Direct frontalis flap with and without levator pulley for correction of severe ptosis with poor levator function in the same patient.

Purpose: To compare two techniques of frontalis muscle flap suspension in different eyelids of the same patient for correction of severe ptosis with minimal levator function.

Material And Methods: A prospective study of four patients with severe bilateral ptosis and poor levator function, who underwent direct frontalis muscle flap on the right eyelid and frontalis muscle flap with levator pulley on the left eyelid was conducted. Eyelid studies measurements were taken at baseline, 2 months, one year and 5 years after surgery. The presence of complications, flap function and palpebral contour were evaluated.

Results: Despite the surgical technique performed, good results in terms of functionality, contour and aesthetics were observed. In the eyes that underwent frontalis muscle flap (FMF)-direct, there were 2 cases with moderate anteriorization of eyelid margin in extreme upgaze and all patients showed eyelash ptosis that persisted one year after surgery, but improved after 5 years. In the eyes that underwent FMF-pulley, no upgaze anteriorization of eyelid margin was observed and three patients had eyelash ptosis of lesser extent than the fellow eye, improving after 1 year follow-up. FMF-pulley showed more long-term stability in eyelid height, compared with FMF-direct.

Conclusions: Frontalis muscle flap with a pulley in the levator aponeurosis prevents some complications caused by the excessive vertical component of the direct frontalis muscle flap, especially in deep-set eye patients, with better stability of the eyelid height and contour over time.