Severe upper eyelid ptosis, defined as any type of ptosis associated with poor or absent levator palpebrae superioris muscle function, has been managed since the nineteenth century with a variety of different slings connecting the tarsal plate to the frontalis muscle (FM).1 , 2 The undisputed rationale of all types of brow suspension is based on the concept that slings are the best way to simultaneously suspend a ptotic eyelid and transmit the contractile action of the FM to its tarsal plate. However, since the early 80s, a significant number of consecutive articles have suggested that the eyelid can be effectively suspended by directly suturing the FM or the orbital portion of the orbicularis oculi muscle (OOM) to the tarsus.3 The aim of the present article is to review the literature of ptosis correction with frontalis–orbicularis muscle flaps to determine if the procedure is performed in a standard manner and if there is enough evidence to recommend FM advancement as a useful operation.
The authors searched the Medline, Lilacs, and Scopus databases for all articles in English, Spanish, and French that used as keywords the terms “frontalis muscle flap,” “ orbicularis muscle flap,” and “ptosis.” Some publications cited in the articles were also included even though they were not listed in the database searched. Data retrieved included authorship specialty, country where the surgeries were performed, number of patients and eyelids operated, characteristics of the ptosis included in the studies, type and dimensions of the flaps used, time of follow-up, rate of undercorrection, and complications.
Thirty-eight articles were found and included in this review.4–41 Seventy-one percent of this literature comes from China (11/28.9%),4 , 5 , 9 , 22 , 29 , 33 , 34 , 37–39 , 41 Taiwan (7/18.4%),12 , 15 , 16 , 24 , 26 , 30 , 36 and Korea (9/23.7%).6–8 , 14,18,21,25,28,32 Only 6 (15.8%) articles originated from 2 western countries: 3 (7.9%) from the United States10 , 11 , 17 and 3 (7.9%) from Spain.20 , 28 , 31 Other Oriental countries, such as Turkey,19 Pakistan,13 India,40 Thailand,25 and Iran,27 contributed one article each. All data from China and Korea were published by general plastic surgeons.
Depending on the planes of dissection and location of OOM incision, 2 basic flaps and their variants have been used to advance the FM. The first flap, designed by Song in 1982,4 was formed by the FM only. The author used an eyelid crease incision to expose the upper border of the tarsal plate and a second horizontal infrabrow incision to divide the transition between the OOM and the FM. The FM was then dissected subcutaneously in the cephalad direction and on a deep plane over the periosteum of the frontal bone, probably between the galea fat pad42 and the FM. Song used a large vertical incision of 30 to 35 mm placed on the medial aspect of the FM (lateral to the supraorbital nerve bundle) to mobilize the flap in an L shape configuration (Fig. 1A). The FM was then brought down under the OOM and sutured to the tarsal plate.
Following this first description, many surgeons5 , 6 , 8–11 , 13 , 14 , 17 , 20–22 , 27 , 29 , 31–35 , 38 , 39 used different variants of the original Song’s flap as follows: to improve the distribution of forces on the tarsal border, the FM flap was divided into 29 or 36 strips which were sutured separately on the tarsus, and several authors used only an eyelid crease incision to perform the whole procedure.5 , 7 , 9 , 11 , 12 , 14–17 , 19 , 20 , 24–27 , 30 , 31 , 33 , 34 , 36–39 The planes and the extent of FM dissection have also been modified. While the Song’s L-shaped flap was adopted by few authors,6 , 20 , 34 most mobilized the flap with 2 relaxing parallel vertical incisions placed laterally and medially (Fig. 1B)5 , 8–11 , 13 , 14 , 32 , 33 , 35 or even did not dissect the muscle.27 The length of the vertical incisions varied. Some surgeons incised the muscle up to the superior margin of the brow or the orbit (Fig. 1C),29 while others extended the incisions 5 to 20 mm beyond the superior orbital rim.9 , 10 , 22 The horizontal dimension of the flap is another parameter that has not been well described. In some articles, the width of the flap was not stated or was reported to be less than the eyelid width.
The integration of different portions of the OOM into the flap formed the second type of procedure described (Fig. 1D).7 , 8 , 12 , 14 , 15 , 19 , 24–26 , 30 , 36 The dimension of the OOM used varied from small strips of the orbital portion of the muscle8 to large segments of the preseptal OOM.7 , 12 , 15 , 16 , 24 , 25 , 36 In the latter modality, the authors believed that a dissected and shortened OOM sutured to the tarsus was sufficient to enhance the lift power of the FM, correcting eyelid ptosis. An interesting variant of the FM-OOM flap is shown in Figure 2. In the so-called double-breast technique, the supratarsal portion of the OOM is preserved and used to reinforce the flap.19 , 30
The orbital septum is another eyelid structure that has been managed in different ways during the different surgical procedures. Some surgeons preferred not to open it,5 , 8 , 9 while others incised the septum21 , 38 and removed some pre-aponeurotic fat.6 More importantly, some even used the septum to reinforce the muscle flap.7 , 22
To analyze the rate of undercorrection/complications, the authors tabulated only the studies where at least 10 patients were operated and monitored. Out of the 38 articles, 15 were excluded due to lack of postoperative information,4 , 23 small sample size,10–13 , 15,16,18–20,25,28,41 or simultaneous levator surgery.17
The data obtained from the 23 articles included and listed in Table are highly heterogeneous. Although most patients had congenital ptosis, a substantial number of cases were labeled as acquired without a clear definition of the etiology of ptosis. In 5 reports, the levator palpebrae superioris function was not measured, and eyelids with up to 8 mm of excursion were included. Pre- and postoperative margin reflex distances were quantified in only 9 articles. In the remaining 14 series, eyelid position was estimated relative to the upper limbus and postoperative symmetry.
Taking into account the variability of the surgical procedures performed, the heterogeneity of samples studied and the different methods of measurement of eyelid position, the rate of undercorrection ranged from 1.8%6 to 38 %,21 with a median value of 12.2%. Small rates of overcorrection ranging from 0.7% to 9.4% were noticed in only 6 series.6 , 21 , 32–34 , 38
The main complications reported with low rates of occurrence were eyelid crease abnormalities, hematoma, supraorbital nerve injury, and entropion/trichiasis.
Fergus is reported as the first to use in 1901 the FM to correct a single case of bilateral congenital ptosis.43 In his procedure, a large frontalis flap 50 mm in length was brought through a brow incision to the lower portion of the tarsus. His procedure was not well accepted until 1982 when Song described the L-shaped medial-based FM to lift ptotic eyelids.4
Since Song’s pioneer description, the use of FM flaps to correct severe ptosis4 has been extensively reported mainly by plastic surgeons from China, Taiwan, and Korea. Although we are not in a position to explain the lack of ophthalmologic literature on this procedure, this might reflect the preponderant involvement of general plastic surgeons in the management of ptosis in these oriental countries.
From a surgical point of view, the FM flap can be considered an autogenous frontalis suspension. The incorporation of different segments of OOM into the flap is justified by the well-known interdigitation between the FM and OOM described in classic texts of anatomy44 and emphasized in more recent work on the anatomy of the brow region.42 , 45 We believe that several surgeons who described their technique as FM advancement were in fact also using parts of the orbital portion of the OOM. Technically, the dissection of the OOM in the cephalad direction up to the superior orbital rim is straightforward. Through an eyelid crease incision, the OOM is easily separated from the septum. Alternatively, the septum can be opened allowing a fast and bloodless postseptal dissection to the superior orbital rim. If the OOM is used as an extension of the flap, the OOM also needs to be dissected on the subcutaneous plane with care taken not to perforate the delicate preseptal skin of the eyelid, a minor complication reported in some articles.24 , 26 Maximal preservation of the preseptal portion of the OOM using a segment of the supratarsal OOM to reinforce the FM-OOM flap (double-breast technique) and to minimize the occurrence of lagophthalmos is an interesting modification first proposed by Borman and Maral19 and used with success by Lai.30
The dissection of the brow area is more challenging. To reach the FM, the dissection plane needs to change. The OOM is transected at the level of the superior orbital rim and a biplanar dissection is then performed in the subcutaneous and subgaleal planes. Bleeding can arise from damage to the transverse supraorbital vein that passes at the level of or above the superior orbital rim46 or from the rich vascular plexus of the subcutaneous plane. As noticed by Li,37 transillumination with a surgical headlight is helpful to maintain a correct subcutaneous plane in the frontal area.
The way the FM is mobilized is a critical parameter in this procedure. Song did not report any postoperative data, but he was very careful when dissecting the FM and avoided any lateral vertical incision on the FM. The reason for the L-shaped design of his flap is self-explanatory because it is well know that the motor innervation of the FM is laterally based. Although the course of the fronto-temporal branch of the facial nerve on the temporal fossa has been well described,47 , 48 less attention has been given to the lowest point where the terminal branches of the fronto-temporal nerve reach the FM. According to Zhang, the mean lowest point of the fronto-temporal nerve entering the FM is 7.6 mm ± 1.5 SD from the supraorbital margin.49 These data indicate that vertical lateral incisions beyond the supraorbital margin carry a high risk of FM denervation and should be avoided during direct FM advancement. This critical point was not observed in the only 2 early studies published in the United States10 , 11 and might explain the disappearance of the procedure from the American literature.
The lack of homogeneity of the operated patients and variability of the procedures performed are other points that deserve to be addressed. In most studies, ptosis is reported to be severe. However, some series include patients with moderate levels of levator palpebrae superioris function between 6 mm and 8 mm.6 , 9 , 14 , 24 , 29 As noticed by Sira et al., some of these patients could have benefited from alternative procedures of ptosis correction.50 Another difficulty in analyzing the results pooled from the articles listed in Table is related to the diversity of flap design used, especially regarding the use of the OOM as an extension of the FM. Some authors believe that as the orbital portion of the OOM and the FM interdigitates at the superior orbital rim, a rectangular segment of the preseptal OOM would work as a dynamic extension of the FM.26 Others, on the contrary, suture the FM directly to the tarsal plate without interposing any tissue between the FM edge and the superior border of the tarsal plate.27
Despite the lack of homogeneity of the samples operated and the multiple variants of the procedures, all surgeons who tried the surgery reported positive results with few complications. These surgeons believe that FM muscle advancement has fewer complications than traditional frontalis slings even though there are no comparative studies on these 2 techniques. Undercorrection was the most common complication, with a median value of 12.2%. The wide range of reported undercorrection and lack of standardization of the surgery makes it difficult to associate this complication with a specific surgical variant, especially if the ethnic context of the patients is considered. As mentioned before, most data involve oriental patients. Taking into account that the margin reflex distances of white Americans is at least 1 mm higher than that of Asians,51 the level of undercorrection of the surgery might be higher in western countries than in Asia.
Another postoperative event that is specifically mentioned in several articles8 , 30 , 33 , 35 is hematoma formation. Although the authors state that subcutaneous dissection over the FM is the main factor for early hematomas and some even use a drain in this region during the immediate postoperative period,35 we believe that blunt dissection in the subgaleal plane may be also a source of bleeding resulting from supraorbital vein lesion.
We believe that the FM advancement is a technique that deserves to be compared with conventional sling procedures. Well-controlled comparative studies with western patients are still lacking.
The authors sincerely thank Dr. Ivana Cardoso Pereira for her kind assistance in literature searching.
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