Outcomes and complications of frontalis flap versus frontalis sling surgery in congenital ptosis: a systematic review and meta-analysis.

BACKGROUND: To systematically compare the outcomes and complications of flap advancement, silicone rod, and autologous fascial suspension techniques in the surgical management of congenital ptosis. METHODS: A meta-analysis was performed in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. MEDLINE, Embase, and PubMed were searched without language or date restrictions. Included studies involved patients with congenital ptosis who underwent frontalis suspension using flap advancement (frontalis or orbicularis), silicone rods, or autologous fascia lata. Primary outcomes included postoperative margin reflex distance 1, undercorrection, overcorrection, and recurrence. Secondary outcomes included eyelid- and cornea-related complications. Risk of bias was assessed with the Cochrane Risk of Bias Tool for randomized controlled trials and the Risk Of Bias In Non-randomized Studies of Interventions tool for nonrandomized studies. A proportion meta-analysis was conducted for each outcome. RESULTS: Forty studies were included. There were no statistically significant differences between the 3 groups in undercorrection, overcorrection, or total complication rates. Recurrence was significantly greater in the silicone group (7%) compared with the flap and fascial group. Flap advancement techniques had greater postoperative margin reflex distance. CONCLUSIONS: Most of the case series were of good quality, whereas nonrandomized studies generally had a moderate risk of bias. Most randomized controlled trials had a moderate risk of bias. Flap advancement, silicone rod, and fascial suspension techniques demonstrate comparable rates of correction and complications in the treatment of congenital ptosis. Recurrence was more frequent in the silicone group. These findings show flap advancement as a promising and effective alternative. Standardized, long-term comparative studies are needed to refine technique selection and outcome reporting.