Outcomes of Frontalis Advancement With or Without External Levator Advancement for Congenital Ptosis: A Retrospective Comparative Study.

Abstract

To compare outcomes of frontalis flap advancement alone versus frontalis flap advancement combined with external levator advancement (ELA) using a bilayer technique for congenital ptosis with poor levator function. Retrospective comparative clinical cohort study. Eyelids of patients with severe congenital ptosis with poor levator function who underwent either frontalis advancement flap alone or in combination with ELA were included. Exclusion criteria were noncongenital, neurogenic, traumatic, or aponeurotic ptosis. This study evaluated characteristics and postoperative outcomes of the above subjects, with emphasis on comparing outcomes between frontalis advancement alone or combined frontalis advancement with ELA using a bilayer technique. Statistical testing included paired and Students t-testing, chi-squared testing, and multivariate linear regression. The primary outcome was to change in marginal reflex distance-1 (MRD1). Secondary outcomes included change in lagophthalmos, eyelid symmetry, and adverse events. Ninety-two eyelids from 76 patients (mean age 6.9 ± 9.2 years) were included. Sixty-five eyelids underwent frontalis flap alone and 27 underwent frontalis flap + ELA. Both groups showed significant MRD1 improvement postoperatively (P < .001 for both) at mean follow-up of 12.0 months. The frontalis flap + ELA group had significantly greater postoperative MRD1 (3.9 ± 0.8 mm vs 3.2 ± 1.2 mm, P = .004) and change in MRD1 (3.4 ± 1.2 mm vs 2.5 ± 1.6 mm, P = .002). Lagophthalmos remained stable from baseline in both groups and did not significantly differ between groups. No patients in the frontalis flap + ELA group required revision, compared to 7.6% in the frontalis-alone group. All patients achieved visual axis clearance at most recent follow-up. Frontalis advancement flap, particularly when combined with ELA using a bilayer technique, is a safe and effective surgical strategy for congenital ptosis with poor levator function, providing excellent eyelid elevation that optimizes visual axis clearance without the need for synthetic or autologous suspension materials.