Highlights
1. Evidence does not identify a clearly superior operation
In this American Academy of Ophthalmology assessment, frontalis flap, frontalis suspension, and maximal levator resection showed broadly overlapping rates of postoperative success, revision, and exposure-related complications in children with severe congenital ptosis.
2. Complication profile may be more clinically useful than nominal success rate
Because definitions of “success” varied substantially across studies and comparative evidence was sparse, the practical differentiator among procedures may be the type of complications each technique introduces rather than a demonstrated efficacy advantage.
3. Frontalis-based repairs carry unique risks
Frontalis suspension was associated with sling-specific problems such as infection, extrusion, and granuloma. Frontalis flap procedures carried the distinctive concern of lid displacement with supraduction, while all techniques shared some risk of postoperative exposure keratopathy.
4. Better comparative pediatric data are urgently needed
The literature remains limited by mostly level III evidence, heterogeneous populations, and inconsistent outcome reporting. Long-term, prospective, multi-institutional comparative studies are needed to guide procedure selection more reliably.
Proposed Article Structure
This topic is best understood through a clinically oriented structure: clinical background and disease burden; review methods and evidence base; procedure-specific findings; safety and complication patterns; interpretation for surgical decision-making; limitations of the evidence; and research priorities. That framework is used below.
Background: Why Severe Congenital Ptosis Matters
Severe congenital ptosis is more than a cosmetic eyelid abnormality. In children, marked upper eyelid droop can obstruct the visual axis, induce compensatory chin-up head posture, and contribute to amblyopia risk through deprivation, refractive error, or anisometropia. The condition is typically defined clinically by poor levator palpebrae superioris function, and in this review severe disease was defined as levator function of 4 mm or less.
The central therapeutic challenge is straightforward to state but difficult to solve: the surgeon must elevate the lid enough to clear the pupil and improve symmetry while avoiding lagophthalmos, corneal exposure, and poor blink protection. That balance is particularly delicate in young children, who may not reliably report symptoms and may have immature ocular surface defense mechanisms. In addition, congenital ptosis surgery often must account for unilateral versus bilateral disease, brow recruitment, Bell phenomenon, associated strabismus, and family expectations regarding cosmesis and reoperation.
Historically, three broad operative strategies dominate management of severe congenital ptosis: frontalis suspension, frontalis flap, and maximal levator resection. The biologic logic differs among them. Frontalis-based procedures recruit brow elevation to lift the eyelid when the native levator is very weak, whereas maximal levator resection attempts to extract the greatest possible functional effect from a poorly functioning but still present levator complex. Surgeons often have strong preferences, but robust comparative pediatric evidence has been limited.
Study Design and Methods
Review question
The American Academy of Ophthalmology report sought to review the literature on outcomes of severe congenital ptosis repair in the pediatric population and to assess the rates of exposure keratopathy and other complications.
Search strategy and eligibility
The literature search was conducted in PubMed and last updated in May 2025. Included studies were original English-language reports with detailed postoperative data on at least 25 eyelids undergoing a given repair technique for severe congenital ptosis, with a minimum of 6 months of follow-up. Severe congenital ptosis was defined as levator function of 4 mm or less.
The initial search yielded 209 citations. Thirty articles underwent full-text review, and 11 studies met inclusion criteria.
Evidence grading
Methodologic quality was assessed by the panel methodologist. Of the 11 included studies, 1 was rated level I, 1 level II, and 9 level III. This distribution immediately signals a key interpretive constraint: most of the evidence comes from nonrandomized or less rigorous designs.
Population and interventions
The studies covered a broad pediatric age range, from infancy through 16 years, although the mean age in the included cohorts generally fell within younger childhood, roughly 1 to 8 years. Surgical approaches included frontalis flap, frontalis suspension, and maximal levator resection.
Outcomes of interest
The main outcomes were postoperative success, revision surgery, and exposure keratopathy, along with other procedure-related complications. However, as the report emphasizes, outcome definitions varied across studies, limiting direct pooled interpretation.
Key Findings
Overall effectiveness: overlapping results rather than clear hierarchy
The principal finding is negative in the scientifically useful sense: the literature does not establish clear superiority of frontalis flap, frontalis suspension, or maximal levator resection for severe congenital ptosis in children. Across studies, reported success rates overlapped substantially among the three procedures.
This matters because surgeons and families often seek a single “best” operation for severe disease. The review suggests that such certainty is not currently supported by the evidence. Apparent differences in performance are difficult to interpret because studies used different thresholds for acceptable lid height, symmetry, contour, and need for secondary procedures. Some emphasized margin reflex distance, others a more global aesthetic or functional assessment, and not all studies incorporated the same follow-up duration.
Revision surgery: common enough to influence counseling
Revision surgery rates also overlapped across techniques. That finding is clinically important because congenital ptosis repair is not always a one-time intervention. As the child grows, facial proportions change, brow recruitment changes, and the relationship between lid position and ocular surface protection may shift. A procedure that initially appears successful may later require adjustment for undercorrection, contour abnormality, asymmetry, or exposure symptoms.
The report stops short of providing clear equivalency data, but it supports a practical counseling point: surgeons should prepare families for the realistic possibility of staged management or later revision regardless of the initial technique chosen.
Exposure keratopathy: shared concern across all procedures
Exposure keratopathy emerged as a cross-cutting complication rather than one limited to a single technique. This is expected biomechanically. Any operation that elevates the upper lid in a child with poor levator function risks increasing lagophthalmos and reducing blink-mediated corneal protection, particularly during sleep.
The review found substantial overlap in exposure-related outcomes among frontalis flap, frontalis suspension, and maximal levator resection. Again, interpretation is hindered by inconsistent reporting. Some studies documented frank exposure keratopathy, others noted lagophthalmos without corneal sequelae, and the severity spectrum was not uniformly categorized. Even so, the practical message is clear: ocular surface surveillance is essential after any severe congenital ptosis repair.
Frontalis suspension: broad use, broad reported efficacy range, unique device-related complications
Among the included literature, frontalis suspension studies showed the widest range of efficacy. The report notes that this may be influenced by the greater number of studies defining success for this technique rather than by true biological variability alone. Frontalis suspension has long been attractive in severe ptosis because it bypasses weak levator function by linking the tarsus or eyelid to the frontalis muscle, allowing brow elevation to assist lid opening.
Its unique liabilities are clinically familiar and were reinforced in this review: sling infection, extrusion, and granuloma. These complications are important because they are technique-specific and may necessitate further intervention, including removal or revision. Material choice, tissue handling, postoperative hygiene, and patient age may all influence these outcomes, but the review was not positioned to determine which technical modifications best reduce risk.
Frontalis flap: avoids implanted sling material but introduces dynamic lid-position issues
Frontalis flap techniques similarly rely on frontalis recruitment but differ from suspension approaches by using local tissue rather than a separate sling construct. In principle, this may reduce implant-related problems. However, the AAO review highlights a distinctive flap-related issue: lid displacement with supraduction.
That complication underscores the dynamic nature of this operation. The eyelid may behave differently in primary gaze versus upgaze, which can have cosmetic and possibly functional consequences. For some surgeons, that tradeoff may be acceptable in selected children, especially if avoiding foreign material is a priority. But families should understand that a technically successful elevation in primary gaze does not guarantee natural lid movement across all gaze positions.
Maximal levator resection: conceptually appealing, but not clearly safer or more effective
Maximal levator resection seeks to maximize the lifting effect of the native eyelid elevator apparatus, even when preoperative function is poor. Some surgeons favor it in unilateral disease because it may preserve more natural eyelid dynamics and avoid brow-dependent opening. Yet the review found that its success and exposure rates also overlap with those of frontalis-based procedures.
This is a useful reminder against overinterpreting theoretical advantages. In severe congenital ptosis, biomechanics are constrained by very poor muscle function. Aggressive resection can improve elevation, but it may also compromise eyelid closure and contour. As with the other procedures, the present evidence base does not demonstrate a decisive benefit that would make maximal levator resection the universal preferred approach.
Clinical Interpretation: How Should Surgeons Choose?
Because efficacy outcomes overlap and the evidence is heterogeneous, procedure selection in severe congenital ptosis should remain individualized. The AAO report supports a decision framework based less on presumed superiority and more on anatomy, surgeon expertise, and anticipated complications.
In children at high risk of amblyopia from visual axis obstruction, timely surgery remains the priority. In unilateral cases, cosmetic symmetry and dynamic eyelid behavior may carry greater weight. In bilateral cases, especially with absent or near-absent levator function, frontalis-based techniques may be more intuitive. But whichever route is chosen, the surgeon must balance lid height against corneal safety.
Ocular surface factors deserve special attention. Poor Bell phenomenon, reduced tear film resilience, or a history suggesting exposure vulnerability should push the surgical plan toward conservative elevation targets and closer postoperative monitoring. Parents should also be counseled that “more open” is not always “better” if it comes at the cost of corneal compromise.
Another practical implication is the importance of discussing technique-specific adverse events upfront. Families considering frontalis suspension should understand the possibility of sling-related inflammation, infection, extrusion, or granuloma. Those considering frontalis flap should understand the potential for abnormal lid movement, including displacement with upgaze. Families considering maximal levator resection should understand that use of the native levator does not eliminate the risks of undercorrection, asymmetry, lagophthalmos, or exposure.
Strengths and Limitations of the Evidence Base
Strengths
The report provides a rigorous and clinically relevant synthesis focused specifically on severe congenital ptosis in the pediatric population rather than ptosis surgery in general. Its minimum thresholds for eyelid number and follow-up enhance clinical usefulness, and its explicit attention to exposure keratopathy is particularly valuable because corneal safety is often underemphasized in cosmetically driven discussions.
Limitations
The evidence base remains thin. Only 11 studies were included, and 9 of those were level III. Definitions of success, revision, and exposure were variable. Age ranges, laterality, severity nuances, and technical details likely differed substantially. Follow-up duration may not have been sufficient in all studies to assess durability, late contour changes, or evolving need for reoperation as children grow.
The review also appears limited by the scarcity of direct head-to-head comparisons. Without robust comparative trials or well-adjusted multicenter observational cohorts, overlap in reported outcomes does not prove equivalence. It simply means superiority has not been convincingly demonstrated.
Another likely limitation is publication-era heterogeneity. Surgical materials, perioperative care, and operative refinements may differ across studies in ways that meaningfully affect outcomes. For frontalis suspension in particular, the type of sling material can influence both efficacy and adverse events, yet available studies may not permit clean comparisons.
Practice and Research Implications
For current practice, this review supports a personalized approach grounded in functional need, ocular surface risk, family priorities, and surgeon experience. It also argues for greater standardization in outcome reporting. Future studies should use consistent definitions for success, undercorrection, overcorrection, lagophthalmos, exposure keratopathy, and revision surgery. Reporting should ideally include both objective eyelid metrics and patient- or parent-centered outcomes.
The authors appropriately call for long-term, multi-institutional, comparative prospective studies. That recommendation is especially important in pediatric oculoplastics, where single-center retrospective series dominate and practice patterns vary widely. A well-designed prospective registry or pragmatic comparative study could capture durability, growth-related change, amblyopia outcomes, corneal morbidity, and reoperation burden more reliably than the current literature allows.
Several additional research questions follow naturally. Does unilateral versus bilateral disease modify the relative value of maximal levator resection compared with frontalis-based approaches? Which preoperative features best predict exposure risk? How much do sling material and fixation technique influence complications? Can standardized photographs and masked grading improve comparability across studies? These are answerable questions, but they will require collaboration across centers.
Funding and Trial Registration
This publication is an American Academy of Ophthalmology evidence review, not a registered interventional clinical trial. No ClinicalTrials.gov registration applies. The abstract notes that proprietary or commercial disclosures may be found after the references.
Conclusion
This AAO report offers a clinically useful but sobering message: in severe congenital ptosis repair, the pediatric literature does not support a single best operation. Frontalis flap, frontalis suspension, and maximal levator resection all appear capable of achieving useful lid elevation, but all also carry meaningful risks, including postoperative exposure. The more actionable distinction may be in the nature of complications rather than in reported success rates alone.
For now, surgical choice should be individualized, with careful attention to amblyopia risk, ocular surface protection, anatomic factors, and the adverse-event profile of each technique. For the field as a whole, the priority is clear: stronger comparative evidence, longer follow-up, and standardized pediatric outcome reporting are needed before confident procedure rankings can be made.
References
1. Dagi Glass LR, Aakalu VK, Grob SR, Liu CY, Vagefi MR, Yoon MK, Pineles SL, Wladis EJ. Severe Congenital Ptosis Repair: A Report by the American Academy of Ophthalmology. Ophthalmology. 2026-04-30. PMID: 42059847. Available at: https://pubmed.ncbi.nlm.nih.gov/42059847/
