Revision of autologous fascia frontalis sling
Richard C. Allen, MD, PhD, FACS
Additional Notes: Length 5:01
Posted Feb 10, 2017
This is Richard Allen at the University of Iowa. This video demonstrates a revision of a previously placed autologous fascia frontalis sling in a patient with a unilateral congenital ptosis. The lid crease has been marked with a marking pen. An incision is then made with a 15 blade along the marking. Dissection is carried out through the orbicularis muscle to the underlying orbital septum. The preaponeurotic fat is then identified. The goal of this dissection is to identify the previously placed frontalis sling. This is demonstrated. This was placed as a single pentagon. Each side of the frontalis sling is then identified and dissected from the preaponeurotic fat. The frontalis sling is then dissected from the anterior surface of the tarsus. The sling was fixated to the anterior surface of the tarsus with Mersilene suture. The goal here is to dissect the frontalis sling cleanly from the surrounding tissue and not transect it. This is performed with the thermal cautery. Once the sling is completely dissected from the tissue, it will be tagged with a 4-0 silk suture. In order to create a lid crease in this patient, the levator aponeurosis will be dissected from the underlying Mueller's muscle. This was not performed in the previous surgery. Therefore, the levator aponeurosis will be advanced in order to assist in creating an eyelid crease. The levator is dissected from the underlying Mullers muscle with the thermal cautery. The silk suture is then taken off of the frontalis sling. Some of the residual tissue is dissected from the frontalis sling. The sling is demonstrated. A 5-0 Mersilene sutures then placed through the anterior surface of the tarsus. The suture then engages the medial arm of the sling relatively superior in order to advance the sling to the anterior surface of the tarsus. This is performed for the lateral arm as well. This effectively results in tightening the sling. The contour is inspected which appears be appropriate. The sutures will be left untied. Attention is then directed to the levator aponeurosis. A double-armed 5-0 nylon suture is placed through the anterior surface of the tarsus. Each arm then engages the levator aponeurosis as far superiorly as possible. The suture is then tied with a temporary tie and the contour is inspected. The suture is then converted to a permanent tie. The Mersilene sutures are then tied to tighten the sling. This results in adequate elevation of the eyelid. The lid crease will then be closed by engaging the levator aponeurosis in the closure. The suture used is a 5-0 fast absorbing suture. The sutures are left untied due to the difficulty in engaging the levator aponeurosis if the adjacent suture is tied. The sutures are then tied, and in this case, the patient had medial lash ptosis. Therefore an additional lid crease suture was placed trans-conjunctively in order to assist in creation of the eyelid crease. At the conclusion of case, erythromycin ophthalmic ointment is placed over the incision. The patient will be patched overnight and follow-up in approximately 1 week.
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