Surgical Technique Battles: Frontalis Sling vs. Flap

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In the first of the TOP Surgical Battle Series, Dr. Natalie Homer (Stanford) moderates a debate between the frontalis sling (Dr. John Ng, OHSU) and frontalis muscle flap (Dr. Richard Allen, TOC Eye and Face) techniques for correction of myogenic ptosis.

In this episode, Dr. John Ng advocates for the frontalis sling procedure, emphasizing its straightforward nature, time-tested effectiveness, and adaptability. Dr. Ng discusses the various materials used, including silicone and fascia lata, and the procedure’s suitability for teaching and clinical practice. He addresses the potential for infection, material failure, and the cosmetic aspects of the procedure.

Dr. Richard Allen alternatively defends the frontalis muscle flap procedure, making a compelling case for its efficiency and durability. He details his comprehensive technique, incorporating elements such as levator resection. He shares his experience on patient outcomes, complications, and long-term results with this procedure. 

Key Takeaways:

• The frontalis sling procedure is known for its straightforward approach and adaptability, particularly useful in teaching environments and varying patient anatomies.
• A variety of materials can be used in the frontalis sling procedure, including silicone and fascia lata. Each material has its pros and cons, such as durability and infection risks.
• The frontalis muscle flap procedure can avoid the use of foreign materials, offering a potentially longer-lasting solution. The technique includes levator resection for optimal eyelid contour and function.
• Post-operative care and complication management, including lagophthalmos and dry eye, are critical regardless of the technique used.
• Both procedures have unique indications and may be chosen based on individual patient needs, anatomical considerations, and potential for future adjustments.

Notable Quotes:

1. “The advantage of the [frontalis] sling is…for teaching at a teaching institute. The anatomy and the procedure is a lot easier to teach and has a...shallower learning curve.” - Dr. John Ng
2. “The beauty of a frontalis flap procedure is that you’re making a single incision across the eyelid, at the eyelid crease.” - Dr. Richard Allen
3. “I think that if you don’t do it,…they’re gonna find someone that does.”- Dr. Richard Allen
4. “It’s…representation of how the materials and techniques have evolved over time, balancing traditional methods with newer innovative practices.” (Regarding the frontalis muscle flap procedure) - Dr. John Ng