Frontalis Muscle Flap Suspension for Severe Senile Ptosis: Key Considerations and Surgical Techniques

Frontalis muscle flap suspension (FMFS) is a well-established surgical option for severe ptosis in patients with poor levator muscle function. Although its efficacy has been widely reported in congenital ptosis, the application of FMFS in elderly patients remains insufficiently addressed. Age-related anatomic and physiological changes, including chronic frontalis muscle hyperactivity, reduced tissue elasticity, and decreased ocular surface tolerance, may increase the risk of postoperative complications in this population. This retrospective case series presents 3 elderly male patients (aged 83-87 y) with severe ptosis and poor or absent levator function who underwent FMFS. Preoperative evaluation emphasized frontalis muscle activity, eyelid skin redundancy, brow-to-lid distance, and baseline ocular surface tolerance. Technical considerations included conservative skin excision, preservation of the palpebral orbicularis oculi muscle, avoidance of overcorrection, and flexible modification of flap design and fixation. All patients demonstrated improvement in upper eyelid position and functional visual field. Two patients achieved stable correction without clinically significant lagophthalmos, ectropion, or ocular surface complications. One patient with a severe sunken upper eyelid and a long brow-to-lid distance developed early postoperative overcorrection and lagophthalmos, which were successfully managed with revision surgery using an inferiorly based orbital septal flap. These cases highlight that FMFS can be safely and effectively applied in elderly patients with severe ptosis when age-specific anatomic and functional factors are carefully considered. Meticulous surgical planning and individualized technical adjustments are essential to minimize complications and achieve stable outcomes in this challenging patient population.