Surgical Management of Severe Congenital Ptosis: A Systematic Review.

OBJECTIVE

Severe congenital ptosis, primarily caused by levator palpebrae superioris (LPS) underdevelopment, may impair visual development and facial aesthetics. Although multiple surgical techniques exist, optimal procedure selection and long-term outcomes remain debated.

METHODS

A systematic review was conducted following PRISMA guidelines. The authors searched PubMed, ScienceDirect, and Google Scholar for English-language studies (2014-2024) on severe congenital ptosis (MRD1 <1 mm, LPS function ≤4 mm). Inclusion criteria encompassed primary surgical intervention, detailed technique description, and ≥6 months of follow-up. Studies of acquired ptosis or syndromic cases were excluded. Two reviewers independently performed screening, data extraction, and quality assessment.

RESULTS

Fourteen studies were included. Three core surgical approaches were identified: (1) frontalis suspension, (2) levator resection, and (3) conjoint fascial sheath-levator complex fixation (CFS+LM). Outcomes varied by patient age, LPS function, and anatomical maturity.

CONCLUSIONS

Surgical management of severe congenital ptosis should be individualized. Based on the evidence, a decision-making algorithm was developed incorporating patient age and LPS function. Frontalis suspension remains the preferred option for markedly impaired LPS function, whereas levator resection and CFS-based techniques are viable alternatives when anatomical conditions allow. Prospective studies with standardized outcome measures are needed to confirm long-term effectiveness.

LEVEL OF EVIDENCE: Level III.