Frontalis suspension with fascia lata for severe congenital blepharoptosis using enhanced involuntary reflex contraction of the frontalis muscle

Summary Increased stretching of the mechanoreceptors in Mueller's muscle induces involuntary reflex contraction of the ipsilateral frontalis muscle. We used this neurophysiological mechanism during surgery on 50 patients with severe unilateral or bilateral congenital blepharoptosis that does not have the levator muscle but has Mueller's muscle. To facilitate contraction of the superior rectus muscle to sufficiently stretch the mechanoreceptors in Mueller's muscle, transverse fibrous tissues that restrict the stretching are medially and laterally incised. Without fascial or muscular advancement, the fascia lata was grafted as far between the frontalis muscle and the tarsus as possible. After 15.5% postoperative shrinkage of the grafted fascia lata, all 50 patients involuntarily elevated their ptotic eyelids over the pupillary centre on primary gaze without severe lagophthalmos on eye closing. Forty-five patients could lift the upper eyelid over the pupillary centre even on upward gaze. Our procedure appeared to enhance the involuntary reflex contraction of the ipsilateral frontalis muscle, providing satisfactory dynamic retraction of the upper eyelid through fascia lata. We consider our procedure an alternative for reconstructing not only severe congenital blepharoptosis but also severe acquired blepharoptosis after orbital trauma or orbital tumour resection, in patients who do not have or lose the levator muscle while the Mueller's muscle, the superior rectus muscle and the trigeminal proprioceptive nerve function to induce involuntary reflex contraction of the frontalis muscle.