Silicone frontalis sling for congenital ptosis
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This is Richard Allen at the University of Iowa. This video demonstrates placement of a silicone frontalis sling in a child with a history of unilateral congenital ptosis, s/p failure of a previous levator resection. The 15 blade is used to make an incision along the eyelid crease through the skin and orbicularis muscle. Dissection is then carried out with a needle tip cautery through the orbital septum to visualize the preaponeurotic fat. Westcott scissors are then used to incise the septum and dissect the preaponeurotic fat from the underlying levator muscle. There is scar from the previous surgery. A thermal cautery is then used to disinsert the levator from the anterior surface of the tarsus. Dissection is then carried out between the levator muscle and the underlying Mullers muscle. This is performed in order to incorporate the levator aponeurosis into the skin closure later to aid in eyelid crease formation.
A 15 blade is then use to make a stab incision in the markings above the brow. A hemostat is used to bluntly open the incisions and make a subcutaneous pocket above the superior incision. A 5-0 mersilene suture is then placed partial thickness through the anterior surface of the tarsus 2 mm inferior to the superior border of the tarsus. This suture is tied to attach the frontalis sling to the tarsus. Two additional sutures are placed. Pulling on the sling demonstrates an appropriate contour. The sling is then placed retroseptal and exits the medial stab incision. The other arm of the sling is then placed in a retroseptal fashion to exit out the lateral stab incision. Tension is placed on the slings to examine the contour which appears appropriate. Each arm reenters their respective stab incisions to exit out the superior central incision. The eyelid crease incision will then be closed with 5-0 fast absorbing suture. The suture is placed through the lower border of the skin, followed by the levator aponeurosis, followed by the superior border of the skin. I believe this is an important maneuver to aid in lid crease formation. In addition you want to place these sutures prior to tightening the sling due to the tension that is needed to be placed on the sling in patients with congenital ptosis. Sutures are placed in this fashion along the length of the eyelid.
The stab incisions are then closed with a horizontal mattress sutures. The sling is tightened to the appropriate amount. Two sleeves are placed over the sling. A 5-0 mersilene suture is tied around the upper sleeve to secure it to the sling. An addition mersilene suture is tied around the sling, inferior to the inferior sleeve. The sling is seated by pulling down on the upper eyelid. The redundant portion of the sling is excised. The sling is then placed into the subcutaneous pocket superior to the superior brow incision. The upper stab incision is closed with a horizontal mattress suture. The eyelid appears to be in appropriate position.
At the conclusion of the case, erythromycin ophthalmic ointment is placed over the incisions and into the eye. The eye is patched for 24 hours. The patient returns in one week for reevaluation.