Is frontalis sling my last option to correct ptosis? (Photo)

Hello, I was born with congenital ptosis and I've have multiple surgeries to correct them. Last surgery I had the doctor performed maximal resection of both levetor muscles. My eyes still look droopy. He said only other option is the frontalis sling method where he'd take tendon from my leg and it would leave a scar. Is this my only option?

Doctor Answers 3

Your eyelids already have good height and symmetry, so a frontalis sling should be carefully considered, and perhaps postponed

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Thank you for your question. You submitted a single photo limited to just your eyes, asking if frontalis sling is your last option. You state you had congenital ptosis, and have undergone multiple surgeries, with your most recent surgery was a maximal levator resection. You feel like your eyelids are still drooping, and your surgeon suggested considering a frontalis sling. You want to know if this is a best option or if this is a good choice.

I can share with you my experience and opinion about this type of scenario. A little background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years. I have performed a lot of surgeries for congenital ptosis in a full range of ages. I can share with you first the way I educate my patients about the causes of congenital ptosis, and how it impacts how the correction is performed.

You probably are familiar that congenital ptosis is due to a developmental limitation in the muscle that lifts the eyelid called the levator muscle. In ptosis cases, this muscle neither contracts fully nor does it relax fully. The goal for any ptosis operation is to first measure and evaluate the degree of strength of the levator muscle prior to surgery, as well as different parameters of the height of the eyelid relative to the pupil, and the eye’s ability to protect itself from exposure - there’s a whole constellation. Your doctor determined you would benefit from a maximal levator resection, meaning the muscle is probably fairly weak and the lid level was probably relatively low. In maximally shortening that muscle, the lid level was brought to a certain height.

The challenge when we’re doing this type of procedure, especially in adults, is the eyelid still has to close properly to protect the integrity of the eye. Even if the eyelid height during surgery is as high as is achievable, and is able to be set higher, even overcorrect it slightly, there is always an equilibrium that applies to levator resection and frontalis sling, which I’ll explain further. Ultimately, the goal is to have the eyelid open enough so when you are in a normal social setting, the eyelid height clears the pupil, you have a good vision, relatively good symmetry, and you can close your eyes.

Even when the eyelid is elevated beyond what is usual, the body protects the eye, so people naturally start to squeeze to blink and lubricate the eye. I have seen situations wherein an adult, someone in their late to  mid-50s who never had their ptosis corrected and get it done at that stage of life, one or two millimeters can make the difference between exposure, irritation, tearing, and comfort. That’s one major factor you need to consider, also understanding the protective mechanism is necessary.

Beyond that, there’s always a certain amount of equilibrium that’s ultimately achieved because although the lid is lifted, whether it’s with the levator muscle or with the frontalis sling, the eyelid continues to close every time you blink, and sometimes you have to force blink. People with congenital ptosis often after surgery have a little gaping or opening of the eyelid when they sleep because of the baseline tension. As I said earlier, the muscle doesn’t fully relax so you have to be careful about lubrication.

As far as frontalis sling is concerned, yes this is an option. In frontalis sling surgery, especially with adults, the same issues remain - you cannot overcorrect to the point where the eye is exposed and is going to be dry. Interestingly, children under 6 years old can tolerate the eyes being really open a lot better than adults, most likely because of the ability to liberally lubricate the eye, as well as the way the eye is able to protect itself. There’s kind of a natural adaptation that occurs with these type of surgeries in children where you can really lift that eyelid very high and they won’t have exposure. Their eyes may be wide open when they sleep, which can a little be unsettling for the parents, but they tend not to have the dry eye issues that adults do.

I think you have to make this decision based on how much more you are willing to tolerate. When I look at your photo and at your eyes, I would say you have a reasonable outcome which might not be as high as you like, but you’ve achieved a reasonable degree of symmetry and height. One of the golden rules of aesthetic surgery is that the enemy of a great result is a perfect result. You may find yourself regretting it if your eyelid is forced a little higher, then you’re dealing with eye exposure.

So yes, I’m sure your doctor, wants to do the best job possible for you, but at the same time it’s very important to understand you’ve already had multiple surgeries, which is not unusual for someone with congenital ptosis throughout their lifetime. The muscle changes as you age with continuous bit of stretching, and the lids will likely calm down a little, which varies from person to person. As the person gets older, they may need another surgery, so you may want to save that frontalis sling option for later. It doesn’t mean you can’t repeat that surgery anyway, but for the interest of minimizing the number of surgeries you have, you may want to factor these variables that are less predictable and potentially can be problematic with eye exposure, symmetry, aesthetics, and other issues that could occur. You need to have this discussion with most likely your oculoplastic surgeon who performed this for you. I hope that was helpful, I wish you the best of luck, and thank you for your question.

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Congenital ptosis

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If you have already had a maximal levator resection, then yes, a frontalis sling will be your only option to correct your ptosis. In your photo, it appears you are hiking the eyebrows to compensate for the ptosis. You would be in control of when and by how much the eyes open depending on the use of your eyebrows. There are several different types of materials that can be used for a frontalis sling. I would definitely not go for fascia lata, as suggested by your surgeon, as this will make the sling permanent. In adults, it is harder for the cornea/ocular surface to get used to a sling and you want to have the option of reversing the sling. A silicone material can be safely used as the sling and this can be easily reversed if needed. Be prepared to lubricate the eyes aggressively in the week to months after surgery. Good luck!

Katherine Zamecki, MD, FACS
Danbury Oculoplastic Surgeon

In my opinion, frontalis sling surgery will not be a good option for you.

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You do use your eyebrows in an effort to open the eyes.  The challenge is that the frontalis sling surgery is not well tolerated by adults.  I would get several consultations with university based oculoplastic surgeons regarding your situation before making a decision.

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

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