The use of Whitnall's ligament for sling redirection in frontalis suspension ptosis surgery

To evaluate the cosmetic and functional outcome of a modified frontalis suspension technique when the sling force vector is redirected through Whitnall's ligament.

Non-comparative retrospective study. Twenty-nine eyes of 23 patients with poor levator function of 4 mm or less. Patients underwent frontalis suspension with polytetrafluoroethylene (Gore-Tex) (PTFE). The sling was inserted in a single circular fashion through 3 brow incisions. An additional eyelid crease incision was created to allow the passage of the sling beneath Whitnalls' ligament, to permit securing the sling to the tarsus, to perform a limited blepharoplasty, and to reform the eyelid crease. Postoperatively, patients were followed up for at least 24 months.

All cases achieved elevation of the ptotic eyelid in the primary position. Three eyes of 2 patients had under correction in the primary gaze. Twenty-eight of 29 eyes retained the same level of eyelid elevation after 2 years of follow up. Symmetry in the primary gaze was achieved in 4 of 6 (67%) patients with bilateral ptosis and in 12 of 17 (71%) patients with unilateral ptosis. One patient had sling infection with granuloma formation. Lagophthalmos was common, but none developed exposure keratitis.

Frontalis suspention technique modified with redirecting the sling pulling force vector by passing beneath Whitnall's ligament can achieve a natural-looking eyelid in primary gaze and does not interfere with functional outcome.