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This is a review of 43 patients (47 eyes) with severe congenital ptosis who underwent a suspension procedure using a frontalis flap technique. The average age of patients was 6 +/-2.5 years, and all had a severe ptosis with an average upper lid margin reflex distance (MRD1) of -1.3 +/-0.9mm and a levator function of 3mm or less. All patients had a positive Bell’s phenomenon. The surgery was performed via an upper lid skin crease incision to expose the tarsal plate and then a plane dissected superiorly between the septum and orbicularis to the orbital rim, and then further up subcutaneously beyond the orbicularis on the surface of the frontalis. A deeper plane between the frontalis and the pericranium was also dissected, followed by wide undermining to allow frontalis to be mobilised. Once freed, the edge of the frontalis was brought down and sutured to the tarsal plate, aiming to lift the lid margin to 1mm below the limbus. Postoperatively the mean MRD1 improved to 3.0 +/-0.7mm, with only one patient having a significant overcorrection with 3.5mm of lagophthalmos. All cases had some initial lagophthalmos but this diminished to a mean of less than 1.5mm within a month of surgery. None had exposure keratitis. The authors achieved good results with their technique, and relate this to the more natural dynamic characteristics of the frontalis muscle compared with fascia lata or alloplastic materials. They stress the importance of wide undermining to free up the frontalis flap, and preservation of orbicularis during dissection.

Improved eyelid muscle tension balance with refined frontalis muscle flap suspension in the treatment of severe ptosis.
Zhu X, Ma Y, Woo DM, et al.
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James Hsuan

Aintree University Hospital, Liverpool, UK.

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