Fascia frontalis sling
This Richard Allen at the University of Iowa. This video demonstrates placement of a fascia frontalis sling.
Fascia can be autogenous or obtained from the tissue bank. The patient has history of a previous frontalis sling that has failed. The previous incision sites will be used above the brow as well as across the eyelid. The 15 blade is used to make stab incisions above the brow. An incision is then made across the eyelid. Dissection is then carried out through the orbital septum with the monopolar cautery. The preaponeurotic fat is exposed and the thermal cautery is used to dissect the preaponeurotic fat from the underlying levator aponeurosis. The levator aponeurosis is then dissected from the anterior surface of the tarsus. The patient's previous frontalis sling is not able to be identified. The fascia is then obtained and laid across the eyelid. A 5-0 Mersilene suture is then placed partial thickness through the anterior surface of the tarsus at the superior boarder of the tarsus. This is then tied around the fascia. Approximately three sutures are placed along the length of the eyelid to obtain the appropriate contour. A large needle is then used to engage the fascia and passed in a retroseptal fashion to exit out each of the brow incisions. The contour is then inspected and found to be acceptable. The lid incision is then closed with 7-0 Vicryl suture which incorporates the cut end of the levator aponeurosis in order to aid in lid crease formation. This is placed along the length of the eyelid. The lid height and contour are inspected as well as the formation of the lid crease. The fascia is relatively short so the needle is placed first to the central incision, followed by engagement of the fascia and passage through the central incision. The fascia is then tied over the 5-0 Mersilene sutures. Once the appropriate height and contour are obtained, the suture is tied around the single throw of the fascia. The fascia is then tied over the suture to create the knot, and the suture is tied one more time over the knot. The suture is cut and the fascia is trimmed and then placed into the pocket above the superior incision. The brow incisions are then closed with 7-0 Vicryl suture placed in a vertical mattress fashion. Approximately two sutures are needed on each incision. This patient will have a Frost suture post-operatively for one day with a patch to prevent immediate post-operative exposure keratopathy. The patient will return the following morning for patch and frost suture removal.