Minimal Dissection Direct Frontalis Muscle Advancement Flap for Congenital Ptosis Repair

Abstract

Background: Frontalis flap advancement is an alternative means of congenital ptosis repair from frontalis suspension utilizing autologous fascia or allogenic implants. Variations in technique, including flap division, location and number of skin incisions, and dissection planes, are described in the literature. Materials and Methods: A retrospective case series of patients with congenital myogenic ptosis treated with simplified, minimal dissection frontalis flap advancement involving a single upper eyelid crease incision with dissection in the preseptal and subcutaneous planes without division to mobilize the frontalis flap. Inclusion criteria: pediatric patients age < 18 years with either primary or recurrent congenital ptosis following previous surgical repair. Exclusion criteria: ptosis of neurogenic etiology or postoperative follow-up < 3 months. Primary outcome measures were postoperative margin-reflex distance 1 (MRD1), the difference in MRD1 between surgical and nonsurgical eyelids in unilateral ptosis, and lagophthalmos. Secondary outcome measures included recurrence and complications. Results: Twenty-six patients met inclusion criteria, 24 males and 2 females. Mean postoperative MRD1 at last follow-up was 2.9 AE 1.2 mm and the mean difference in MRD1 between surgical and nonsurgical eyelids at last follow-up was 1.1 AE 1.0 mm. Average lagophthalmos at postoperative month 2 to 5 was 0.6 AE 0.7 mm. One patient demonstrated postoperative lid retraction that required re-operation. Four of 31 eyelids (12.9%) demonstrated ptosis recurrence at 5, 12, or 24 months.Conclusions: In this retrospective series, the authors report clinically and statistically significant surgical eyelid height improvement and symmetry between nonsurgical and surgical eyelids in congenital ptosis patients treated with minimal dissection direct frontalis flap advancement.

“Extended Frontalis Muscle Advancement Technique for Severe Congenital Blepharoptosis”

“…Plastic and Reconstructive Surgery • November 2023 886e the original eyelid crease and infrabrow double incisions, [6][7][8][9][10][11] the eyelid crease single-incision has become the most popular incision design over the past decade because of fewer scars. [12][13][14][15][16][17][18][19] However, the conventional frontalis muscle advancement technique still has some disadvantages, such as residual lagophthalmos (RL); eyebrow ptosis; eyelid contour abnormality; and especially, undercorrection, with a median value of 12.2%. 3,[10][11][12][13][14] Insufficient separation leads to poor flap mobility, which may be the main reason of RL, eyebrow ptosis (Fig.…”

“…3,10 The subcutaneous separation range of the conventional frontalis muscle flap is usually limited and does not exceed 1 cm above the superior margin of the eyebrow because of the limited visualization and uncertainty with the surgical anatomy of the forehead, as seen through the eyelid crease incision. [13][14][15][16][17][18][19] Recent understanding of the forehead anatomy, in particular, the description of the forehead compartments, 20 has provided the knowledge to harvest extended frontalis muscle flap with more certainty, safety, and predictability through the eyelid crease incision. The superficial forehead compartments are located in the subcutaneous fat layer of the forehead.…”

Severe unilateral congenital ptosis with poor levator function: tarsoconjunctival mullerectomy plus levator resection vs frontalis sling procedure

“…Severe and moderate PEEs were not found in any patient. Lagophthalmos ≥ 1 mm was more common in the TCMLR group in all three follow-ups, but the difference was not statistically significant [12,12,13 cases in TCMLR group and 11, 12, 11 cases in frontalis sling group in 1, 3, 6mo followups respectively (P=1)]. Furthermore, the lid lag > 3 mm was statistically similar in both groups [19,19,19 cases in TCMLR group and 21, 22, 22 cases in frontalis sling group in 1, 3, 6mo follow-ups respectively (P=1)].…”

“…S evere unilateral congenital ptosis with poor levator function (LF) is the most challenging category of congenital ptosis varieties [1][2] . Frontalis sling is the choice procedure for congenital ptosis with poor LF, which could be performed by different materials such as silicone rod, sutures, frontalis muscle flap, temporalis fascia, fascia lata and etc [1,[3][4][5][6][7][8][9][10][11][12][13][14][15] . Although unilateral ptosis frontalis sling surgery does not achieve perfect eyelid function and cosmetic appearance as well as bilateral ones [3] .…”

Application of e-PTFE Frontalis Suspension in the Treatment of Congenital Ptosis in Children

“…This result also showed that there was no significant difference between the two groups in comparing the cosmetic results at 1, 6 and 12 months after surgery. This may be due to the fact that the clinical use of the frontalis muscle flap for suspension has good elasticity, high muscle strength, and the operator can adjust the lid curvature according to the actual situation of the child, As a result, the double eyelid curvature after surgery is well formed, the appearance is natural, and the effect is lasting ( 22 – 24 ); Instead, the e-PTFE frontalis suspension surgery uses individualized double eyelid surgery, the surgeon tried to bury the e-PTFE material under the muscle as much as possible during the operation, and the broken end of the material is directly sewn with sutures firmly to increase the flatness, in addition, e-PTFE has excellent biocompatibility and extensibility, stable chemical properties, slow degradation rate, and long retention time, which is conducive to maximizing the postoperative aesthetic effect and long-term maintenance of children.…”