Frontalis muscle flap advancement with a pulley in the levator aponeurosis in patients with complete ptosis and deep-set eyes

PURPOSE: To offer an alternative to frontalis sling techniques to achieve a more horizontal traction vector force with the frontalis muscle flap. The proposed technique avoids malpositions such as pulling the upper eyelid in an anterior plane during maximum opening and ptosis of the eyelashes. METHODS: The technique, performed in 5 patients with complete unilateral ptosis and an absence of levator function, consisted of advancing a flap of frontalis muscle and creating a pulley with the aponeurosis of the levator muscle. Mean follow-up was 12 months. RESULTS: Ptosis was corrected in all 5 patients, with good aesthetic outcome. There were no cases of anterior eyelid advancement, entropion, or eyelash ptosis. The only complication was 1 case of lagophthalmos with corneal erosion. CONCLUSIONS: In this preliminary series, the technique was safe and effective for correcting severe blepharoptosis, with good aesthetic and functional results even in patients with deep-set eyes and without the eyelid malpositions that commonly occur in frontalis sling techniques.