Entropion as a complication of the frontalis muscle flap direct advancement

Purpose The use of the frontalis muscle in a direct attachment is an alternative to the traditional techniques of frontalis muscle flap advancement. This new variant, which is considered the most physiological, shows better functional results, but it may associate entropion as adverse effect. Methods Through a unique incision on the eyelid crease or making another incision on the superciliar area, a flap of frontalis muscle is created and attached to the tarsal plate with a non-resorbable suture. It is important to attach the flap to the upper third of the tarsal plate for a correct elevation of the eyelid. A lower union otherwise could create long term complications principally residuary progressive entropion, which until now was only seen after traditional techniques of aponeurosis reinsertion of elevator muscle. We present two case reports showing severe ptosis after frontalis muscle flap direct suspension in which a medium third of the tarsal plate union was performed. Results Both patients showed progressive entropion which needed correction through surgery. Conclusion To prevent entropion in the frontalis muscle flap direct advancement, the muscle flap should be attached to the upper third of the tarsal plate, which allows physiological distribution of the tractional force in spite of maintaining the vertical vector, preventing the eyelid margin inversion.