in 1977. This modified transconjunctival frontalis suspension (TCFS) procedure is described. It has been used at the Oregon Health Sciences University in its original or modified form since 1970. To better understand how this procedure successfully corrects blepharoptosis in patients with poor levator function, a study was undertaken to discern the anatomic relationship of the suspension material to important ocular adnexal structures. The findings are based on gross anatomic dissection and histologic examination of a cadaver eyelid after postmortem transconjunctival fascia lata frontalis suspension. The distal, horizontal limb of the fascia suspends the central portion of the levator aponeurosis in a hammock-type fashion. The two vertical limbs pierce the aponeurosis at the level of Whitnall's ligament and incorporate this ligament. The fascia then exits the orbit through the orbital septum near the arcus marginalis and is incorporated into the frontalis muscle near the junction of the medial one-third and lateral two-thirds of the brow, temporal to the supraorbital neurovascular bundle. This anatomic location is not only relatively easily and safely attained, but also maximizes the principles of more traditional frontalis suspensions while minimizing the effort and surgical manipulation.