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AAO 2023 Oculofacial Plastic Surgery Subspecialty Day: Is Frontalis Sling Surgery Dead?

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I don’t take pronouncing a death lightly.  I remember the first time I did it, on the first night of call for my internship.  The nurse paged me and asked me to come and pronounce a patient dead.  I was unaware this was part of being on call, but, as a good intern, I ran to the floor.  I am not sure why I felt the need to run.  I asked the nurse what I was supposed to do.  She showed me into the room, where the patient was lifeless.  I listened for a heartbeat and checked for respirations and agreed with her assessment.  I felt completely inadequate in doing this.

Pronouncing a surgery dead is a different ordeal, especially when the surgery has been part of my life for the last 20 years.  But, at the Oculofacial Plastic Surgery Subspecialty Day at the AAO in San Francisco, I did just that.  I think my exact words were “stop doing frontalis slings on children”.  The frontalis flap has arrived, and it is not going away.  I feel very adequate in making this pronouncement.

In the treatment of congenital ptosis, there are usually two issues:  timing of surgery and choice of surgery.  Our choice of surgery has essentially been limited to three types of procedures:  posterior approach for mild ptosis, levator-based surgery for most moderate ptosis, and frontalis suspension for severe ptosis.  Frontalis sling surgery, using synthetic or autologous materials, has been a mainstay.  However, synthetic slings for children under the age of four usually sentences them to another surgery, and the use of fascia after the age of four involves harvesting the fascia.  

I started to experience something different in my clinic a few years ago.  Parents would come and ask if I did a frontalis flap.  At the time, I thought the surgery was a fad and said that I did not.  I had good results with frontalis sling surgery, why would I change?  They thanked me for my time and said they would go find a surgeon that would do it.  This happened more than a few times, and it was then that I knew I had to learn the surgery.  

With the help of some friends in Brazil, I learned the surgery and started to perform it on my patients.  No longer did I use synthetic slings with the understanding that a fascia frontalis sling would be performed later around the age of four.  And no longer did I have to harvest fascia, which at times can be tricky with some kids limping around for weeks.  Parents began to travel to see me with their kids from all over the country.

The frontalis flap is a surgery that uses a single eyelid crease incision.  There are no incisions above the brow as in frontalis sling surgery.  There is no concern for foreign body reactions or infections that you can see with synthetic slings.  There is no more harvesting of fascia from children and giving them a scar for life on the leg.  And, it works.

The parents of kids with congenital ptosis have become very sophisticated in their understanding of the condition and the treatments available.  There are social media groups where the parents compare the results from different surgeons and the techniques they do.  The parents have embraced frontalis flap surgery, and there is no reason that we should not as well. 

So, I am now pronouncing the death of frontalis sling surgery in children.  The frontalis flap isn’t a fad, and it isn’t going away.  If you decide not to do it, your parents will find someone who does.  

Dr. Allen has no conflicts of interest to report.

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