Surgery: Frontalis Sling with Silicone Rods

She’s a 4-year-old girl with unilateral ptosis on the right side, no levator function, and so we’re planning on doing a frontalis sling with silicone rods. And I’m getting ready to mark. We want to match to the other side, in terms of the crease. Because that will allow her to have symmetry. Because during the procedure, we will do a crease formation, so it’ll be even when we’re done. And so it’s right about here. Okay? Centrally. It’s about 6 millimeters. Okay? So that’s where we’re gonna aim for. To give her that symmetry. And make sure the contour of the crease is very similar on both sides. And in terms of the markings on the forehead, I like to feel for where the supraorbital notch is, which is right here. And I like to mark it. A lot of people will do the medial markings, so that it’s actually lateral to the supraorbital notch. I actually feel like you get a little better contour if you go a little medial to it. So you’re medial to the medial limbus. That’s your first landmark. And then for your lateral, you want to be lateral to your lateral limbus. And that’s right at the brow hairs for your medial and lateral. And for your central site, it’s about the level of the pupil, and it’s about a centimeter up from the brow hairs. I always like to evert the lid. And take a look at the tarsal plate to make sure it is as high as where I’m gonna put the crease. Because that’s about as high as you can make the crease. Is the height of the tarsal plate. Because that suture, which then creates the lid crease, is fixated on the superior border of the tarsal plate, and so you just want to make sure those two numbers correlate. So it’s right at 6. And this marking was right at 6. So this is a mixture of Xylocaine with epinephrine and bupivacaine. Basically it’s the full length of the incision. Just a little inside where the lashes start and end. Yeah. And so now we’ve made an incision. We’ve gone through the skin, of course. That’s the orbicularis. You’re looking at the septum. Right here. And I’m getting ready to open the septum. And notice I’m actually pushing the globe quite a bit, to allow the fat to prolapse out. That in turn is protecting the levator, which is right underneath the fat, of course. So I’m opening up the septum, and there’s preaponeurotic fat. So we’ve exposed the fat. So all we’re trying to do at this point is expose to the levator. Here’s the preaponeurotic fat. And I’m opening it up the rest of the way. And we should be looking right at the levator. What we’re holding right here is the levator. As you can see, a lot of fatty infiltration noted on the levator. There’s the levator. And now what I need to do is disinsert the levator from the superior border of the tarsal plate. Notice I’m pointing the tips of my Westcotts down, and I’m going all the way across, and you start to see the superior border of the tarsal plate. And if you grab, as you make this incision, if you grab a little deeper, and you lift it up off the globe, you can actually visualize the superior border of the tarsal plate a lot more easily. And so you want to expose pretty much the entire length of it. And then just a few anatomical landmarks. So this is the disinserted levator right here. The part that’s bleeding right there, that is the peripheral arcade, and the muscle right below that is of course the Muller muscle. So that is your landmark for knowing you’re right in between levator and Muller. And so this is the cut edge of the levator right here, that we’re looking at. I just like to take a quick look at the contour, in terms of where I’m going to have my two points of fixation for the silicone sling. It’s going to be fixated on two areas, on the superior border of the tarsal plate, and so I’m basically just trying to get an idea if those two areas would give a good contour. So that’s all I’m checking for at this point. And kids typically have a really poorly — or kind of floppy tarsal plate, poorly developed, or a floppy tarsal plate medially, and so oftentimes if you try to go too medial, thinking that’s the correct place, you can see how it starts to peak, and looks like an upside down B, and that’s not a good contour. And so your medial bite typically tends to be a little lateral to that, just so it has a nice rounded contour, rather than that upside down V look, so it’s not peaked. So right here is where the levator used to be, and now it’s disinserted. And so that’s bare tarsal plate that you’re looking at, which is where the silicone rod will be fixated. So it’s very important that when you pass the suture — so this is a spatulated needle, typically, it’s a spatulated needle, and it’s just like passing a scleral bite. You want to go partial thickness, and you can go parallel, or you can go at a slight angle. That’s okay. Whatever is comfortable. And we’ll pass it. Partial thickness. And to confirm it was partial thickness, I’m going to evert the lid, and we’ve confirmed that it did not go full thickness. And so now the suture is underneath the silicone rod, as you can see. And then this is where I’m going to form the crease. So this is the cuff of orbicularis. And so you want to pass this needle deep to superficial, and then grab it. And then go in the opposite direction. And go superficial to deep. And then you tie it down. And that has secured the rod onto the superior border of the tarsal plate, as well as created the lid crease. And the reason why that’s important, that cuff of orbicularis, you see once it’s tied that knot, as well as the silicone rod, is completely covered with that orbicularis. It is something that you want to be sure to protect and cover. So that you are decreasing the risk of it becoming infected, extruding, and so this flap of orbicularis that I’ve used to cover it — it’s a very important step. So we do it one more time. Laterally. Again, partial thickness plate. Evert. Make sure that’s partial thickness. And then I create the lid crease again. All right? So same step. Deep to superficial. Come out right adjacent to the cut edge of skin. And then go in the opposite direction. Superficial to deep. And you want to make sure there’s no air knot. So I’m cinching it down. And yep, if you could evert that orbicularis — perfect. And if at any point you don’t like the contour of the lid, you would just revise where you’re fixating on the superior border of the tarsal plate. Either move it medially, laterally, whatever you need to do, to correct the contour. So now we make the suprabrow incisions. This is more of a stab incision. And you want to go pretty deep. Preperiosteal. That’s the depth that I’m going to. And it’s gonna bleed, and that’s okay. It always stops on its own, so not to worry. So what I like to do is create little pockets. Make sure that I’m at the correct depth. That I am preperiosteal. This one I like to create a little extra pocket, spoiler, because this is where the silicone rod is going to be buried. So this is something called a right needle that will help us thread the silicone rod through to the suprabrow sites. Now, when you insert this, you want to go in perpendicular, and then you want to turn. But you always want to be mindful of where the tip of the right needle is. So if you overturn, then you’re gonna end up passing the needle a little too superficially. So you want to turn just so that you’re remaining parallel to the lid. So I turn. But you see, I don’t overturn, because you start to see the tip. So it’s about — right here. All right? Now, you pass this through. And you’re aiming for basically right under the fat. Because you’re aiming for right on top of levator. It’s a nice smooth sharp bright needle. And then once you pass that through, and then you want to thread this through… And then you pull through. So now we repeat this on this side. Now, oftentimes people worry that the right needle is gonna go full thickness or what-not. And so you can put a corneal light shield, if you want, you can put a Jaeger lid plate, just to protect the globe, if you’d like. And so now this is where we can kind of double check the contour. See if we like that. It’s a nice smooth rounded contour. So we like that so far. So we’re gonna proceed with that. And now this is the most important step, because if the silicone rod is going to extrude or get infected, it’s always this spot. Not here. It’s this spot. So you want to make sure you are going deep. You’re preperiosteal. And then you pass. So this is the fixation sleeve. So this came as a set. But sometimes they do not come in a set, and you have to purchase them separately. One thing to keep in mind is the internal diameter of the sleeve. All right? So typically the rods are about a millimeter in diameter. And the ideal internal diameter of your sleeve is about 0.75 millimeters. So I load it onto the Watzke spreader. So you pass the rod through the fixation sleeve, and then you slide off. You just want to leave that in place for now. Don’t tighten quite yet. You want to close your lid incision first. And then tighten. So we’re gonna do the orbicularis closure first, and you’ll notice I don’t start all the way at the apex of the skin incision. So I’m doing a double layer closure. I was mentioning that it’s one of the few instances where we do a double on the eyelid, and it’s because there’s a foreign body. Again, this is all in an effort to minimize extrusion of the foreign body. Which in this case is a silicone rod. Another common instance where I would do a double layer closure is placement of a gold weight. In terms of the material options for the sling, my two favorites are either a silicone rod or fascial slings. For fascia, they basically have to have legs long enough for me to harvest about 10 centimeters. And she was a little too short. So right around 4 years old, 4 to 5, depending on their height, is when they are tall enough for me to harvest enough of that fascia. We’ve closed up the orbicularis. Now we close up the skin. So if you want to do this interrupted, that’s fine. I typically just run it, and it’s usually not an issue. So you want to avoid closing the septum typically, as a general rule, on the eyelid. It can cause middle lamellar scarring. It’s really not necessary with this procedure. But typically, even if you weren’t doing this, and in terms of closing any incisions on the eyelid, you don’t want to close the septum, because it’ll cause a retraction. To tighten, you just slide the sleeve down. And that’s all you have to do. And so you can pretty much tighten all the way, and you know it’s gonna drop a little bit. And again, not an issue for children. So it’s gonna look wide open at the end of your case. It does not stay like this. It does close up a little bit more. So now I trim the rest of this down. And remember, I had created that pocket earlier. And that’s because that’s where the silicone rod is going to get buried. As I mentioned, this is the site that can often give you trouble with a silicone rod, and so you will see this is the only site that I will do a double layer closure. If you wanted to do a double layer closure with a vicryl for the rest of them, that’s okay. You can do that. That’s not an issue. But usually the other two sites — not a problem. So it’s a buried interrupted with a 6-0 vicryl. So now unlike the lid, which heals up beautifully, the forehead incision site tends to become depressed as it heals. So it looks indented in as it heals. So in order to prevent that from happening, I typically like to close the forehead site with a horizontal mattress. I’m using a 6-0 fast again, for the skin closure. So it’ll be gone in about a week or so. So the main thing, during the recovery — I always send them home with a shield and tell them to keep it on, even when they’re sleeping, for about a week. Kids do very well. It’s very well tolerated. And they heal amazingly fast from the surgery. And now we’re all done.