Combined Levator, Frontalis Muscle Advancement Effective for Treating Recurrent Severe Ptosis

Droopy eyelid. 35-year-old man with ptosis (droopy eyelid) of the right eye due to sarcoidosis. Also known as Boeck’s disease, sarcoidosis is a chronic inflammation of the lymph nodes or organs. It causes multiple granulomas (nodular growths) in the affected tissues. The most commonly affected organs are the eyes, lungs and skin. The disease has no known cause and spontaneously clears after a few years. Ptosis can be corrected by surgery.
Investigators report that the method yields pleasing cosmetic outcomes and minimal complications in patients with recurrent severe congenital ptosis.

Combining levator resection and frontalis muscle advancement is effective for treating patients with poor function from recurrent congenital ptosis, according to a case series published in Eye.

Between 2017 and 2020, researchers performed a retrospective review of patients who underwent combined levator resection and frontalis muscle advancement for recurrent congenital ptosis. The inclusion criteria consisted of levator function of 4 mm or less and margin reflex distance 1 (MRD1) of 0 mm or less. The main study outcome measures were postoperative MRD 1, lagophthalmos, lash angle, grades of eyelid contour and crease. The study outcomes were evaluated by reviewing medical charts and photographs. A single surgeon performed all surgeries.   

A total of 35 eyelids from 31 patients (mean age: 9.23±5.76 years, age range: 2 to 23 years, 17 women, 14 men) fulfilled the inclusion criteria. The mean follow-up period was 27.32 months (SD: 11.23, range: 14–52 months). The mean preoperative MRD1 in the surgical eyelids was -1.14±1.56 mm, and the mean preoperative levator function was 1.87±1.37 mm, according to the study. All patients experienced improvement in MRD1 after surgery, with an average MRD1 at the last follow-up of 3.93±0.52 mm.

The researchers observed lagophthalmos in all patients postoperatively. However, lagophthalmos gradually decreased with time, with an average of 0.91±0.74 mm at the last follow-up. At the final follow-up, 91.4% of eyelids showed excellent eyelid contour, crease, and eyelash angle. Only 1 eyelid required revision surgery. No other significant complications were reported. 

“Direct frontalis flap advancement is reliable for the treatment of recurrent severe ptosis,” the researchers report. “Adjuvant levator muscle advancement appears to maximize functional and cosmetic outcomes. It helps prevent eyelid malpositions associated with frontalis flap advancement, including eyelash inversion, entropion, and eyelid popping.”

Study limitations include its retrospective design and the small sample size of patients. 


Diab MMM, Abd-Elaziz K, Allen RC. Combined levator and frontalis muscle advancement flaps for recurrent severe congenital ptosis. Eye. Published online April 25, 2022. doi:10.1038/s41433-022-02071-w