14 Frontalis Suspension Ptosis Repair
Frontalis suspension ptosis repair is required in cases of complete or near complete absence of levator function. This occurs in congenital ptosis, congenital fibrosis of the extraocular muscles (CFEOM), blepharophimosis, chronic progressive external ophthalmoplegia (CPEO), third nerve palsy, oculopharyngeal dystrophy, and Marcus Gunn jaw winking syndrome. The incidence of childhood ptosis has been estimated at 7.9 per 100,000 children (<19 years). When the levator palpebra is too weak to oppose gravity and orbicularis tone, severe ptosis is the result. In many cases in which levator function is <5 mm, frontalis suspension is the only option to improve lid height. In this technique, implant material effectively suspends the upper eyelid margin from the brow to oppose the action of gravity and antagonistic orbicularis tone. Suspension materials can be autogenous, alloplastic, or synthetic. Silicone rods tend to last as long as if not longer than banked fascia lata; use of the latter actually results in more initial lag and a less stable long-term effect. Autogenous fascia lata can last a lifetime, but it places the patient at risk for exposure to keratopathy, particularly in environments known to cause tear breakdown (e.g., high altitudes, low humidity, or airplane travel). Also unknown is the long-term effect of childhood fascia lata harvest on the aging knee.
Elevate the ptotic eyelid(s).
Minimize amblyopia in infants and children.
Improve peripheral visual fields in all patients.
Provide reconstruction in those with facial deformity or asymmetry (Fig. 14‑1, Fig. 14‑2).
Frontalis suspension techniques offer a more certain postoperative elevation of the eyelid than maximal levator resections in those with very poor or absent levator function. Silicone, in particular, offers some elasticity, 1 lessening the degree of lagophthalmos. In addition, frontalis suspension does not disrupt the underlying levator anatomy and, with certain materials, can be reversible and/or adjustable.
Postoperative improvement in ptosis is immediate.
The procedure induces some lagophthalmos with sleep and downgaze, the degree of which varies based on sling material, sling tension, and individual facial characteristics (such as brow prominence).
Postoperative subjective and objective blink will be less robust, stiffer, or in some cases nearly absent.
Lid height and symmetry in primary gaze will be improved.
14.4 Key Principles
All non-autogenous materials will likely need to be replaced during a patient’s lifetime, especially in congenital ptosis or ptosis acquired in childhood. The material requiring fewest revisions is autogenous fascia lata, 2 but using this material requires longer surgical time and can lead to harvest site pain, infection, or scarring. Another theoretical risk that has yet to be explored in the orthopedic literature is the long-term sequelae of fascia lata harvesting on the aging knee or hip. The fascia lata and associated iliotibial (IT) band support the knee, extend from the iliac crest to the lateral condyle of the tibia, and function as a hip abductor (used in activities such as soccer and horseback riding). Unknown long-term effects of removal of the central strip of this band—especially for the youngest patients, in whom a more substantial section of fascia will be harvested—merit mention in preoperative discussions with patients and families (Fig. 14‑3). In practice, the advantages of silicone over fascia lata are reversibility, adjustability within the first year, and ability to stretch.
For temporizing repair, such as in an infant with complete ptosis, silicone rods offer reversibility if the levator improves during the first year of life. Silicone rods come swedged onto straight needles that are smaller in caliber than Wright fascia needles, so these cause less trauma to the infant’s pretarsal anatomy. Another advantage of silicone is that it can be adjusted with relative ease during the first 1 to 2 postoperative years. After that point, it becomes increasingly brittle and develops calcifications, which increase the likelihood of breakage during adjustment. The elasticity of silicone renders less postoperative lagophthalmos, which is helpful in those patients with poor tear film (e.g., mature adults with oculopharyngeal dystrophy and patients with poor Bell phenomenon due to third cranial nerve palsy, CFEOM, or CPEO). This elasticity also tends to slightly reduce the severity of the wink in patients with Marcus Gunn jaw winking. Finally, the decreased lagophthalmos with sleep and downgaze associated with the elasticity of silicone is far less troubling to parents than the stiff lid seen with fascia lata (although the initial lagophthalmos with fascia lata does typically improve after the first 6 months).
The importance of managing patient and parental expectations preoperatively cannot be overemphasized. It is helpful to frame this procedure as a structural bypass of a defective or functionally absent muscle rather than a physiologic repair of a stretched or weak muscle.
Frontalis suspension for ptosis repair is the procedure required in absent or near complete absence of levator function.
Severe ptosis with <5 mm of levator function.
Acquired or congenital complete third nerve palsy.
Marcus Gunn jaw winking (both to improve baseline ptosis and decrease the severity of retraction wink). Patients with this condition have good levator function, but aberrant innervation between the levator and usually the lateral pterygoid muscle renders anomalous and variable lid positioning dependent on jaw position. In cases with severe ptosis, a sling (with or without extirpation of the levator) is warranted.
Patients with a poor Bell reflex, such as CFEOM or extraocular muscle limitation, should be approached with caution. In these patients, conservative and reversible sling tension should be employed so that exposure does not occur postoperatively.
Patients with some levator function but ipsilateral amblyopia may benefit more from a maximal levator procedure or a Whitnall suspension, since they are less likely to have spontaneous brow elevation. 3
Patients with underlying poor or absent frontalis function should be counseled that they may be disappointed with frontalis suspension, and that Whitnall suspension may be a better choice. 4