Sir,

We read with interest your publication of Garrott et al's1 recent case series, highlighting the long-lasting benefit of 2-0 Prolene brow suspension for congenital ptosis. Our experience of ∼10 years of performing suture brow suspension in children and adults, for a number of different indications, echoes these findings. In addition, we found that repeat brow suspension, when necessary, was a more straightforward undertaking using this technique. This technique avoids the sequelae of autologous fascia lata harvesting2 and the soft tissue complications associated with the use of mersilene mesh.3

A retrospective case note review highlighted 41 eyes having undergone brow suspension surgery using 3-0 Prolene over a 9-year period (2001–2009) at our institute. All cases with a levator function of <5 mm were included in the analysis, irrespective of cause of ptosis and age, to provide a realistic clinical picture. Mean age at operation was 23 years (range 1–74 years). Recorded palpebral aperture improved significantly following the surgery (P<0.0005; mean 4 mm pre-operation, 7 mm post-operation). The majority were free from complications, although seven (17%) experienced a recurrence of their ptosis requiring a further operation and five (12%) experienced discomfort or a lump at the site of the suture knot. The Kaplan–Meier plot shows the cumulative survival for the group (Figure 1).

Figure 1
figure 1

Kaplan–Meier plot demonstrating cumulative survival for brow suspensions using 3-0 Prolene.

Full size image

Unfortunately, no randomized controlled trials have been undertaken to determine the optimal material for brow suspension surgery. We commend Garrott et al for publishing their long-term outcomes and agree that fascia lata brow suspension is not a prerequisite for successful, long-lasting brow suspension surgery in children. Indeed fascia lata use is not without its complications, at both the harvesting site2 and through proposed contracture of the fascia lata itself leading to variability in the cosmetic results.4 In addition, we suggest a Prolene sutured brow suspension can be used in a broader group of patients, to provide adults with ptosis and poor levator function, a cosmetically and functionally satisfactory result in the long-term. It is worth noting that we have performed this procedure under local anaesthesia in a small number of adults. It is an easily reversible and repeatable procedure.