Frontalis Suspension Research Articles

Factors associated with pediatric silicone rod frontalis sling exposure or infection: single-institution experience of 193 eyelids.

To determine the pre-operative, peri-operative, or post-operative risk factors that contribute to pediatric frontalis sling infection or exposure. Retrospective study of 193 eyelids that underwent silicone-rod frontalis sling surgery at a single institution between 2014 and 2019. A total of 222 eyelids were originally identified. Of the 222 eyelids that underwent frontalis sling surgery, 193 (86.9%) received silicone-rod slings (SRS), 24 (10.8%) received autologous fascia lata sling (AFS), and 5 (2.3%) received Gore-Tex slings (GS). The 193 eyelids that received SRS met inclusion criteria and underwent further statistical analysis. Patients with SRS who did not receive intra-operative antibiotics had a higher risk of infection or exposure compared to patients with SRS that did receive intraoperative antibiotics (P = 0.03). There was no association between SRS exposure and the other studied risk factors (all P-values > 0.41). Intraoperative antibiotics should be considered in silicone-rod frontalis suspension surgery, as it associated with a decreased risk of exposure or infection.

Silicone sling surgery for congenital ptosis: Tarsal tunnel technique.

This was a prospective, interventional, comparative study conducted on patients with congenital simple severe ptosis. A novel method of silicone rod fixation to the tarsus (tarsal tunnel technique, group 1) was done compared with a conventional technique of silicone rod fixation (suture fixation technique, group 2) in frontalis suspension surgery. A total of 30 patients were randomized into two groups of 15 patients each. Postoperatively, MRD1, vertical palpebral aperture, and eyelid fold height were comparable in both groups till the last follow-up with stability in eyelid position. Patient satisfaction scores showed similar results with good-fair satisfaction grading in 13 patients in group 1 and 11 patients in group 2 at 6 months follow-up. No significant complications occurred in either group. Tarsal tunnel fixation of silicone rods is a novel method in sling surgery with optimal cosmetic and function outcomes. Further long-term studies are needed to validate the results of the technique.

Successfully Modified Dillman-Anderson Myectomy for Marcus Gunn Jaw Winking Ptosis Repair: A Case Report

Introduction: Marcus Gunn jaw winking ptosis (MGJWP) is a type of ptosis present from birth which is characterized by winking of the ptotic eyelid during jaw movement. Case illustration: A 6-years-old child came with a complaint of a right eyelid drooping since birth. The eyelid droop was not progressive. Patient had difficulty to read at a distance, since two years ago. The eyelids moved when the patient chews, sucks, or moving jaw from side to side. Examination did not demonstrate any apparent ptosis of either eyelid nor the movement of eyelids when chewing. On examination of ptosis status on right/left eye, MRD1:0/3, MLD:1/5,LA:4/12 and FIP:6/10.Modified Dillman and Anderson’s myectomi with removal of levator muscle above whitnall’s ligament followed by frontalis suspension using autogenous fascia lata was performed successfully on this patient. Discussion: MGJWP is ptosis in one eye since birth which causes the ptosis eyelid to wink due to provocation of the same side pterygoid muscle. The jaw winking movement is caused by mouth movements such as opening, moving the mouth to the right and left, chewing and sucking. Modified Dillman and Anderson's myectomi with removal of levator muscle followed by frontalis suspension was chosen because it has a better outcome. In the postoperative period, there were no more complaints of ptosis and the jaw winking was resolved. Serious postoperative complications of this surgical technique such as entropion, worsening jaw winking and exposure keratopathy were not found. Conclusion: For severe MJGWP , Modified Dillman and Anderson’s myectomy technique gives satisfactory results in both ptosis correction and jaw winking without serious complications.

Journey of frontalis muscle advancement in severe blepharoptosis: Review of the techniques, modifications, and outcomes.

We aimed to review the degree of standardization of frontalis muscle (FM)-orbicularis muscle advancement techniques in the management of severe congenital blepharoptosis and also study the evidence which supports the procedure correcting blepharoptosis. The undisputed rationale of all types of brow suspension in the management of severe blepharoptosis is based on the concept that slings are the conventional way to simultaneously suspend a ptotic eyelid and transmit the contractile action of the FM to the tarsal plate. Traditionally, frontalis suspension using sling has been used to treat patients with severe congenital blepharoptosis with poor levator function; however, postoperative lagophthalmos, forehead scarring, and recurrence remain major concerns. Since the early 80s, a significant number of consecutive articles have suggested that the eyelid can be effectively suspended by directly suturing FM to the tarsal plate. This review article intends to evaluate the level of standardization of FM advancement techniques in the management of severe blepharoptosis. 'In addition, to determine if the procedure should be performed in a standard manner, and is there enough evidence available to recommend FM advancement as a useful surgical technique.

Delayed infections following polybutylate-coated polyester (Ethibond) suture frontalis suspension surgery for severe blepharoptosis

ABSTRACT Purpose To describe the incidence and management of delayed infections following frontalis sling suspension with polybutylate-coated polyester suture (Ethibond). Methods Retrospective, interventional case series of 177 eyes of 150 patients, who underwent frontalis suspension surgery with Ethibond (Johnson and Johnson, USA), at L V Prasad Eye Institute, Hyderabad, India, between January 2016 and February 2022. Patients were assessed for chronic secondary sling infection, defined as infection/suture granuloma occurring beyond 6 weeks post-surgery. All patients received postoperative oral antibiotics. The clinical profile, microbiological evaluation, antibiotic sensitivity patterns, and management outcomes were analyzed. Results Delayed infection following Ethibond sling suspension was noted in 14 eyes of 13 patients (7.9%). Of these, eight cases (61.5%) were females. The average time interval from surgery to presentation was 7.5 months (range: 2.5 months to 2.5 years). Eleven eyes underwent sling removal. Of the three who received initial antibiotic course, two eventually needed sling removal. Microbiological evaluation was available in seven eyes (50%), with Staphylococcus aureus as the most common organism. Of the six positive cultures, five (83.3%) were resistant to fluoroquinolones (FQs). Conclusion Frontalis suspension with Ethibond has an 8% incidence of delayed infections, with Staphylococcus aureus as the most common organism. The authors recommend early sling removal in all patients with infection and recommend consideration of an alternative material in the event of future revision surgery.

Sling for the sling: a new technique for long-term correction of severe congenital ptosis

IntroductionSevere congenital ptosis poses a complex challenge for oculoplastic surgeons, requiring meticulous surgical intervention to restore eyelid function and improve aesthetic outcomes mainly by using frontalis sling approach. A crucial issue in frontalis sling surgeries is the sustainability of effect.PurposeThis retrospective study reports the outcomes of two surgical techniques for treating severe congenital ptosis in the paediatric age group: Silicon rods ptosis sling and a novel technique involving the use of Silicon rods with green braided polyester (Ethibond) sutures to secure the rods in place “sling for the sling”.MethodsThe medical records of children who underwent frontalis suspension were reviewed in a retrospective fashion. We identified two groups; the first group (20 patients: 35 eyelids) had the traditional frontalis suspension surgery using silicone suspension set, the second group (14 patients: 25 eyelids) was operated using the new “sling for sling” technique. We used the postoperative marginal reflex distance-1 (MRD-1) as the primary outcome measure while the frequency of both wound related complications and recurrence were considered as secondary outcome measures. Post operative data were collected and compared after 1 month, 6 months, 12 months, and 18 months.ResultsPreliminary results indicate promising outcomes for both techniques, with significant improvement in eyelid elevation observed in both groups. However, the novel technique using Silicon rods with Ethibond sutures demonstrated enhanced sustainability, leading to a more durable outcome with significantly less recurrence.ConclusionThis study highlights the potential benefits of the novel technique in treating severe congenital ptosis and introduces an innovative approach to Silicone rods fixation to achieve a long-term corrective effect.

Management of Ptosis in Kearns-Sayre Syndrome: A Case Report and Literature Review.

Kearns-Sayre syndrome (KSS) is a rare mitochondrial disease that affects young adults, due to a deletion of mitochondrial DNA and characterized by the triad: age of onset lower than 20 years, chronic progressive external ophthalmoplegia, and an atypical pigmentary retinopathy. It is also characterized by other endocrine, neurological, and especially cardiac impairment with a very high risk of cardiac complications during surgical procedures under all types of anesthesia. We report a case of KSS revealed by severe bilateral ptosis and confirmed by a muscle biopsy with "ragged red fibers." The ptosis was surgically managed by cautious Frontal suspension under local anesthesia "Frontal nerve block." Through this case, we discuss challenges in the management of KSS patients.

CLINICAL PROFILE OF PTOSIS PATIENTS IN DR. M. DJAMIL HOSPITAL PADANG

Abstract
 Introduction & Objectives : Ptosis is one of the most common upper eyelid abnormalities. Ptosis surgery is indicated when there is visual compromise. Patient clinical profile is important in diagnosing and planning treatment for ptosis correction. The aim of this study is to describe the clinical profile of ptosis surgery patient in Dr. M. Djamil Hospital Padang.
 Methods : This study was conducted in descriptive and retrospective manner. This research has been approved by the Medical Faculty of Andalas University research ethics committee No: 332/UN.16.2/KEP- FK/2021. All patients that were diagnosed with ptosis in Dr. M. Djamil Hospital Padang from January 2016 to December 2021 were included.
 Results : There were 33 patients included in this study. Most common age range was 11-20 years old (51.5%), patients were dominantly female (51.5%). According to laterality, the most common was unilateral ptosis, 21 cases (63.6%). Congenital ptosis comprises 51.5% of the cases with myogenic as the most common etiology. Severe ptosis was found in 20 cases (57.6%), poor levator function was found in 17 cases (51.5%). Levator resection was performed in 19 cases (57.6%). Thirty patients (90.9%) had MRD1 ≥2 mm post-surgery.
 Conclusion : Levator function is important in determining the surgical method. In severe ptosis with poor levator function, frontalis suspension is the surgery of choice. Appropriate surgical procedure in accordance to accurate pre-operative evaluation will show a good surgical result.

RECURRENT CONGENITAL PTOSIS MANAGEMENT BY SUPRAMAXIMAL LEVATOR RESECTION TECHNIQUE

Introduction : Congenital ptosis is an abnormal low position of the eyelid since birth. Levator resection technique is one of the surgery technique for ptosis corection. Recurrence could be occured even after ptosis correction
 Case Illustration : A 22 year old male presented with a chief complaint of droopy left eyelid since birth. Visual aquity were 0,08 pinhole 0,2 and 0,25 pinhole 0,63 respectively. Opthalmology examination revealed interpalpebral fissure (IPF) 4 mm, margin reflex distance (MRD)1 0 mm, MRD2 4 mm and levator function test (LFT) 6 mm on the left eye (Figure 1). Levator resection technique was conducted on his left eye with a good result, MRD1 2 mm, MRD2 5 mm, IPF 7 mm. But the lid dropped again after3 months (Figure 2). Opthalmology examination of the left eye showed IPF 5 mm, MRD1 0 mm, MRD2 5 mm, LFT 2 mm and lagophtalmos 1 mm. Second surgery was done with supramaximal levator resection technique. Good result was achieved after second surgery, MRD1 3 mm, MRD2 5 mm, IPF 8 mm (Figure 3).
 Discussion : Recurrent ptosis could occured after ptosis surgery and had challenges due to scar from previous surgery. Frontal suspension technique was recommended for congenital ptosis levator function less than 4 mm. Supramaximal levator resection was done for this patient, with resection of 30 mm levator muscle, which had result as good as of frontal suspension technique.
 Conclusion : Levator resection technique could be repeated to repair recurrent congenital ptosis. Supramaximal levator resection technique is one of the option.

Outcomes for expanded polytetrafluoroethylene strip in frontalis suspension surgery

ABSTRACT Purpose This study evaluates surgical outcomes and complication rates of frontalis suspension with expanded polytetrafluoroethylene (ePTFE). Methods This retrospective cohort study reviewed all patients undergoing frontalis suspension surgery using ePTFE as the sling material from January 1 2012 to March 3 2020 by a single surgeon at a single academic center. Two different surgical techniques were evaluated in the placement of the sling material. Demographic, clinical, and operative data were extracted. Outcome data including postoperative lid height, reoperation, and complication rate were extracted for the cohort and compared between the two surgical techniques. Descriptive statistics were utilized. Results Sixty-four eyes from 49 unique patients were included in this study. Forty-three (67.2%) patients had isolated congenital blepharoptosis; 14 (21.9%) had blepharophimosis, ptosis, and epicanthus inversus syndrome (BPES); and 2 (3.1%) had cranial nerve III palsy. Fifty-one (79.7%) patients had no prior blepharoptosis surgery. Lid crease incision and stab incision techniques were utilized for 24 (37.5%) and 40 (62.5%) eyes, respectively. Overall, 21 (32.8%) eyes required reoperation with ePTFE to achieve appropriate eyelid height or contour. Only one patient experienced implant infection, requiring removal of ePTFE sling after a second reoperation. There were no cases of implant exposure or granuloma formation noted during the study period. Conclusion An ePTFE strip soaked in cefazolin prior to utilization in surgery is a viable material for frontalis suspension surgery, with a lower infectious or inflammatory complication rate than previously reported. However, reoperation rate was still relatively high.

Blepharospasm Secondary to Deep Brain Stimulation of the Subthalamic Nucleus in Parkinson Disease: Clinical Characteristics and Management Outcomes.

Deep brain stimulation of the subthalamic nucleus (STN-DBS) is an effective treatment for patients with motor symptoms of Parkinson disease but can be complicated by disabling blepharospasm and apraxia of eyelid opening (ALO). Currently, there is no clear consensus on optimal management, and addressing these issues is further hindered by systemic morbidity and resistance to treatments. We aim to describe the different phenotypes of these eyelid movement disorders, to report our management approach and patient responses to treatment. A retrospective case series of all patients with blepharospasm/ALO secondary to STN-DBS that were treated at a tertiary center between 2011 and 2020. Data collected included date of Parkinson diagnosis, date of DBS surgery, date of development of blepharospasm/ALO symptoms, STN-DBS stimulation settings, and treatment given. Patients' symptoms before and after treatment were measured using the blepharospasm disability index and Jankovic Rating Scale. Five patients were identified with eyelid movement disorders secondary to STN-DBS. All patients had moderate-to-severe symptoms at presentation. Four patients received periocular botulinum toxin injections. Three patients underwent surgery in the form of frontalis suspension or direct brow lift with or without upper lid blepharoplasty. All reported an improvement in symptoms following treatment. A multimodality, patient-specific approach is required in the treatment of blepharospasm/ALO secondary to STN-DBS. Botulinum toxin injections can be effective, but patients may require surgery if toxin treatment alone becomes ineffective. Tailoring treatment to individual needs can result in a measurable improvement in symptoms.

Surgical Outcomes After Frontalis Suspension Using Expanded Polytetrafluoroethylene Sling for Congenital Ptosis.

Purpose The purpose of the study is to assess short- and long-term functional outcomes after frontalis suspension using expanded polytetrafluoroethylene (ePTFE) sling for congenital ptosis repair. Methods A retrospective, observational case review was conducted on pediatric patients who underwent frontalis suspension using ePTFE sling from 2008 to 2020. Functional success was assessed by lid height, lid symmetry, and parental satisfaction with the cosmetic outcome.Clinical course and long-term functional outcomes after surgery were assessed. Results Twenty-one cases met the inclusion criteria and were assessed. The follow-up time ranged from 13 monthsto 11 years (mean: six years). Functional success after one surgery was 62% at early and late postoperative periods. Six of 21 cases (29%) required revisional surgery in the early postoperative period due to undercorrection. Three cases (14%) were complicated by infection and/or granuloma formation. There were no cases of ptosis recurrence in the long term if success was seen in the early postoperative period. Conclusion ePTFE slings remain an excellent option for severe congenital ptosis repair with frontalis sling, demonstrating long-term functional success, with satisfactory lid symmetry and acceptable cosmetic outcome. This is of important consideration in patients younger than three years of age, where autogenous materials may not be recommended. The need for early revisional surgery for undercorrection is not uncommon. The current authors also demonstrate a low but considerable risk for infection and/or granuloma formation.

Frontalis Suspension through Infrabrow Skin Excision for Blepharoptosis in Asian Patients.

Frontalis suspension is the preferred approach for blepharoptosis with compromised levator function. Various studies have explored the use of different materials or material shapes for performing this procedure; however, a limited number discuss the specifics of skin incisions. Given that blepharoplasty demands not only functional but also aesthetic results, the authors applied an infrabrow incision, a technique commonly used in cosmetic surgery. This study, the first report involving a series of blepharoptosis cases treated using this technique, explores its viability as a promising alternative to traditional frontalis suspension. This technique was used in 7 consecutive patients exhibiting poor levator function who were treated at the University of Tokyo between September of 2019 and February of 2022. A retrospective analysis was conducted on clinical photographs and charts. In 1 representative case, visual field angle and frontal muscle tone were also measured. The average duration of postoperative follow-up was 9 months. In all cases, the frontalis muscle was adequately exposed to allow suspension through the infrabrow approach. Significant improvements were observed in the marginal reflex distances without effort from -1.9 to 2.1 mm ( P = 0.0027) and marginal reflex distances with effort from 0.0 to 5.4 mm ( P < 0.0001). Complications included a hematoma ( n = 1), eyelash entropion ( n = 1), transient sensory loss of the forehead ( n = 1), and transient dry eye ( n = 3). The infrabrow incision is a good alternative for frontalis suspension owing to its capacity to offer a broad surgical field, provide effective access to the frontalis muscle, and facilitate excess skin excisions without resulting in conspicuous scarring. Therapeutic, IV.

Surgical results of retroauricular fascia graft in frontalis suspension surgery: A case series study

Frontalis suspension surgery is commonly used for repair of congenital ptosis and involutional blepharoptosis with poor levator function. Grafts for this procedure have been developed using many a variety of different materials, each with advantages and disadvantages. The retroauricular fascia graft might be beneficial in this surgery. This article reports the surgical results of blepharoptosis, who were treated with the retroauricular fascia, which is a new autologous graft for the frontalis suspension technique. This case series study targeted patients with ptosis who underwent frontalis suspension surgery with the retroauricular fascia graft at Wakayama Medical University in Japan between May 2016 and May 2023. Patients with insufficient follow-up (<6 months) were excluded from the study. Eligible patients were categorized into one of the following three assessment groups: ‘good’ (improvement of palpebral fissure height without laterality, MRD-1Margin reflex distance-1 gap between right and left side < 0.5mm), ‘fair’ (improvement of palpebral fissure height with laterality) or ‘poor’ (poor improvement of palpebral fissure height). Thirty-five eyes in 25 patients were treated with the retroauricular fascia graft. The mean postoperative follow-up was 27 months. Eight patients were classified as good (32%), 15 as fair (60%), and two as poor (8%). Two patients (8%) had postoperative lagophthalmos. No patients had eyelash inversion, tarsal deformity or recurrence of ptosis recurrence. Scars along the edge of the hairline were inconspicuous and there were no hypertrophic scars. Functional reconstruction of the eyelids using the retroauricular fascia graft technique is described here for the first time. This graft technique may be a useful alternative for frontalis suspension surgery because it can be harvested with easy access and without leaving conspicuous scars.

Extended frontalis orbicularis oculi muscle flap shortening for treating refractory apraxia of eyelid opening associated with blepharospasm.

Refractory apraxia of eyelid opening (AEO) is mostly unresponsive to botulinum toxin (BTx) and inevitably leads to functional blindness. To treat this challenging condition, an innovative surgical technique was proposed. The extended frontalis orbicularis oculi muscle (FOOM) flap shortening consisting of frontalis suspension, partial myectomy, and myotomy in situ of eyelid protractors was applied to treat refractory AEO associated with blepharospasm. The postoperative outcomes and patient satisfaction were evaluated. Seven patients (mean ages 64.1 ± 3.9 years) of 14 eyelids in total had an average flap shortening distance of 24.4 ± 1.3 mm. During a mean follow-up of 31.6 ± 11.4 months, the average BTx dosage reduced from 58.6 ± 12. 1 units to 30.0 ± 8.2 units, with a mean injection interval decreasing from 2.3 ± 0.5 months to 4.1 ± 0.9 months (p < 0.05). Palpebral fissure height increased from 1.4 ± 0.5 mm to 7.9 ± 0.7 mm, and the disability scale decreased from 78.8% ± 7.2% to 12.6% ± 7.0% (p < 0.05). The postoperative BTx dosage and frequency were significantly reduced. All patients restored voluntary eyelid opening and reported high postoperative satisfaction (average Likert scale 4.6 ± 0.5). Extended FOOM flap shortening is an effective treatment to solve refractory AEO associated with blepharospasm.

Outcome of silicone sling frontalis suspension in children with simple congenital and complex ptosis

ObjectifComparer les résultats de la suspension frontale (SF) avec sonde à ptosis en silicone dans le ptosis congénital simple et complexe au sein d'une cohorte d'enfants. NatureÉtude de cohorte rétrospective. ParticipantsTous les enfants qui ont fait l'objet d'une SF avec sonde à ptosis en silicone entre 2009 et 2020 dans un établissement unique. MéthodesLes patients ont été divisés en 2 groupes en fonction de l’étiologie du ptosis : ptosis congénital simple et ptosis congénital complexe. Les mesures de la distance entre le reflet pupillaire et le bord libre (MRD1, pour margin-to-reflex distance) avant et après l'intervention ont été déterminées à partir de photographies cliniques. La différence en matière d'amélioration de la hauteur de la paupière et le taux d'intervention répétée entre les groupes constituaient les principaux paramètres de mesure. RésultatsOnt été inclus 208 enfants : 139 cas de ptosis simple et 69, de ptosis complexe (83 filles; 40 %). L’âge moyen (± é.-t.) au moment de l'intervention était de 1,9 ± 2,9 ans. Les cas de ptosis congénital complexe comprenaient, entre autres, le syndrome blépharophimosis-ptosis-épicanthus inversus (n = 35), le phénomène de Marcus Gunn (n = 12), la paralysie oculomotrice (n = 8), la fibrose congénitale des muscles extraoculaires (n = 3) et l'ophtalmoplégie externe progressive chronique (n = 3). La MRD1 moyenne s'est améliorée d'environ 1,6 mm dans les 2 groupes. On a dû répéter la correction du ptosis chez 50 des 171 patients (29 %) qui n'avaient pas d'antécédents d’échec de la chirurgie du ptosis; ce taux était semblable dans les cas simples et dans les cas complexes. Le risque d'intervention répétée était plus élevé chez les enfants de moins de 3 ans que chez les enfants plus âgés (n = 59 sur 175 [34 %] vs n = 5 sur 33 [15 %]; p = 0,03; test χ2). ConclusionsLa SF avec sonde à ptosis en silicone a donné des résultats favorables chez 70 % des enfants. La MRD1 préopératoire et finale, ainsi que les taux d'intervention répétée, étaient semblables dans les 2 groupes, ce qui laisse entendre que les résultats étaient similaires, en dépit de la plus grande complexité des cas atypiques.

Метод подвешивания при птозе верхнего века тяжелой степени: преимущества техники скользящей восьмерки

Relevance. Frontalis suspension is used in patients with severe upper eyelid ptosis. Despite the long history of the operation and multiple modifications, none of them gives a lifelong result. The use of suspensions sling materials that grow into tissue increases the surgical trauma during their removal if correction is necessary or recurrence of ptosis. Thus, the task is to choose a method of frontalis suspension, that would be easy to perform have an excellent result. Purpose. To evaluate the effectiveness, execution simplicity and reliability of the frontalis suspension using the «sliding eight» technique with polypropylene suture in patients with severe upper eyelid ptosis. Material and methods. A retrospective study of 84 patients (110 eyelids) with severe ptosis of upper eyelid. A frontalis suspension surgery for removing upper eyelid with the use of 4/0 polypropylene suture was performed in he all patients. The threads were passed into the thickness of the eyelids and brows through previously made skins incisions. The patients were divided into 3 groups: in the first group (25 patients) we used polypropylene frontalis suspension with two needles of the pentagon suspension designs, in the second group (28 patients) we used two polypropylene sutures in the form of two rectangles, in the third group (31 patients) we used the «sliding eight» technique. Results. In the first group, in 5 cases there was a deformation of the upper eyelid contour, in 2 cases a recurrence of ptosis was diagnosed. In the second group, the deformation of the upper eyelid contour was in 4 cases, and a recurrence of ptosis also developed in 2 patients. In the third group, we did not notice any deformation of the upper eyelid contour and palpebral folds. In two cases, recurrent ptosis was diagnosed. The operation time in the first group of patients was 30.21±5.048 min, in the second group – 32.97±3.68 min, in the third – 26.5±3.03 min. The duration of the operation was statistically significantly different between groups 1 and 3 and groups 2 and 3. Conclusion. Surgical treatment of severe ptosis of upper eyelid using the «sliding eight» technique has shown its effectiveness, ease of execution and reliability. This elegant technique minimizes postoperative complications in the form of asymmetry in the position of the upper eyelid, is easy to perform, leaves virtually no scarring, and can be repeated without significant surgical trauma. Key words: severe ptosis of eyelids, brow suspension surgery, polypropylene

Frontalis Suspension Surgery for Patients with Essential Blepharospasm Unresponsive to Botulinum Toxin Injections

Purpose: To report the efficacy of frontalis suspension using a silicone rod or preserved fascia lata for patients with blepharospasm who exhibit persistent symptoms and visual dysfunction unresponsive to botulinum injections.Methods: The clinical records of five patients (10 eyes) with essential blepharospasm who underwent frontalis suspension were reviewed. Patients who continued to report eyelid-opening difficulties despite prior administration of botulinum toxin were included.Results: The mean patient age was 60.2 years; and 40% of the patients were women. The frontalis was suspended using silicone rods (n = 3) or preserved fascia lata (n = 2). Blepharospasm frequency and severity were measured using the Jankovic Rating Scale (JRS). Compared with preoperative scores, the summed JRS scores decreased 1 week, 1 month, and 3 months after surgery. Postoperatively, two patients (40%) did not require further botulinum toxin injections. In three patients, the intervals between injections were increased after surgery. No patient experienced any significant complication.Conclusions: Frontalis suspension is safe and effective for patients with blepharospasm and apraxia of eyelid opening, who have not responded to botulinum toxin injections.

SURGICAL TREATMENT OF SEVERE TRAUMATIC PTOSIS BY CONTRALATERAL FRONTAL SUSPENSION

Ptosis, a common congenital or acquired disease, is an upper palpebral droop secondary to impaired action of the levator muscle of the upper eyelid. In its severe form, he is very unresponsive or inactive. Severe traumatic ptosis is most often the result of neurogenic, myogenic or scarring lesions. The treatment of severe ptosis is essentially surgical, with a variety of techniques giving acceptable results. Frontal suspension is the therapeutic method of choice, performed according to the Fox or Crawford procedure. But it requires an active homolateral forehead muscle, capable of raising the decient eyelid; criteria that could be missing. So what would be our alternative? In our study, we report a case of severe traumatic ptosis in a young patient, associated with a palsy of the homolateral frontal muscle, treated by contralateral frontal suspension using autologous material

Marcus-Gunn jaw winking syndrome: case series study and management algorithm

ABSTRACT Purpose To identify a rationale for treatment of patients with Marcus Gunn jaw winking syndrome (MGJWS). Methods Retrospective review of 38 consecutive patients with MGJWS referred to a single tertiary institution. Clinical data included visual acuity, ocular motility, side of jaw-wink, presence or absence of ptosis, levator function, clinical photographs, and management undertaken. Thirty-two patients were operated on with customized surgery by a senior surgeon (FQL). Results Cases with no ptosis or mild ptosis were managed conservatively. Levator advancement (LA) was successful in case of moderate ptosis and negligible synkynesis but resulted in a more evident synkinesis. Levator resection (LR) in patients with severe ptosis was associated with high rate of ptosis recurrence. Ptosis was adequately corrected in all patients submitted to uni- or bilateral levator excision (LE) and bilateral frontalis suspension (FS) or unilateral frontalis flap (FF). Jaw winking resolved in all patients submitted to LE but recurred in three cases at a later stage. Strabismus surgery was performed simultaneously in case of associated esotropia or hypotropia. Conclusions Moderate ptosis can be corrected with LA, but success is not related to levator function and synkinesis becomes more evident postoperatively. In severe ptosis, LR showed unpredictable results. In case of severe ptosis and severe synkinesis, uni- or bilateral LE and bilateral FS are recommended; unilateral FF is an alternative in patients who refuse bilateral treatment, as the cosmetic outcome is usually better than after unilateral FS.