Thank you for your question.
You submitted a single photo and you’re limited to just your eyes and you’re asking
is frontalis sling your last option.
And you state that you had congenital ptosis, having undergone multiple surgeries that your
most recent surgery performed was a maximal levator resection.
You feel like your eyelids are still drooping and your surgeon suggested possibly considering
a frontalis sling.
And of course you want to know if this is a best option or if this is a good choice.
Well, I can certainly share with you my experience and opinion about this type of scenario.
A little bit of 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 and in a full range of ages.
So I can share with you first, the way I educate my patients about the causes of congenital
ptosis and how it impacts on how the correction is performed.
So to begin with, you probably are familiar in that you understand that congenital ptosis
is due to a developmental limitation in the muscle that lifts the eyelid called the levator
muscle.
This muscle neither contracts fully as in a normal muscle would nor does it relax fully.
And so the goal for any ptosis operation is to first measure and evaluate the degree of
strength of that muscle prior to doing the surgery as well as different parameters relative
to the height of the eyelid relative to the pupil, the eye’s ability to protect itself
from exposure.
There’s a whole constellation.
Now your doctor determined that you would benefit from what’s called the maximal levator
resection which means that 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.
Now the challenge especially when we’re doing this type of procedure in adults that
the eyelid still has to close properly in order to protect the integrity of the eye.
And so, even if the eyelid height during surgery is lifted as high as is achievable and is
able to be set higher even overcorrect it slightly, there is always an equilibrium and
this also applies to levator resection and a frontalis sling and I’ll explain further
about that.
But ultimately, what our goal is to have the eyelid open enough so that when you are in
a normal social setting, the eyelid height clears the pupil, that you have a good vision,
relatively good symmetry and you are able to close your eyes.
Now even when the eyelid is elevated beyond what is the usual, the body protects the eye
and so people naturally start to squeeze in order to blink and lubricate the eye.
I have seen situations wherein an adult, someone in their late 50s or mid-50s who never had
their ptosis corrected and they get it done at that stage of life, one or two millimeters
can make the difference between exposure, irritation and tearing and comfort.
So that’s one major factor that you need to consider also understanding that the protective
mechanism is necessary.
Now 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.
And people with congenital ptosis often after surgery have a little bit of gaping or opening
of the eyelid when they sleep because of the baseline tension and as I said earlier, the
muscle doesn’t fully relax so you have to be careful about lubrication.
Now as far as frontalis sling is concerned, yes this is an option.
And 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, this are children under 6 years old can tolerate the eyes to
be 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 but there’s kind of a natural adaptation that occurs where
you do 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 and certainly that can a little be unsettling
for the parents but they don’t tend to have the dry eye issues that adults do.
So I think that you have to make this decision based on how much more you are willing to
tolerate.
You know, when I look at your photo and I look at your eyes, I would say that you would
have a reasonable outcome that although it might not be as high as you like, you’ve
achieved a reasonable degree of symmetry and reasonable amount of height.
And 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 if your eyelid is forced a little bit higher then you’re
dealing with eye exposure.
So yes, your doctor, I’m sure wants to do the best job possible for you but at the same
time, I think it’s very important to understand that you’ve already had multiple surgeries
and it is not unusual for someone for congenital ptosis to need multiple surgeries throughout
their lifetime because as far as that muscle changes, as you age, with continuous little
bit of stretching, the lids will likely calm down a little bit.
It just varies from person to person.
But 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 that you can’t repeat that surgery anyway but just for the interest
of minimizing the number of surgeries you have, you may want to just factor these variables
that are less predictable and potentially can be problematic in terms of eye exposure,
symmetry and aesthetics and other issues that could occur.
So you just have to have this discussion with most likely your oculoplastic surgeon who
performed this for you.
So I hope that was helpful, I wish you the best of luck and thank you for your question.