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Floppy Eyelid Syndrome: An Unfamiliar Entity for Plastic Surgeons

Lee, Chia-Chen, MD*; Lai, Hsin-Ti, MD; Kuo, Yur-Ren, MD, PhD, FACS; Lee, Su-Shin, MD, PhD; Lai, Chung-Sheng, MD, EMBA, PhD*†

doi: 10.1097/SAP.0000000000001311
Clinical Papers

Background Floppy eyelid syndrome (FES) is typically characterized by chronic eye irritation and an increased laxity of the upper eyelid that can be easily everted by applying minimal upward traction. However, it is a clinical entity that is less known to most plastic surgeons. Blepharoptosis is one of the most common features, which links to FES, for which a thorough differential diagnosis has become important in directing proper medical treatment.

Purpose This review aims to discuss current understanding about FES in a broader spectrum, encompassing the clinical features and evaluation of FES, the underlying etiologies, systemic associations, and surgical procedures for upper eyelid tightening.

Methods The literature search was conducted in Endnote interface using the keyword “floppy eyelid” through March 2017. All search abstracts were reviewed without language restriction. Citations of identifiable articles were also examined.

Results Despite the exact definition of FES remains ambiguous, patients with FES often demonstrate unresolvable blepharoptosis, dermatochalasis, eyelash ptosis, entropion, or ectropion of the lower eyelid. The pathological course of FES can be worrisome because it is often associated with both ocular and systemic morbidities, most notably papillary conjunctivitis, keratoconus, and obstructive sleep apnea (OSA). Decades of research into the pathogenesis has lent further recognition linking the eyelid floppiness with a loss of elastic fibers, an increased expression of matrix metalloproteinases, and possible collagen gene mutations. Surgery is usually prompted if conservative measures give limited responses. High surgical success rates with different follow-up time have been reported.

Conclusions For plastic surgeons, early recognition of FES is important because of its chronic, distressing course and the associated morbidities. We believe that surgical intervention is the most effective treatment of choice. The indication for embarking on surgery is based on the clinical severity of the condition. A variety of blepharoplasty techniques for FES have been proposed, including full-thickness wedge excision of the tarsus, medial and lateral canthal ligament ligation, conchal cartilage graft, lateral tarsal strip with flap, and lateral tarsorrhaphy. Most of the procedures have provided excellent visual and aesthetic outcomes; therefore, early surgical intervention is encouraged if early diagnosis can be made.

From the *School of Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University; and †Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.

Received October 17, 2017, and accepted for publication, after revision October 24, 2017.

Conflicts of interest and sources of funding: none declared.

Reprints: Chung-Sheng Lai, MD, EMBA, PhD, No. 100, Tzyou 1st Rd, Kaohsiung, 807, Taiwan. E-mail:

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