Pediatric bilateral frontalis sling
This is Richard Allen at the University of Iowa. This video demonstrates placement of a bilateral supramid sling in an 8 month old patient with blepharophimosis epicanthus inversus syndrome.
Three stab incisions are made above the brow, one corresponding to the medial canthus, one the lateral canthus and one half way between these two 1 cm above them. An incision is then made along the proposed eyelid crease with the 15 blade. Dissection is then carried out through the orbital septum with a combination of the monopolar cautery and Westcott scissors to expose the preaponeuotic fat. Again this can be difficult in kids just because the septum is so thick.
The preaponeurotic fat is then dissected from the underlying levator aponeurosis. The levator aponeurosis is then disinserted from the anterior surface of the tarsus for approximately 5 mm. The supramid sling is then placed on the anterior surface of the tarsus and sutured to the tarsus with Mersilene suture. I believe in tarsal fixation for all frontalis slings. I know some people would just place the sling in the eyelid with stab incisions. The sutures are placed centrally and then at the level of the lateral and medial limbus. The sling is then placed in a retroseptal fashion to exit out each of the brow incisions. The sling is then passed through to the central superior incision. The sling is tightened but not tied to inspect the contour. The same procedure is performed on the other side. Prior to tying the sling, I close the eyelid as it can be difficult to close the lid after the sling has been tightened. The eyelid incision is closed by incorporating the levator aponeurosis into skin closure to aid in lid crease formation. The suture is a 5-0 fast absorbing suture. These are placed along the extent of the eyelid incision. The brow incisions are then closed with the same suture with a single horizontal mattress suture. The sling is then tightened and tied in order to obtain an appropriate height and contour.
I think it is very difficult to get the sling too tight. In general I try to get these as tight as possible without distorting the brow. The sling is then placed under the skin and the forehead incision is again closed with the horizontal mattress suture.
Antibiotic ointment is placed over the incisions and the patient is seen in approximately one week.