The refined frontalis muscle flap suspension (FMFS) yields excellent cosmetic outcomes in patients with severe ptosis, according to a study published in Ophthalmic Plastic and Reconstructive Surgery

The tension balance of the upper eyelid after ptosis treatment is critical to ensure a successful postoperative outcome, researchers report. To improve on existing surgical treatment, they developed a new and refined FMFS technique for severe ptosis repair

In total, 47 eyes of 43 patients with severe congenital ptosis (mean age 6.07±2.55 years, age range 2 to 13 years) were included in the study. Between January 1, 2010 and December 31, 2017, all patients underwent refined FMFS with complete orbicularis preservation at the Wenzhou Eye Hospital, in China.

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The investigators noted that the preoperative mean margin reflex distance (MRD1) was -1.29±0.88 mm and the preoperative levator function was 1.87±0.82 mm (range 0 to 3.0 mm). After surgery, lagophthalmos was observed in all cases during the first week with a mean palpebral fissure height of 1.68±0.40 mm, but diminished within 3 months. At 6 months following surgery, the MRD1 improved and maintained at +3.04±0.68 mm. 

Cosmetic results were graded as excellent with regard to MRD1, eyelid contour, eyelid crease, and eyelash angle at various postoperative evaluation intervals. No significant complications were reported. 

FMFS is not appropriate for patients with impaired frontalis function, which includes frontalis muscle dysplasia, trauma, or neurological paralysis, the investigators emphasize. They also assert that a patient should have good Bell’s reflex before surgery to ensure adequate cornea protection. Following surgery, there may be a residual hang-up eyelid on down gaze, and clinicians should inform parents about this and manage their expectations, according to the research. Overall, the study recommends guidance from a skillful surgeon.

“In particular, when it comes to frontalis muscle flap creation it is crucial to ensure adequate identification, exposure, separation and fixation of the flap,” the study says. “Improper operation could lead to tissue damage and frontal hematoma.”


Zhu X, Ma Y, Woo DM, et al. Improved eyelid muscle tension balance with refined frontalis muscle flap suspension in the treatment of severe ptosis. Ophthalmic Plast Reconstr Surg. 2021;37(6):534-540. doi:10.1097/IOP.0000000000001933