Maximal levator resection as a revision strategy following failed silicone frontalis sling: outcomes on eyelid position, ocular surface and patient satisfaction

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Abstract
Frontalis sling surgery (FSS) is the standard treatment for congenital blepharoptosis with poor levator function; however, long-term failure and material-related complications are common, particularly with silicone slings. Evidence regarding optimal revision strategies after failed silicone FSS remains limited. This study evaluated the anatomical outcomes, ocular surface safety, and patient satisfaction following maximal levator resection surgery (MLRS) performed after silicone frontalis sling removal. This retrospective study included 20 eyes of 17 patients who underwent MLRS following silicone frontalis sling removal between 2019 and 2023. Preoperative and postoperative assessments included best-corrected visual acuity, margin reflex distance-1 (MRD-1), levator function, lagophthalmos, corneal fluorescein staining, punctate epithelial keratopathy, and patient satisfaction. Postoperative evaluations were performed at 1 week, 1 month, 3 months, and 6 months. Statistical analyses were conducted using paired and repeated-measures tests, with a significance level set at p < 0.05. The mean age at the time of MLRS was 11.05 ± 5.94 years, and the mean preoperative levator function was 4.85 ± 2.49 mm. Revision surgery was indicated for undercorrection in 18 eyes (90%) and conjunctival complications in 2 eyes (10%). Mean MRD-1 increased significantly from 0.25 ± 0.85 mm preoperatively to 2.55 ± 0.60 mm at 6 months postoperatively (p < 0.001), with stable values across follow-up visits. Lagophthalmos increased slightly postoperatively but did not differ significantly from preoperative measurements (p > 0.05). Mild corneal surface changes were observed in the early postoperative period and were successfully managed with medical treatment. Additional revision surgery was required in 2 eyes (10%). Most patients and their parents reported high satisfaction, with dissatisfaction primarily related to insufficient postoperative eyelid elevation. MLRS following silicone frontalis sling removal is associated with significant and stable improvement in eyelid position, with acceptable ocular surface safety and high patient satisfaction in selected patients across a range of levator function values. However, given the retrospective design, small sample size, and lack of a comparative control group, these findings should be interpreted with caution. MLRS may be considered as a potential revision option rather than a definitive or superior approach.

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