The results of frontalis suspension (double rhomboid technique with preserved homologous cadaver fascia) were compared in two surgical groups: 1) patients in whom the fascia was sutured to the tarsus and 2) patients in whom the fascia was not sutured to the tarsus. The study was performed to determine the optimum surgical technique and to determine whether preserved cadaver fascia is a suitable suspensory material. All data retrospectively reviewed included 1) predisposing cause of severe blepharoptosis, 2) results in the two groups of patients, suture fixation and nonsuture fixation, and 3) surgical complications. Of the 27 patients (36 eyelids), the fascia was sutured to the tarsus in 15 patients (20 eyelids) and not sutured to the tarsus in 12 patients (16 eyelids). In the suture fixation group, no undercorrections occurred, but four of 20 eyelids had lower than expected eyelid creases and six had residual dermatochalasis. Six patients had lagophthalmos with corneal exposure that required intense corneal lubrication, and three such patients required temporary tarsorrhaphy for 3 weeks. In the group without suture fixation, two patients had undercorrection (one with ocular cicatricial pemphigoid and the other with myotonic dystrophy). The mean followup period was 44 months. We conclude that preserved fascia provides excellent results with or without fixation of the fascia to the tarsus. In patients with suture fixation, the eyelid crease may form just above the point at which the fascia is sutured to tarsus and result in a low eyelid crease. Excision of excess skin should be considered at the time of frontalis suspension in selected patients in whom the fascia is fixated to the tarsus or who have preexisting dermatochalasis. Patients with suture fixation may have significant temporary postoperative lagophthalmos.