Frontalis-Orbicularis Muscle Advancement for Correction of Upper Eyelid Ptosis: A Systematic Literature Review

Purpose: To review the level of standardization of frontalis-orbicularis muscle advancement to correct severe blepharoptosis and the degree of scientific evidence supporting the procedure as a useful modality of blepharoptosis repair. Methods: 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. Data retrieved included authorship specialty, geographic region where the surgeries were performed, characteristics of the samples reported, type and dimensions of the flaps used, time of follow-up, rate of undercorrection, and complications. Results: Thirty-eight articles were retrieved and analyzed. Most studies originated from Asian countries, especially China, Taiwan, and Korea. Many variations of the procedure were encountered, including location of incisions and frontalis flap design. There were 23 case series with more than 10 patients. None compared the procedure to conventional frontalis suspension surgery. The samples were not homogeneous, including patients with different type of ptosis, variable degrees of levator function, and using distinct methods of evaluating eyelid position. Undercorrection rates ranged from 1.8% to 38% with a median value of 12.2%. The rate of complications (eyelid crease abnormalities, entropion, hematoma, and supraorbital nerve injury) was low. Conclusions: The direct frontalis-orbicularis muscle advancement has been judged positively in all reports analyzed. However, the level of standardization of the surgery is low, and the reported series are not homogeneous. Further studies are needed to better evaluate this operation.