Improved Eyelid Muscle Tension Balance With Refined Frontalis Muscle Flap Suspension in the Treatment of Severe Ptosis

Background: The tension balance of the upper eyelid following ptosis repair is crucial to a successful postoperative outcome. To improve on existing surgical techniques, the authors developed a new refined frontalis muscle flap suspension (FMFS) for severe ptosis repair and explored the balancing effect between the orbicularis muscle and frontalis muscle following surgery. Methods: Forty-three patients (47 eyes) with a mean age of 6.07 +/- 2.55 years old were diagnosed with severe congenital ptosis and underwent refined FMFS with complete orbicularis preservation between January 1, 2010 and December 31, 2017 in the Wenzhou Eye Hospital, Wenzhou, China. The outcomes measured include upper eyelid margin reflex distance (MRD1), degree of lagophthalmos, and cosmetic outcome (lash angle, eyelid contour, and crease). Surgical complications were also recorded. Results: The preoperative mean M RDI was -1.29 +/- 0.88 mm and preoperative levator function was 1.87 +/- 0.82mm (ranged from 0 to 3.0mm). Following surgery, lagophthalmos was observed in all cases in the first week with a mean palpebral fissure height of 1.68 +/- 0.40 mm and diminished over 3 months. The MRD1 improved to 13.04 +/- 0.68mm at 6 months following surgery. All cases showed excellent cosmetic outcomes. There were no significant complications. Conclusion: The refined FMFS is a safe and reliable surgery in treating severe ptosis. The eye-closing power of the intact orbicularis muscle is sufficient at countering the lifting power of the frontalis muscle suspension, achieving a balanced blink mechanism and eyelid closure.