The best suspensory material is autogenous fascia lata harvested from the thigh. Children under four years are generally too small to enable autogenous fascia lata to be used. Other autogenous materials include palmaris longus tendon and temporalis fascia. Non-autogenous materials are plentiful and all have the advantage of being easily available but their long term success rate is not as good as with autogenous fascia lata. Some non-autogenous materials include stored fascia (irradiated or lyophilised), Prolene, Supramid

(polyfilament cable-type suture), Mersilene mesh, silicone cords (adjustable immediately post operatively when secured with a Watske sleeve), Gore-Tex (polytetrafluoroethylene, PTFE) and ePTFE (expanded PTFE).

Autogenous suspensory material is generally arranged as a double triangle (Crawford method - Figure 5.8a) thought to give a good lid contour whereas non-autogenous material is inserted as a pentagon (Fox method - Figure 5.8b) where less material is used and any subsequent Crawford brow suspension can be performed through uninvolved tissues. Brow suspension will only be effective if the patient uses frontalis muscle post operatively. If the ptosis is unilateral, some surgeons advocate division of the normal levator and bilateral brow suspension to gain greater symmetry. The options need to be discussed carefully with patients and their parents.

Levator transposition procedure - several surgeons advocate using the levator muscle itself as the suspensory material thus transposing the divided end of the muscle into the brow, eliminating the need for alternative suspensory material. In certain patients, neurotisation of the levator muscle from frontalis results in some post operative gain in levator function.

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