Comparison of Nylon Monofilament Suture and

Polytetrafluoroethylene Sheet for Frontalis Suspension

Surgery in Eyes With Congenital Ptosis
KENGO HAYASHI, NOBUTADA KATORI, KENICHIRO KASAI, TARO KAMISASANUKI, KENICHI KOKUBO,
AND KYOKO OHNO-MATSUI

PURPOSE: To compare nylon monofilament suture with
polytetrafluoroethylene sheet for frontalis suspension
surgery to treat eyes with congenital ptosis.

DESIGN: Retrospective, nonrandomized, comparative,
interventional case series.

METHODS: We reviewed the medical records of 49
patients who had undergone 79 eyelid frontalis suspension surgeries to treat congenital ptosis. All of the patients
were younger than 16 years and had congenital ptosis
with poor levator muscle function. They were treated
with frontalis suspension surgery with either a nylon
suture or a polytetrafluoroethylene sheet and were
followed up for at least 1 year. A single rhomboid loop
sling was used for the nylon suture surgery. For the polytetrafluoroethylene sheet, an incision was made in the
eyelid crease, and one end of the sheet was fixed to the
tarsus and the other was fixed to the frontalis muscle.
The main outcome measures were postoperative recurrences and complications.

RESULTS: We evaluated 37 eyelids of 25 patients after
nylon suture surgery and 42 eyelids of 31 patients after
polytetrafluoroethylene sheet surgery. Among these, 9
eyelids of 7 patients were included in both groups. The
median postoperative follow-up period was 32 months
in both groups. The recurrence rates were 62.2% for
the nylon suture group and 0% for the polytetrafluoroethylene sheet group (P < .001). The postoperative
complication rates were 0% for the nylon suture group
and 7.1% for the polytetrafluoroethylene sheet group
(P > .05).

CONCLUSIONS: Frontalis suspension using a polytetrafluoroethylene sheet with direct tarsus and frontalis
muscle fixation is a reasonable technique with low rates
of recurrences and complications. (Am J Ophthalmol
2013;155:654663. 2013 by Elsevier Inc. All rights
reserved.)
Accepted for publication Oct 30, 2012.
From the Department of Ocular Plastic and Orbital Surgery, Seirei
Hamamatsu General Hospital, Hamamatsu-shi, Japan (K.H., N.K.,
K.Ka., T.K., K.Ko.); and the Department of Ophthalmology and Visual
Science, Tokyo Medical and Dental University, Tokyo, Japan (K.H.,
K.O.-M.).
Inquiries to Kengo Hayashi, Department of Ophthalmology and Visual
Science, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyoku, Tokyo 113-8519, Japan; e-mail: kengoh@mist.ocn.ne.jp

654

2013 BY

YELID FRONTALIS SUSPENSION SURGERY IS A COM-

mon operative procedure used to correct severe

blepharoptosis in eyes with poor levator muscle function.1 Poor function is generally defined as an eyelid elevation of 4 mm or less.2 The main indication for frontalis
suspension surgery is severe blepharoptosis secondary to
myogenic, neurogenic, mechanical, and traumatic disorders.3 At present, congenital severe ptosis is repaired by
frontalis suspension surgery, which consists of connecting
the tarsal plate to the eyebrow with various types of sling
materials.
Different methods are used to pass the sling material from
the eyelid to the eyebrow area in the suborbicularis plane
during frontalis suspension surgery. In addition, different
types of loop designs, such as a single triangle, a single rhomboid, a single pentagon (Fox procedure), a double pentagon
(Crawford procedure), and an open loop have been
used.1,35 Autogenous fascia lata is generally considered
to be the most effective sling material, with lower
recurrences and lower rates of complications, for example,
infections and granuloma formation.1,3,68 However, this
technique requires the harvesting of the fascia lata, which
carries the risk of postoperative donor-site complications
such as local hypertrophy and scarring.9 Young children
3 years of age or younger are generally considered too young
to undergo the surgery for the collection of a sufficiently
long fascia lata, and ophthalmic surgeons are generally
reluctant to perform this type of surgery because of the difficulty of harvesting the fascia lata.4 Preserved fascia lata is an
alternative material for a frontalis sling. The main advantage of using preserved fascia lata is that an additional
harvesting procedure is not necessary. It is particularly valuable for patients 3 years of age or younger. However, the
recurrence rate is generally higher than that associated
with autogenous fascia lata, with a long-term recurrence
rate of approximate 50%.7,1012
Synthetic materials, such as monofilament and polyfilament nylon, monofilament polypropylene, silicone, and
polytetrafluoroethylene (PTFE; Gore-tex; W.L. Gore &
Associates Inc, Newark, Delaware, USA) have been used
as alternative materials for frontalis suspension surgery.
Frontalis suspension surgery with nylon suture or silicone
rod has a relative high rate of recurrence of the ptosis, and
it is generally considered to be a temporary treatment.7,13,14

ELSEVIER INC. ALL

RIGHTS RESERVED.

0002-9394/$36.00
http://dx.doi.org/10.1016/j.ajo.2012.10.022

However, the procedure has been used in young children

with severe ptosis, and we have used nylon suture in
young children to prevent occlusion amblyopia.1,7
The recurrence rate after polytetrafluoroethylene use
is relatively low and comparable with that after fascia
lata surgery.7,14 However, soft tissue complications,
such as infectious granuloma caused by the polytetrafluoroethylene strip or suture, have been reported.7,14,15
We have used polytetrafluoroethylene in the form of
a sheet as an alternative method because of its stability
and safety.
Although there have been many reports on the effect of
frontalis suspension with synthetic materials, most reports
tend to have a small number of cases and short follow-up
periods. In addition, these studies used either sutures or
strips of the materials with different looped designs for
the surgeries. Because of these variations, it remains
difficult to determine which type of synthetic material
and which loop design is best for frontalis suspension
surgery.
Thus, the purpose of this study was to determine the
long-term results and incidence of complications of frontalis suspension surgery for the treatment of congenital ptosis.
We compared the results using a nylon monofilament
suture with those using a polytetrafluoroethylene sheet as
the suspension materials.

METHODS
THIS WAS A RETROSPECTIVE, NONRANDOMIZED, COMPARA-

tive, interventional case series study. Approval of this study

was obtained from the Institutional Review Board of Seirei
Hamamatsu General Hospital. The study was conducted in
accordance to the tenets of Declaration of Helsinki.
Informed consent for the surgery was obtained from the
parents of the patients after a complete explanation of
the procedures and possible complications.
We reviewed the medical records of all patients who had
congenital ptosis with poor levator muscle function. All of
the patients were treated with frontalis suspension surgery
with either a nylon suture or a polytetrafluoroethylene
sheet and were followed up for at least 1 year after the
surgery. All operations were performed by the attending
surgeons, and the surgeries were performed between April
2004 and March 2011 in the Department of Ocular Plastic
and Orbital Surgery, Seirei Hamamatsu General Hospital,
Hamamatsu-shi, Japan.
This study included only cases of simple congenital
ptosis or blepharophimosis. Because acquired aponeurotic
ptosis could develop in older adult patients with congenital
ptosis with aging, we limited the patients to those younger
than 16 years. The indications for surgery were congenital
ptosis severe enough for the eyelids to cover the visual axis
and block the view of the corneal light reflex when the eyes
VOL. 155, NO. 4

were in the primary position. These factors also were used

to define whether a recurrence of the ptosis had occurred.
We divided the complications into 2 groups: postoperative recurrence of ptosis and occurrence of other complications including infection, granuloma formation, exposure,
overcorrection, and undercorrection. To try to determine
the cause of a recurrence when the nylon suture was
used, we reviewed the movies of the reoperation to
examine the condition of the nylon suture in the eyelids.

SURGICAL TECHNIQUES:

Surgery was performed under

general anesthesia, and the eyelid and eyebrow were anesthetized with 0.5% lidocaine with 1:100 000 epinephrine.
Topical antibiotics were used during surgery, and antibiotic
eye ointment was used after surgery.
For the nylon suture surgery, a single rhomboid loop
was used for the sling (Figure 1).14,16 First, 2 points
approximately 10 mm apart were marked on the upper
eyelid corresponding to the medial and lateral limbus of
the cornea. The marks were approximately 3 to 4 mm
higher than the lash line. Two other points were marked
above the eyebrow in line with the 2 points marked on
the eyelid. Then, 4 incisions 1 to 2 mm long were made
through the skin and orbicularis muscle with a no. 11
scalpel at the marked points. One of the incisions above
the eyebrow was enlarged slightly so that the knot of
the suture could be buried in it at the end of surgery. A
4-0 or 5-0 nylon monofilament suture was passed through
the tarsal tissue from one puncture incision in the eyelid
to the other with an 18-mm round needle (a half-circle).
A corneoscleral protector was placed under the eyelid
during these procedures. The eyelid was everted to ensure
that the needle did not penetrate through the eyelid.
Then, the suture was passed from one eyelid incision site
to the corresponding eyebrow exit site deep through suborbicularis tissue or under the orbital septum with a 37-mm
cutting needle (a three-eighths circle). The suture was
passed horizontally from one eyebrow puncture point to
the other with an 18-mm round needle (a half-circle).
The 2 ends of the suture were tightened and adjusted to
achieve the desired eyelid elevation and contour. Then,
the ends were tied and the knot was buried subcutaneously.
For the polytetrafluoroethylene sheet surgery, a 0.3-mm
thick polytetrafluoroethylene sheet was cut to a rectangular
piece 50 mm long and 5 mm wide. The polytetrafluoroethylene surgical method was based on the technique used for
direct tarsal and frontalis muscle fixation (Figure 2).3,17
Three lines were marked on the upper eyelid and
eyebrow: a horizontal eyelid incision line to create a
palpebral crease, a central vertical line just above the
pupil to the eyebrow, and a small horizontal incision line
above the eyebrow. A wide eyelid crease incision was
made with a no. 15 scalpel to expose the tarsal plate and
the orbital septum. A tunnel was made deep to the
orbital septum from the eyelid incision to above the
eyebrow along the marked central line. A small incision

COMPARISONS OF DIFFERENT MATERIALS FOR FRONTALIS SUSPENSION

655

FIGURE 1. Photographs demonstrating the surgical steps of frontalis suspension surgery using a nylon suture. (Top left) The sling is
made into a single rhomboid loop. Two stab incision points are marked on the upper eyelid and 2 are marked on the eyebrow. (Top
right) The nylon suture is passed from one eyelid stab incision to the other deep through a partial thickness tarsal passage. (Bottom
left) The suture then is passed from one eyelid incision site to the corresponding eyebrow exit site through a deep suborbicularis plane
or under the orbital septum. (Bottom right) The 2 ends of the suture are tightened and adjusted to achieve the desired eyelid elevation
and contour.

was made above the eyebrow to the tunnel. The

polytetrafluoroethylene sheet was passed through the
tunnel. The lower part of the polytetrafluoroethylene
sheet was divided into 2 branches to form an inverted Y.
The 2 limbs of the Y were fixed with 6-0 suture to the
upper tarsus. The upper limb was pulled up and adjusted
to ensure that the eyelid had a natural contour. To
achieve satisfactory lid contour, the 2 branches of the
sheet were moved medially or laterally before securing
the sheet to the tarsus. The pretarsal tissue was repaired
and the lower polytetrafluoroethylene sheet was covered.
The eyelid crease was created by internal fixation to
prevent eyelash ptosis. The eyelid crease incision was
closed with 7-0 suture. The upper limb of the
polytetrafluoroethylene sheet was adjusted for the desired
eyelid elevation. The upper polytetrafluoroethylene
end was fixed with 5-0 suture to the frontalis muscle
and the subcutaneous tissue under the eyebrow. Excess
polytetrafluoroethylene material of the upper limb was
trimmed off and buried in the tunnel. The small incision
above the eyebrow was closed with 7-0 suture.

STATISTICAL ANALYSES:

The significance of the differences in the age at the time of surgery and the postoperative
follow-up period between the nylon suture group and the

656

polytetrafluoroethylene sheet group was determined by

MannWhitney U tests. Comparisons of the frequency of
ptosis recurrences and complications between the 2 groups
were made by Fisher exact probability tests. Kaplan-Meier
analysis was used to calculate the cumulative occurrence of
events defined as recurrences or complications. The difference in the event-free survival between the 2 groups was
analyzed by log-rank test. A P value less than .05 was
accepted as being statistically significant. The statistical
analyses were performed using JMP software version 8.0.1
(SAS Institute Inc, Cary, North Carolina, USA).

RESULTS
SIXTY-SIX PATIENTS WITH CONGENITAL PTOSIS UNDER-

went frontalis suspension surgery using either a nylon

suture or a polytetrafluoroethylene sheet between April
2004 and March 2011. Among these, 9 patients were
excluded because the follow-up period was less than 1
year, and 8 patients were excluded because they were older
than 16 years. In the end, 70 eyelids of 49 patients with
congenital ptosis who had undergone frontalis suspension
surgery and were followed up for at least 1 year were

AMERICAN JOURNAL OF OPHTHALMOLOGY

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FIGURE 2. Surgical steps of frontalis suspension surgery using a polytetrafluoroethylene sheet. (Top left) Three lines are made: an
eyelid incision line, a vertical center line, and a small incision line above the eyebrow. (Top middle) A tunnel is created in a plane deep
to the orbital septum through the eyelid incision to above the eyebrow. (Top right) The polytetrafluoroethylene sheet is passed
through the tunnel. (Bottom left) The 2 branches of the sheet are fixed with 6-0 sutures to the upper tarsus. (Bottom middle)
The upper polytetrafluoroethylene end is fixed with a 5-0 suture to the frontalis muscle and the subcutaneous tissue under the
eyebrow. (Bottom right) The excess of the upper end is trimmed off, and the end of the strip is buried in the tunnel.

TABLE 1. Patient Characteristics and Results in 2 Groups : Nylon Suture Group and Polytetrafluoroethylene Sheet Group

No. of patients (eyelids)

Mean age 6 SD (median), y
Mean postoperative follow-up 6 SD (median), mos
Bilateral or unilateral surgery, no. of patients
Bilateral
Unilateral
Previous treatments, no. of eyelids
Levator resection
Frontalis suspension using a nylon suture
Ptosis recurrence, no. of eyelids (%)
Complications, no. of eyelids (%)

Nylon Suture

Polytetrafluoroethylene Sheet

P Value

25 (37)
4.2 6 4.9 (2)
38.3 6 21.5 (32)

31 (42)
5.8 6 3.3 (5)
33.2 6 17.7 (32)

<.001
NS

12
13

11
20

1
0
23 (62.2)
0 (0)

6
9
0 (0)
3 (7.1)

<.001
NS

NS not significant; SD standard deviation.

studied. There were 29 boys and 20 girls and 21 bilateral

and 28 unilateral cases. Simple congenital ptosis was the
initial diagnosis in 44 patients, and blepharophimosis
syndrome was the initial diagnosis in 5 patients.
We analyzed 37 eyelids of 25 patients who had undergone nylon suture primary or secondary surgeries and 42
eyelids of 31 patients who had undergone polytetrafluoroethylene sheet primary or secondary surgeries (Table 1).
Among these, 9 eyelids of 7 patients were included in
both groups, that is, they underwent nylon suture surgery
first and were followed up more than 1 year and then
demonstrated a recurrence of the ptosis and underwent
VOL. 155, NO. 4

secondary surgery with a polytetrafluoroethylene sheet

and were followed up for more than 1 year (Figure 3).
In the nylon suture group, 12 patients underwent bilateral surgery and 13 patients underwent unilateral surgery.
In the polytetrafluoroethylene sheet group, 11 patients
underwent bilateral surgery and 20 patients underwent
unilateral surgery. In the nylon suture group, 1 eyelid had
undergone a previous levator resection surgery for ptosis.
In the polytetrafluoroethylene sheet group, 15 eyelids had
undergone previous ptosis surgery, including 6 eyelids
with levator resection and 9 eyelids with frontalis suspension using a nylon suture.

COMPARISONS OF DIFFERENT MATERIALS FOR FRONTALIS SUSPENSION

657

FIGURE 3. Preoperative and postoperative photographs of a child who underwent a reoperation using a polytetrafluoroethylene sheet
for a recurrence of the ptosis after a primary surgery performed with a nylon suture. (Top left) A 2-year-old child with unilateral
congenital ptosis before surgery. (Top right) Six months after the primary surgery using a nylon suture. (Bottom left) Recurrence
of the ptosis 18 months after the primary surgery. (Bottom right) Eighteen months after the second surgery using a polytetrafluoroethylene sheet at 5 years of age.

The mean age at the time of surgery was 4.2 6 4.9 years
(median, 2 years), with a range of 6 months to 15 years, in
the nylon suture group, and 5.8 6 3.3 years (median,
5 years), with a range of 3 to 14 years, in the polytetrafluoroethylene sheet group. The nylon suture group was
significantly younger than the polytetrafluoroethylene
sheet group (P < .001, MannWhitney U test).
The mean postoperative follow-up period was 38.3 6
21.5 months (median, 32 months), with a range of 12 to
76 months, in the nylon suture group and 33.2 6
17.7 months (median, 32 months), with a range of 13 to
70 months, in the polytetrafluoroethylene sheet group.
The difference in the postoperative follow-up period
between the 2 groups was not significant.
A recurrence of the ptosis was found in 23 of 37 (62.2%)
eyelids in the nylon suture group, which was significantly
more frequent than the 0 of 42 (0%) eyelids in the polytetrafluoroethylene sheet group (P < .001, Fisher exact probability test). The recurrences in the nylon suture group
appeared after a mean of 25.7 6 9.6 months (median,
24 months), with a range 10 to 50 months. Other than
the recurrences in the 14 eyelids, there were no other postoperative complications in the nylon suture group.
In the polytetrafluoroethylene group, there were no
recurrences; however, complications developed after the
surgery in 3 eyelids (7.1%; P .15, Fisher exact probability
tests). Infections and granuloma developed in 2 eyelids
(4.8%) in the polytetrafluoroethylene sheet group. The
658

FIGURE 4. Photograph showing an infection and granuloma

formation above the eyebrow after a polytetrafluoroethylene sheet
sling. The patient underwent excision of the infected material.

2 infections occurred within 3 months after the surgery

and required reoperations (Figure 4). One case of infection
was resolved by incision and drainage. The other case
required removal of the polytetrafluoroethylene sheet,
which was removed easily. Even after removal of the polytetrafluoroethylene sheet, the upper eyelid height was
maintained.

AMERICAN JOURNAL OF OPHTHALMOLOGY

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An undercorrection of the ptosis was found in 1 eyelid

(2.4%) in the polytetrafluoroethylene group, and this
eyelid required a reoperation 1 year after the primary
surgery to adjust the polytetrafluoroethylene sheet. This
child had bilateral ptosis and a downward slant of the
palpebral fissures associated with partial trisomy 22. He
had undergone bilateral suspension surgery using polytetrafluoroethylene sheets. In this case, the ptosis of the left
eyelid was not corrected sufficiently during the first postoperative week, and it was not classified as a recurrence. The
reoperation to adjust the amount of elevation to the
eyebrow incision at a later stage was relatively easy.
Both groups had cases in which the surgery was
a secondary ptosis surgery, that is, 1 eyelid (previous
surgery: levator resection) in the nylon suture group and
15 eyelids (previous surgery: levator resection in 6 eyelids
and frontalis suspension using a nylon suture in 9 eyelids)
in the polytetrafluoroethylene sheet group (Table 1). We
then compared only primary surgery cases, excluding
secondary surgery cases in both groups. A recurrence of
the ptosis after the primary ptosis surgery was found in
22 (61.1%) of 36 eyelids in the nylon suture group and in
0 (0%) of 27 eyelids in the polytetrafluoroethylene sheet
group (P < .001). Other postoperative complications
were found in none of the eyelids in the nylon suture group
and in 2 (7.4%) of 27 eyelids in the polytetrafluoroethylene
sheet group (P .18).
An event for the survival graph was defined as a recurrence of the ptosis or the development of other complications (Figure 5). Although an event-free survival rate at
36 months after the surgery in the nylon suture group
decreased to approximately 30%, the success rate with
the polytetrafluoroethylene sheet was maintained at
approximately 90% throughout the experimental period.
The difference in the survival rate between the 2 groups
was significant (P < .001, log-rank test).
In the end, 17 eyelids (45.9%) in the nylon suture group
and 3 eyelids (7.1%) in the polytetrafluoroethylene sheet
group required reoperations because of a recurrence or
complications. The 17 eyelids with recurrence in the nylon
suture group underwent a repeat of the frontalis suspension
surgery: 14 eyelids with a polytetrafluoroethylene sheet and
3 eyelids with a nylon suture. Of the 14 eyelids using a polytetrafluoroethylene sheet, 13 (92.9%) were found during
surgery to have had a slippage of the nylon suture from
the tarsus (Figure 6). The remaining 1 eyelid (7.1%) had
a break in the nylon suture. The nylon suture was removed
easily with no residual scarring and did not interfere with
the reoperation.

DISCUSSION
THE RESULTS OF FRONTALIS SUSPENSION SURGERY USING

nylon suture or polytetrafluoroethylene in earlier studies

VOL. 155, NO. 4

and this study are summarized in Table 2.68,1315,18 Our

surgeries had a high recurrence rate of 62% and no other
complications in 37 eyelids using a nylon monofilament
suture with a single loop and a mean follow-up period of
38 months. The median time of recurrence was 24 months,
with a range of 10 to 50 months after the surgery.
Wasserman and associates also reported a high recurrence rate of 69.2% and a low complication rate of
7.7% using a nylon monofilament suture; these rates are
comparable with our results.7 However, they studied
only 13 eyelids and the average follow-up period was
10 months. However, Ben Simon and associates reported
a relatively low recurrence rate of 25% and a low complication rate of 5% in 20 eyelids using a nylon suture, but
the follow-up period was not reported.14 They reported
that the time to recurrence was 16.5 months, which is
comparable with our results. Wagner and associates
reported a high failure rate of 40.5% in 121 eyelids using
polyfilament nylon sutures with a mean follow-up period
of 31.5 months.6 They described 2 types of recurrences:
an acute drooping of the lid that occurred at a mean
interval of 3 months after surgery without trauma and
a gradual change in lid position that reached an unacceptable level at a mean interval 20 months after the surgery.
Liu used nylon monofilament suture surgery on 43 patients
with a follow-up period ranging from 3 to 12 years (mean,
7 years), and all had a recurrence of the ptosis within
18 months of the surgery.13
In our study, all of the recurrences were found in the nylon
surgery group, and they appeared after a mean of 25.7 6
9.6 months (median, 24 months), with a range 10 to
50 months. The changes in the eyelid position were slow
and gradual and were not acute. The cause of the recurrences
appeared to be the result of the suture cheese wiring
through the tissue, as suggested earlier by Manners and associates.19 During the reoperation, we found that the most
nylon suture had slipped from the tarsus and were removed
easily, leaving no residual scarring. It also did not interfere
with the placement of the polytetrafluoroethylene sheet,
which was used in the reoperation. Thus, the nylon monofilament suture had minimal adhesion to adjacent structures
with no scaring, which resulted in its slippage from the tarsus
and a recurrence of the ptosis. Overall, our results with the
nylon suture are consistent with earlier reports in being
a safe procedure for temporary suspension in young children to prevent deprivation amblyopia.6,7,13,16
We found no recurrence but the occurrence of other
complications in 3 of 42 (7%) eyelids using the polytetrafluoroethylene sheet with a mean follow-up period of
33 months. Infections occurred in 2 (5%) eyelids, and an
undercorrection of the ptosis was seen in 1 (2%) eyelid.
Earlier studies reported that the polytetrafluoroethylene
material gave better results than other synthetic materials.7,14 Thus, Ben Simon and associates reported that
polytetrafluoroethylene strip surgery had the lowest
percentage of ptosis recurrence (15%) in 27 eyelids as

COMPARISONS OF DIFFERENT MATERIALS FOR FRONTALIS SUSPENSION

659

FIGURE 5. Kaplan-Meier analysis of event-free survival: nylon suture versus polytetrafluoroethylene sheet. An event was defined as
ptosis recurrence or complications.

FIGURE 6. Photograph obtained during the reoperation

showing a slippage of the nylon suture from the tarsus that
was used in the primary suspension surgery.

compared with fascia lata (22%), nylon (25%), and

silicone (44%), although these differences were not
statistically significant.14 Wasserman and associates
reported that there was no recurrence of the ptosis in
11 eyelids using a polytetrafluoroethylene strip that were
followed up for an average of 7.5 months.7 However, they
found a high rate of infection or granuloma formation
(45.5%). They stated that the high incidence of complications required further study of polytetrafluoroethylene
before recommending it for frontalis suspension surgery.
Steinkogler and associates reported a low recurrence rate
of 2.7% and a low rate of other complications of 2.7% in
660

a series of 37 frontalis suspension surgeries using a polytetrafluoroethylene strip in a Fox pentagon sling.18 These
eyelids were followed up for an average of 3 years. The
authors stated that it was especially important to position
the fixation point of the polytetrafluoroethylene deep in
the tissue to prevent contact of the polytetrafluoroethylene
material with the wound. Zweep and Spauwen reported
a high recurrence rate 54% and no other complications
in a series of 19 eyelids using a polytetrafluoroethylene strip
with an open-loop design that were followed up for an
average of 10 months.8 They suggested that poor anchorage
of the polytetrafluoroethylene strip to the surrounding
tissue might have been responsible for the high recurrence
rate in their procedure. Bajaj and associates used a polytetrafluoroethylene suture (CV-4) with the double-triangle
method, and they reported that the ptosis correction was
unsatisfactory in only 7% and the complication rate was
only 7% in a series of 30 eyelids followed up for a minimum
of 1 year.15
Thus, in these reports of frontalis suspension using polytetrafluoroethylene, the surgeons had used it in the form
of a strip or suture with various looped designs such as
a single pentagon or a double pentagon, as with other materials.7,14,15,18 However, the tied knots at the ends of the strip
or suture had to be buried under the skin. The tied knots of
the strip were most likely large, and a large knot under
a shallow subcuntaneous plate could lead to direct contact
of the polytetrafluoroethylene with the skin wound, which
could lead to inflammation and infection, granuloma
formation, or a combination thereof. These changes may
be the main cause for the higher complication rate seen
with the polytetrafluoroethylene strips.7

AMERICAN JOURNAL OF OPHTHALMOLOGY

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TABLE 2. Comparison of Results of Frontalis Suspension Using Nylon Suture or Polytetrafluoroethylene among Previous Studies and
the Present Study
Nylon Suture

Wasserman and
associates7
Ben Simon and
associates14
Wagner and
associates6
Liu13
Zweep and
Spauwen8
Steinkogler and
associates18
Bajaj and
associates15
Current (Hayashi
and associates)

Polytetrafluoroethylene

No. of Eyelids

Follow-up

Recurrence

Complications

Shape

(Patients)

(mos)

(%)

(%)

Type

10

69.2

7.7

Strip

11

25

Strip

27

Strip

19

10

Strip

37

36

2.7

2.7

Suture

30

16

Sheet

42

33

13
20

121

31.5

(43)

84

37

38

28.1
100

62

Eyelids

Follow-up

Recurrence

Complications

(mos)

(%)

(%)

7.5

45.5

15

11

54

12.4

not written.

Several groups have used a sheet-shaped material with

an eyelid crease incision.3,2022 The advantage of this
method is that the fixation of the suspension material to
the tarsus and the frontalis muscle with several sutures
may prevent postoperative sling slippage from the tarsus.
We used a polytetrafluoroethylene sheet because of its
stability and safety. Polytetrafluoroethylene is a synthetic
microporous polymer, comprising nodules interconnected
by multidirectional minute fibers.8 It is known that polytetrafluoroethylene is one of the most biologically and
chemically inert biocompatible synthetic materials.15,23,24
Infection may be suppressed by burying the
polytetrafluoroethylene sheet deep in the tunnel, away
from all the wounds. The deeper placement of the
polytetrafluoroethylene sheet by passing it through the
tunnel under the orbital septum may yield better
cosmetic and functional results.22,25,26 If infections occur,
the polytetrafluoroethylene sheet can be removed easily,
and even after the removal of the polytetrafluoroethylene
sheet, the upper eyelid height may be maintained.18 The
highly microporous structure of polytetrafluoroethylene
material allows fibrovascular ingrowth, which then would
anchor it to the host tissue.15,18,23 The fibrovascular
tissue of capsule surrounding the polytetrafluoroethylene
sheet remains, and its biointegration may maintain the
suspension. In addition, a reoperation to readjust the
amount of correction at a later stage also was easily
possible. It has been reported that if overcorrection or
undercorrection occurred, it was easy to manipulate the
polytetrafluoroethylene sheet above the eyebrow to adjust
the eyelid height.3
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There are some limitations in this study. This study did

not include the results of using fascia lata, which is considered to be the gold standard material. Thus, we could not
compare the polytetrafluoroethylene sheet with fascia
lata. The recurrent ptosis rates of autogenous fascia lata
have been reported to be as low as 4%, whereas use of
the polytetrafluoroethylene sheet in this study had no
recurrences.7 In addition, the complication rate of fascia
lata can be as low as 8%, which is similar to our results
with of 7% with the polytetrafluoroethylene sheet.7 Yoon
and Lee also reported an extreme low recurrence rate of
0.8% in 239 patients using fascia lata with a median
follow-up period of 18 months.21 However, even when
with consistently good functional results, the cosmetic
outcomes were poor. In addition, eyelash inversion was
observed in 11% during the follow-up period. They suggested that this was associated with increased posterior
lamella vertical tension resulting from contraction of the
grafted fascia lata. This contraction caused an elevation
and sometimes overcorrection. The postoperative
shrinkage of grafted fascia lata was reported to be 15.5%,
with a range of 8.8% to 25.6% after 6 months.22 We also
have had some earlier cases in which severe lagophthalmos
and eyelash inversion developed as a result of contraction
of the fascia lata (Figure 7).27 The fascia lata was integrated
firmly into the surrounding tissue, which made it difficult to
remove. Therefore, we used a polytetrafluoroethylene sheet
instead of fascia lata.
Another limitation of this study was that it did not
include the results of silicone, which is commonly used
in young patients with congenital ptosis. Silicone rod

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661

FIGURE 7. Photograph of a patient in whom severe complications of eyelash inversion and lagophthalmos developed in the
left eyelid more than 10 years after frontalis suspension using
fascia lata.

is readily available, is easily adjusted, and is removed

after surgery. It is not incorporated into the surrounding
tissues and can slide freely in the capsule that is formed
around it after surgery.28 However, it can slip and become
detached from the tarsus.3 Therefore, it has been found
to have a relatively high recurrence rate in the long term
and is used mainly as a temporary sling material in children 3 years of age and younger.1,3,14,28 The reported
recurrence rates vary between 7% and 44%.11,14,28,29 Lee
and associates reported that the recurrence rate at 3 years
was 29% (7 of 24 patients) in bilateral cases and 11%
(3 of 27 patients) in unilateral cases, and they suggested
that suturing the rod to the tarsus may help prevent

migration of the rod and may delay recurrence.11 In addition, an improved silicone implant, for example, 2 silicone
rods connected to both sides of a silicone plate, which is
directly fixed to the tarsus with nylon sutures, has been
reported to have a low recurrence rate.30 The recurrence
rate of silicone may be higher than that of the polytetrafluoroethylene sheet (0%), but lower than that of nylon
sutures (62%) of this study. However, a simple comparison
cannot be made because of the very different circumstances
of the surgical procedures. There are very few studies that
reported the complication rates in large number of cases
using silicone rods with long-term follow-up periods.
Morris and associates reported a rate of 9% (n 110)
with a median follow-up of 17 months, and Hersh and
associates reported a rate of 15% (n 46) with a mean
follow-up of 36 months.29,31 Lee and associates reported
that there were no serious complications, and they
suggested sufficient pocket formation and meticulous repair
of the skin incision may be important in preventing
complications.11 The complication rates associated with
the use of silicone may be closer to those associated with
nylon suture (0%) and polytetrafluoroethylene sheet (7%)
in this study. However, there is a case report of orbital
inflammation developing 15 years after frontalis suspension
using a silicone rod for congenital ptosis.32 Thus, a late
inflammatory response to a silicone implant has to be considered.33,34 Therefore, we used nylon sutures in young children
instead of a silicone rod. We conclude that frontalis
suspension using a polytetrafluoroethylene sheet with
direct tarsal and frontalis muscle fixation is a reasonable
technique with low rates of recurrences and complications.

ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST
and none were reported. Involved in Design of study (K.H., N.K.); Conduct of study (K.H., N.K., K.Ka., T.K., K.Ko.); Writing article (K.H.); Critical
revision of article (K.H., K.Ka., T.K., K.Ko., K.O.-M.); Statistical expertise (K.H.); and Literature search (K.H.). The authors thank Dr Duco I. Hamasaki,
Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami School of Medicine, Miami, Florida, and Prof Manabu Mochizuki,
Department of Ophthalmology and Visual Science, Tokyo Medical and Dental University, Tokyo, Japan, for their critical discussions and final manuscript
revisions.

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Biosketch
Kengo Hayashi received his MD degree from Okayama University, Japan in 2002, and joined the High Myopia Clinic at
Tokyo Medical and Dental University in 2004. He researched the treatment of myopic choroidal neovascularization. He
received his PhD degree from Tokyo Medical and Dental University Graduate School in 2011. His current interest is
focused on the ophthalmic plastic and reconstructive surgery.

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