This modified technique produces less bleeding, edema and scarring and better cosmetic results.
Ptosis of the upper eyelid can be disturbing to an individual because of cosmesis and a compromised visual field. Weakness in the muscles, namely levator and Müller’s muscles, lead to ptosis. Ptosis may be caused by damage or trauma to the muscle that raises the eyelid, damage to the nerve that controls the muscle, namely the oculomotor nerve or third cranial nerve, or damage to the superior cervical sympathetic ganglion.
Ptosis may be unilateral or bilateral, and it is more common in the elderly. However, it can also be congenital, in which case the cause remains unknown. Ptosis may be classified as neurogenic (eg, oculomotor nerve palsy), myogenic (eg, myasthenia gravis), aponeurotic (eg, involutional or postoperative), mechanical (eg, upper eyelid tumor), neurotoxic (eg, snake venom) or pseudo ptosis (eg, lack of lid support such as empty socket or atrophic globe or contralateral lid retraction). Surgical treatment depends on the type of ptosis, and it includes levator resection, Müller muscle resection and frontalis sling operation. Proper planning with advanced surgical techniques can often result in an optimal postoperative result and a happy patient.
In this column, Drs. Jacob and Agarwal describe their surgical technique of ptosis repair.
Thomas John, MD
OSN Surgical Maneuvers Editor
by Soosan Jacob, MS, FRCS, DNB, and Amar Agarwal, MS, FRCS, FRCOphth
Congenital ptosis is often associated with poor levator function. The only surgery often possible is a frontalis sling surgery, and the Fox pentagon is the most popular and commonly used technique for this purpose (Figure 1a). Surgery is generally indicated for an improvement in cosmesis, although sometimes, if the ptosis is severe enough to cover the pupil, surgery also clears the visual axis. Either way, enhancing the postoperative cosmesis is always a significant consideration for both the patient and the surgeon. It is therefore surprising that the very surgery that improves cosmesis by improving the lid height and contour also disfigures the face by creating three cutaneous scars in a visible area of the forehead. These scars create an especially bad outcome if the surgery is done bilaterally because it creates six symmetric scars on the forehead (Figure 1b).
Figure 1a. Conventional five-incision frontalis sling surgery. The sling follows the path of the Fox pentagon.
Figure 1b. Poor cosmetic outcome seen secondary to bilateral multiple supra-brow scars.
Source: Agarwal A
The Fox pentagon acts by linking the tarsus of the upper eyelid to the frontalis muscle, thus resulting in a better eyelid position in primary gaze. Different materials, from autologous fascia lata to various suture materials, have been used as a sling. The most commonly used material worldwide is the Seiff silicone suspension set. The tubing of the suspension set consists of a solid silicone rod that is 40 cm in length with two stainless steel needles at either end. The silicone rod runs through a silicone sleeve that secures the rods and also makes possible postoperative adjustment of the sling. Three supra-brow stab incisions and two lid margin incisions are used for the conventional technique (Figure 2a). The multiple incisions heal with fibrosis, resulting in multiple scars that affect the aesthetic outcome of the surgery. Even if made close to the brow, the scars may still be visible, and if made within the brow, they can cause damage to the eyebrow follicles, resulting in permanent loss of brow hair at the incision site.
We have devised a new supra-brow single-stab incision technique for a frontalis sling in an attempt to decrease the number of scars and enhance cosmesis while maintaining good functional outcomes.
Without making any lid margin incisions, the needle is pierced in through the medial mark on the lid margin to pass in the epi-tarsal tissue horizontally from medial to lateral and then pierced out through the lateral lid margin marking, about 2 mm above the lid margin. The lateral needle is reinserted through the skin puncture while taking care not to inadvertently cut the sling. It is advanced vertically upward, dipping behind the septum just below the orbital rim, and then upward to reach the upper lateral corner of the pentagon. Without exteriorizing the needle, the direction of the needle is turned toward the central mark of the pentagon and guided in the same surgical plane to be exteriorized through the central supra-brow incision (Figure 2b). The same procedure is repeated on the other side of the pentagon such that the needle traverses upward to the upper medial corner of the pentagon and is then turned toward the central mark of the pentagon and exteriorized through the central supra-brow incision.
Figure 2a. The conventional procedure has increased intraoperative bleeding and edema. It also takes a longer surgical time than the modified supra-brow single-stab incision procedure.
Figure 2b. In the Jacob-Agarwal modified technique of frontalis suspension, after anchoring the sling at the orbital septum just under the orbital rim, the direction of the needle is changed so that it is brought out through the central stab incision without exteriorizing it at either the upper medial or upper lateral corner.
Source: Agarwal A
The position of the advancing tip of the needle can always be estimated by palpation. Once both the needles are brought out through the centrally placed stab incision, the sling ends are passed through the silicone sleeve, and lid height and contour are modified by adjusting the degree of tension on the sling. The silicone rod ends are tied, and excess length is cut. The sleeve with the knots is buried in the sub-periosteal pocket. The supra-brow single-stab incision is closed with either a single suture or tissue glue. The lid margin sites are only needle puncture wounds and do not need suturing.
The advantage of this technique is that with minimal skin incisions and less surgical time, the clinical outcome of a conventional frontalis sling procedure is obtained. As compared with the supra-brow single-stab incision technique, the conventional procedure involves a total of five stab incisions (three supra-brow and two lid margin) and creates more bleeding intraoperatively and more edema in the postoperative period. Postoperative lid edema, pain and suture-related complications due to multiple sutures can be avoided with our technique (Figures 3a and 3b). The technique can be performed in all eyes with ptosis and poor levator function that necessitate a frontalis sling. The stab incision used is only about 2 mm. The rod may be curved to pass smoothly in case of difficulty while changing the direction of the rod. The sling accurately follows the path of the Fox pentagon because it is anchored superomedially and superolaterally at the orbital septum. It thus creates a good physiological upward direction of traction that gives superior cosmetic results as compared with other minimal incision sling techniques.
Figure 3a. Postoperative day 4 appearance of a patient who has undergone conventional technique shows persistence of supra-brow edema.
Figure 3b. Postoperative day 4 appearance of a patient who has undergone the Jacob-Agarwal modified technique shows minimal supra-brow edema and excellent cosmesis.
Source: Agarwal A
In the worst-case scenario of the surgeon not being able to turn and exteriorize the needle from the central brow incision, it is a relatively simple procedure to make an incision at the corresponding corner of the pentagon where difficulty is being experienced and thus convert to a conventional procedure in a simple manner. The need to have to abort the procedure therefore does not arise. A dimpling of tissues that may be noted in the conventional sling is also not seen because the sling travels in a single plane without being exteriorized. The use of silicone allows for good forcible lid closure by the patient while at the same time allowing adequate elevation of the lid. It is therefore also optimal for ptosis secondary to myopathy, myasthenia gravis and third cranial nerve palsy.
Our comparative case series of 21 eyes with a supra-brow single-stab incision and 21 eyes with a supra-brow three-stab incision, recently published in the Asia-Pacific Journal of Ophthalmology, also showed that while maintaining the usual advantages and functional results of the conventional technique, this modified technique had further advantages of a simple learning curve, decreased intraoperative bleeding, a fewer number of sutures, and less postoperative edema, ecchymoses and scarring due to the minimal number of skin incisions. We believe this technique provides better aesthetic and functional results in patients with poor levator function who require better cosmetic results.
The technique can be performed in all eyes with ptosis and poor levator function that necessitate a frontalis sling. In comparison, the conventional technique is associated with more bleeding in the intraoperative period, edema in the immediate postoperative period and more scarring in the late postoperative period. Thus, we see that our technique of frontalis sling surgery provided clinical outcomes comparable to the conventional technique with superior cosmetic results.
- Allen RC, Zimmerman MB, Watterberg EA, Morrison LA, Carter KD. Primary bilateral silicone frontalis suspension for good levator function ptosis in oculopharyngeal muscular dystrophy [published online ahead of print April 4, 2012]. Br J Ophthalmol. doi:10.1136/bjophthalmol-2011-300667.
- Bagheri A, Ahadi H, Babsharif B, Salour H, Yazdani S. Direct tarsus to frontalis muscle sling without flap creation for correction of blepharoptosis with poor levator function. Orbit. 2012;31(1):48-52.
- Chang S, Lehrman C, Itani K, Rohrich RJ. A systematic review of comparison of upper eyelid involutional ptosis repair techniques: efficacy and complication rates. Plast Reconstr Surg. 2012;129(1):149-157.
- Jacob S, Agarwal A, Nair V, Karnati S, Kumar DA, Prakash G. Comparison of outcomes of suprabrow single-stab and 3-stab incision frontalis sling surgery. Asia-Pacific Journal of Ophthalmology. 2012;1(2):91-96.
- Kim CY, Yoon JS, Bae JM, Lee SY. Prediction of postoperative eyelid height after frontalis suspension using autogenous fascia lata for pediatric congenital ptosis. Am J Ophthalmol. 2012;153(2):334-342.
For more information:
- Soosan Jacob, MS, FRCS, DNB, and Amar Agarwal, MS, FRCS, FRCOphth, can be reached at Dr. Agarwal’s Group Of Eye Hospitals and Eye Research Centre, 19 Cathedral Road, Chennai-600 086, India; fax: 91-44-28115871; email: email@example.com; firstname.lastname@example.org.
- Edited by Thomas John, MD, clinical associate professor at Loyola University at Chicago and in private practice in Oak Brook, Tinley Park and Oak Lawn, Ill. He can be reached at 708-429-2223; fax: 708-429-2226; email: email@example.com.
- Disclosure: No products or companies are mentioned that would require financial disclosure.