In many cases of congenital ptosis, the levator function is poor because of fat and fibrotic infiltration of the muscle during development. In this situation, the eyelid must be slung to the frontalis in order to function and the children learn to raise their foreheads to lift the eyelid.
Various materials can be used to sling the eyelid. In very young babies where amblyopia is a risk factor, the surgery needs to be done in a timely fashion. The bulkier materials are too large for the small eyelids. Supramid slings can be used in this situation. These are 3-0 nylon sutures made by S. Jackson, Inc. The suture comes double-armed and attached to a reverse cutting ski needle, which easily cuts through the appropriate planes of the eyelid. The sutures are durable, but on many occasions, as the child grows, the sutures pull through and the ptosis recurs requiring repair.
When children are a bit older, silicone rods, fascia lata or palmaris longus tendon can be used. Silicone rods have the advantage of avoiding a donor site surgery, but may have a slightly increased risk of extrusion given the fact that it is a foreign body. Fascia lata is a durable material that can be obtained as a donor cadaver graft from a tissue bank or can be harvested from the patient’s leg as an autogenous graft. Avoidance of a donor site surgery is the advantage of the banked fascia lata. Advantage of the autogenous fascia lata is the fact that it is the patient’s own tissue, unlikely to extrude and virtually eliminating any rejection reaction. The patient ideally should be at least 4 or 5 years old so that the leg is long enough to get a good segment of fascia. Good surgical instruments, particularly the fascial stripper, are essential. Harvesting does add a bit of time to the surgery, as well as increased morbidity, but the outcomes are generally very good and children recover well from the leg wound.
A newer technique for frontalis slings is harvesting the palmaris longus tendon from the forearm. Although the tendon is not present in 100% of the population, it is fully developed at birth, so it can be harvested at a younger age. Harvesting of this tissue does not cause functional deficits. It has been widely used for joint and tendon reconstruction by orthopedic surgeons and appears to be a durable and safe alternative.
There are many options available for frontalis suspension in congenital ptosis. Each has its unique advantages and disadvantages. The choice of material must be individualized, of course, and knowledge of each technique is key.