Correction of Congenital Ptosis by Suspension of the Frontalis Muscle Flap Overlapped with the Inferior-Based Orbital Septum Flap

Abstract

Congenital ptosis of the upper eyelid presents a challenging and complex medical problem in ocular plastic surgery. The type of procedure selected to correct congenital ptosis usually is determined by the amount of ptosis and the functional integrity of the levator muscle. Many patients, both pediatric and adult, with congenital ptosis will have depressed or poor levator muscle function. This presents inherent difficulty for the reliability and efficacy of standard procedures such as levator resection or muellerectomy. Left untreated, this condition can result in amblyopia (due to astigmatism or occlusion) and cosmetic concerns. The standard procedure for congenital ptosis with poor levator muscle function involves using frontalis suspension techniques to recruit frontalis muscle and surrounding tissues to aid in elevation of the eyelid. This procedure, although often successful, has many significant side effects or complications. These include morbidity of the donor site, use of foreign materials in suspension of the lid, lagophthalmos and less than natural appearance, and movement of the eyelid. This article represents a straightforward and local approach to this complex and difficult problem. The surgical approach used has the benefit of modifying an already well-established surgical procedure (frontalis suspension) while using the frontalis muscle itself and the orbital septum to provide elevation to the eyelid. The technique is totally local in nature and avoids the associated morbidity of second-site surgery to obtain donor tissue. The surgical technique also uses the patient’s own tissues and avoids problems associated with foreign bodies and grafted materials. Incorporating a blepharoplasty into the surgery improved the cosmetic effect. The article describes in detail the technical steps involved in the procedure and incorporates drawings to facilitate understanding of the technique. A good series of preand postoperative photos demonstrating results and improved cosmetic appearance are provided. The photos demonstrate good postoperative lid positions without the eyebrow strained into severe elevation. The connection of the frontalis flap and the orbital septum/levator can be adjusted to set the lid at the best possible position. Very few if any complications occurred, and the procedure seems to be generally safe and predictable. No patients experienced postoperative problems with keratitis or corneal exposure. It is important in the preoperative evaluation to assess the patient for tear production via a Schirmer’s test and for a Bell’s response. It is prudent to discuss with the patient preoperatively the possibility of corneal exposure/dry eye and to treat it as indicated. This series, although not a large, demonstrated good longevity of results and easy management of all complications. The problem of reduced eyelid excursion in up/ down gaze would be expected due to the fibrotic nature of the levator muscle in congenital ptosis. Further study of this disorder would involve use of the described procedure for pediatric patients because the most common age at pediatric repair is about 5 to 6 years. I believe this technique would be helpful for other ‘‘poor levator muscle function’’ types of ptosis including Marcus Gunn jaw winking syndrome, chronic progressive external ophthalmoplegia, double elevator palsy, and traumatic ptosis. M. N. Longo (&) Ophthalmic Plastic Surgeons of Texas, 7500 San Felipe #200, Houston, TX 77063, USA e-mail: mlongomd@pleasingtotheeye.com