Comment: Double Rectangle Fascia Lata Frontalis Sling: A Rationale Approach for Ptosis

We would like to congratulate the authors for the innovative idea in the repair of eyelid ptosis.[1] The fact that some of these surgeries were done under monitored anesthesia is commendable as there is a lot of skill required for long fascia lata harvesting. There are a few points we would like to highlight from an ophthalmic plastic surgeon's perspective.

Frontalis sling has been established as the procedure of choice for patients with bilateral severe blepharoptosis with poor action.[2] [3] In the current study, the authors mention that 13/20 patients had acquired ptosis, while 7 had congenital ptosis. The most common cause of acquired ptosis is levator muscle disinsertion, also known as aponeurotic ptosis, which is corrected with levator aponeurosis reattachment or resection. The lid crease is a good indicator of the levator disinsertion as most of the acquired ptosis will have a higher lid crease as compared to the contralateral side. The fact that most patients had poor levator muscle function in acquired ptosis points toward the presence of congenital ptosis.

The authors also mention preoperative and postoperative levator functions in their publication. The basis of frontalis sling surgery is the use of the frontalis muscle for eyelid elevation, so the levator function remains unchanged after the surgery. In the postoperative pictures shown, it can be clearly seen that the patients are using the frontalis muscle for eyelid opening as the eyebrows are raised. The evaluation of palpebral fissure height is the appropriate measurement in this context as opposed to the levator function.

Preoperative assessment of Bell's phenomenon is essential before sling surgery to prevent ocular surface complications. The main drawback of any blepharoptosis surgery is the postoperative lagophthalmos, which has not been addressed in this research paper.

In blepharoptosis surgery, functional and cosmetic outcomes are equally important. Frontalis sling with fascia lata has good long-term results but silicon sling is the preferred material for most ophthalmic plastic surgeons as it is easy to perform and there is a scope for readjustment postoperatively.[4] [5] Further, long-term prospective comparative studies would help in establishing this technique as a non-inferior procedure in the correction of blepharoptosis.

Publication History

Article published online:
02 February 2023

• References

• 1 Agarwal P, Sharma D, Agrawal V, Tiwari S, Kukrele R. Double rectangle fascia lata frontalis sling: A rationale approach for ptosis. Indian J Plast Surg 2021; 54 (01) 58-62
• 2 Morris CL, Buckley EG, Enyedi LB, Stinnett S, Freedman SE. Safety and efficacy of silicone rod frontalis suspension surgery for childhood ptosis repair. J Pediatr Ophthalmol Strabismus 2008; 45 (05) 280-288 , quiz 289–290
• 3 Crawford JS. Fascia lata: its nature and fate after implantation and its use in ophthalmic surgery. Trans Am Ophthalmol Soc 1968; 66: 673-745
• 4 Horng C, Sun H, Tsai M, Chien S, Lin F. Impact of silicon frontalis suspension with ptosis probe R for correction of congenital ptosis on Asian eyelids in Taiwan. Life Sci J 2010; 7: 19-24
• 5 Ben Simon GJ, Macedo AA, Schwarcz RM, Wang DY, McCann JD, Goldberg RA. Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material. Am J Ophthalmol 2005; 140 (05) 877-885