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Outcomes of Frontalis Sling Versus Levator Resection in Patients With Monocular Elevation Deficiency Associated Ptosis

Dave, Tarjani Vivek, M.D.; Sharma, Pranjali, M.B.B.S.; Nayak, Arpita, M.D.; Moharana, Ruby, M.D.; Naik, Milind N., M.D.

Ophthalmic Plastic & Reconstructive Surgery: May/June 2019 - Volume 35 - Issue 3 - p 251–255
doi: 10.1097/IOP.0000000000001221
Original Investigations

Purpose: To compare outcomes of frontalis sling (FS) silicone and levator resection (LR) in ptosis associated with monocular elevation deficiency.

Methods: Retrospective interventional comparative case series of FS and LR in monocular elevation deficiency associated ptosis. Favorable outcome was defined as difference in margin reflex distance 1 of ≤1 mm between the 2 eyes in unilateral cases and margin reflex distance 1 of 4 mm in bilateral cases at last follow-up visit.

Results: One hundred four eyes of 95 patients were included. Median age at surgery was 14 years, and the mean follow-up period was 19.75 ± 34.55 months. Ptosis was severe in 91 (87.5%) patients. Associated Marcus Gunn jaw-winking (MGJW) phenomenon was seen in 43 (42%) patients. Frontalis sling was performed in 76 (73%) and LR in 28 (27%). Mean pre- and postoperative margin reflex distance 1 were −1.27 ± 2.17 mm and 2.18 ± 1.49 mm (p < 0.0001). The mean improvement in margin reflex distance 1 was significantly more with FS (4.46 ± 2.19) compared with LR (1.85 + 2.5) (p < 0.0001). There were no cases of exposure keratopathy requiring reversal of surgery in either group. The number of resurgeries required was 42 (55%) in the FS group and 10 (36%) (p = 0.08) in the LR group. Favorable outcome was seen in 54 (71%) in FS group and 16 (57%) (p = 0.17) in LR group.

Conclusions: When compared with levator resection, frontalis suspension with silicone gives a better eyelid elevation but has greater regression requiring more resurgeries. In spite of a poor Bells phenomenon, exposure keratopathy is not a concern.

In patients with mono-ocular elevation deficit associated ptosis, frontalis sling with silicone gives better eyelid elevation than levator resection; however, there is greater recurrence of ptosis and need for repeat surgeries with frontalis sling.

Ophthalmic Plastic Surgery Service, L V Prasad Eye Institute, Hyderabad, Telangana, India

Accepted for publication July 17, 2018.

This study is supported by research grant from the Hyderabad Eye Research Foundation.

The authors have no conflicts of interest to disclose.

Address correspondence and reprint requests to Milind N. Naik, M.D., L V Prasad Eye Institute, Banjara Hills Road No. 2, Hyderabad 500034, Telangana, India. E-mail:

© 2019 by The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc., All rights reserved.