Surgery: Frontalis Sling with Silicone Rods

This is Dr. Joon Kim with Orbis International demonstrating a unilateral silicone frontalis suspension in a child with congenital ptosis. This is a patient of Asian descent, and in this ethnic group, it is especially important to pay attention to the absence or presence of a double eyelid.

Because he did not have a double eyelid on the right upper lid, It was decided to proceed with a supercillary incision for best symmetry.

Two additional sites were marked along the brow hairs, one immediately medial to the medial limbus, and one lateral to the lateral limbus.

The third site was marked at the level of the pupil, a centimeter above the brow hairs.

A local mixture including one percent lidocaine with epinephrine, zero point two five percent Marcane, and hyaluronidase, was injected into the marked site.

A number fifteen blade was used to make the skin incision on the eyelid as well as three stab incisions into the forehead sites.

Bipolar caurtery was used throughout the case for hemostasis.

Westcott scissors were then used to disinsert the levator aponeurosis and expose the superior third of the tarsal plate.

Two forceps were used to gently grab the eyelid to determine the optimal placement of the sutures for the best contour.

A 5-0 polyester suture was then passed partial thickness along the superior border of the tarsal plate at approximately the level of the medial limbus and secured around the silicone rod.

5-0 polyester was then passed, along the superior border of the tarsal plate at approximately the level of the lateral limbus.

And once again, tied around the silicone rod.

The lid was inverted every time the polyester is passed through the tarsal plate to ensure that it did not pass full thickness through the tarsal plate.

A right needle is then utilized to pass the silicone rod from the tarsal plate to the forehead sites.

This is passed, posterior to the septum, but anterior to the levator.

Both ends are then passed to the central forehead site using the right needle.

Care is taken to ensure that this is a deep pass along the preperiosteal plane to minimize the risk of exposure In the event that it is passed to superficially.

Both ends were then cut to an appropriate length and a Watzke spreader was used to place a fixation sleeve around both ends.

Prior to tightening the sleeve, A double layer closure was performed on the eyelid.

The obicularis is closed with a running 6-0 vicryl.

And the skin is closed with a running 6-0 plain.

Certainly an interrupted closure can be performed as well.

Once the closure is complete, the sleeve is then tightened to elevate the lid.

Usually, the lid is placed at approximately the superior limbus or about, a millimeter below.

The ends of the silicone rod, are then placed in the subcutaneous pocket that’s been created.

A double layer closure is performed for the central suprabrow site with a deeper layer being closed with a buried interrupted 6-0 vicryl.

The skin closure, for the forehead sites are performed with a 6-0 plain placed in a horizontal mattress fashion.