Transconjunctival frontalis suspension (TCFS).

We have devised a frontalis suspension technique originally described in an article entitled, "Transconjunctival frontalis suspension for blepharoptosis" (Trans Am Acad Ophthal Otolaryngol 83:684-92), by Swan and Tongue in 1977. This modified transconjunctival frontalis suspension (TCFS) procedure is described. It has been used at the Oregon Health Sciences University in its original or modified form since 1970. To better understand how this procedure successfully corrects blepharoptosis in patients with poor levator function, a study was undertaken to discern the anatomic relationship of the suspension material to important ocular adnexal structures. The findings are based on gross anatomic dissection and histologic examination of a cadaver eyelid after postmortem transconjunctival fascia lata frontalis suspension. The distal, horizontal limb of the fascia suspends the central portion of the levator aponeurosis in a hammock-type fashion. The two vertical limbs pierce the aponeurosis at the level of Whitnall's ligament and incorporate this ligament. The fascia then exits the orbit through the orbital septum near the arcus marginalis and is incorporated into the frontalis muscle near the junction of the medial one-third and lateral two-thirds of the brow, temporal to the supraorbital neurovascular bundle. This anatomic location is not only relatively easily and safely attained, but also maximizes the principles of more traditional frontalis suspensions while minimizing the effort and surgical manipulation.