Oral abstract presentation times

Purpose

To propose an anatomy-based intraoperative algorithm for surgical management of severe simple congenital ptosis with poor levator function.

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Methods

A focused review of current levator-based surgical techniques and intraoperative anatomical findings in severe congenital ptosis was performed. Based on cumulative surgical observations, a practical intraoperative algorithm was developed emphasizing real-time assessment of the levator palpebrae superioris (LPS) complex.

Following skin–orbicularis dissection, septal debulking and selective fibrosis release are performed to improve eyelid elasticity and levator mobility. Surgical strategy is subsequently guided by intraoperative levator morphology:

Preserved healthy orbital levator tissue (>50%) → direct orbital levator advancement to the tarsus.
Predominantly fatty anterior levator with preserved posterior tissue → posterior levator advancement following release of the levator-Müller complex and excision of dystrophic tissue.
Diffuse fatty degeneration or severely attenuated levator tissue → combined procedures incorporating levator resection with adjunctive techniques including conjoint fascial sheath suspension, frontalis muscle flap advancement, or tarso-conjunctival Müllerectomy.

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Results

Severe congenital ptosis demonstrates marked intraoperative variability in levator morphology that is frequently underestimated by preoperative levator function measurements alone. Direct intraoperative assessment permits identification of residual functional levator tissue and allows individualized selection of levator-based or combined procedures. Technical refinements including fibrosis release, orbital muscle recruitment, and adjunctive elevator support may improve force transmission, preserve eyelid elasticity, and reduce postoperative lagophthalmos and recurrence.

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Conclusion

Rigid preoperative formulas may inadequately reflect true levator viability in severe congenital ptosis. The proposed intraoperative algorithm provides a structured anatomy-based framework for surgical decision-making, improving procedural selection and potentially enhancing predictability and physiologic eyelid function.

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Additional Authors

First name	Last name	Base Hospital / Institution
Richard	Allen	Baylor College of Medicine, Houston, Texas, U.S.A.

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