Bilateral Silicone Frontalis Suspension
This Richard Allen at the University of Iowa. This video demonstrates a bilateral silicone frontalis suspension.
Marks have been made about each of the brows. One corresponding to the lateral canthus, one to the medial canthus, and one half way between these two marks in a convenient wrinkle or 1 cm above the brow. A stab incision is made with a 15 blade through each of the marks and then the incisions are bluntly dissected open with a hemostat. A pocket is made above the superior incision for placement of the frontalis sling later in the case.
Attention is then directed to the blepharoplasty marking. Using a monopolar cautery, an incision is made through the skin and orbicularis muscle. The skin and orbicularis is then excised. This should be a conservative blepharoplasty leaving at least 20 mm of skin between the lash follicles and brow. Dissection then proceeds through the orbital septum to expose the preaponeuroic fat. The preaponeurotic fat is then dissected from the underlying levator aponeurosis. A thermal cautery is then used to disinsert the levator aponeurosis from the anterior surface of the tarsus and expose the tarsus. Dissection is carried out between the mullers muscle and levator aponeurosis for 5-10 mm. The silicone sling is then placed over the tarsus and sutured into position with a 5-0 Mersilene suture on a spatula needle. Three sutures are placed, one corresponding to the center of the pupil, one to the lateral limbus, and one to the medial limbus. The suture is on a spatula needle and the needle is placed partial thickness.
The frontalis sling is the placed in a retroseptal fashion. This is a frontalis suspension set that has the large needles attached to each end of the sling. The needle is bent slightly and placed to exit out the medial and lateral brow incision. The sling is then passed through each of the incisions to exit out the superior forehead incision, which is placed in a convenient wrinkle. This frontalis suspension set comes with a sleeve. I cut the sleeve in half and place each half over the ends of the sling. If you don't have this set you can use a Watzke sleeve. At this point, the sling is not tightened completely as the patient will be placed in a sitting position for final adjustments. The redundant portion of the sling is removed with the needles. The same procedure is then performed on the left side. At this point the patient is sat up and by tightening the frontalis sling with the sleeve the appropriate height and contour are attained.
The patients is then placed back in a supine position and sleeves are held into position with the 5-0 Mersilene suture, which is placed around the upper half of the sleeve and an additional suture is tied around the sling inferior to the inferior half of the sleeve. Approximately one centimeter of each end of the frontalis sling above the sleeve is retained and deposited into the dissection pocket through the forehead incision. The forehead and brow incisions are then closed with interrupted 5-0 fast absorbing suture placed in a vertical mattress fashion. You need approximately two sutures per stab incision. The eyelids are then closed with 3-5 lid crease formation sutures. This is performed by incorporating the cut end of the levator aponeurosis in the skin closure. This adds an additional barrier over the sling as well. I think this is an important maneuver to perform for lid crease formation in addition to the preservation of preaponeurotic fat and conservative skin excision. Other things that I think helps with lid crease formation includes tarsal fixation of the sling and retroseptal placement of the sling. The remainder of the eyelid incision is closed with a running fast absorbing suture. Antibiotic ointment is placed over the incisions and the patient is seen one week later.