Blepharoptosis repair

What it treats

• Acquired ptosis is the most common form of ptosis; the drooping lid can affect appearance and vision and lower quality of life (PMID 33927356).
• In involutional ptosis the levator muscle works but its tendon (aponeurosis) shows dehiscence or disinsertion; lids with 8 mm or more of levator excursion suit aponeurotic repair (PMID 1156224).
• Facial rejuvenation patients, 59 consecutive: 57.6% had ptosis (lid margin more than 1.0 mm over the upper limbus); patients with ptosis were older and more often male (PMID 32356151).
• Forehead lines, 160 patients over 50: ptosis in 90% of those with horizontal forehead lines against 76.67% without; all 28 with lines on one side had ptosis on that side (PMID 30030561).
• Surgeon survey: mild to moderate ptosis and different upper lid aging patterns are underrecognized among blepharoplasty patients (PMID 33346340).
• 278 patients presenting for dermatochalasis: up to 21% needed ptosis correction with the blepharoplasty (PMID 38315110).
• One surgeon's 1,923 upper eyelid rejuvenation patients: ptosis correction 55%, blepharoplasty 45% (PMID 41663769).
• Dermatochalasis and ptosis need separate evaluation in the same patient (PMID 3045728).
• Contact lens-related ptosis, 20 patients (mean 20.6 years of wear): Müller muscle surgery succeeded in 93.5% of eyelids (PMID 25906332).
• Ptosis can follow cosmetic blepharoplasty: in 48 such lids the levator aponeurosis was disinserted and bound in septal scar (PMID 31802837).

How it is done

External levator advancement (front approach)

• Jones and colleagues sutured the upper aponeurosis to the lower aponeurosis through a lid crease incision 7 mm above the lashes, 57 eyelids in 34 patients (PMID 1156224).
• Anderson's aponeurotic surgery preserved Müller's muscle and Whitnall's ligament and required overcorrection at surgery, 60 eyelids followed at least 1 year (PMID 375893).
• Fixation measured from the levator musculoaponeurotic junction, 154 eyelids: the formula predicted the exact fixation point in 63% and within 1 mm in 86%; revision 4% (PMID 37387609).
• Survey: 97.4% of surgeons who repair ptosis use levator advancement or plication as their main technique (PMID 33346340).

Müller muscle-conjunctival resection (inside approach)

• Putterman 1975: Müller's muscle and conjunctiva are resected in lids that rise to an acceptable level after 10% phenylephrine drops; satisfactory in 27 of 28 eyelids (PMID 1156223).
• Dresner 1991: a formula sets the amount of Müller's muscle removed; the phenylephrine test also unmasks ptosis on the other side (PMID 1863563).
• Single central suture technique without phenylephrine testing, 985 eyelids: mean lid rise 2.72 mm; symmetry within 1 mm in 95.1%; reoperation 1.42% (PMID 40326565).
• Sutureless technique, 252 eyes: success 88.5%, mean rise 1.61 mm, symmetry 93.3%; wound dehiscence 1.19% (PMID 40577206).
• Sutureless technique described as an adjunct to blepharoplasty for mild ptosis, 34 eyelids: 97% improved, mean 1.4 mm (PMID 30844915).

Choosing the approach

• Müller muscle surgery for minimal ptosis with a normal crease or positive phenylephrine test; levator advancement for tendon dehiscence with a high crease and thin lid; both combine with blepharoplasty (PMID 3045728).
• Mild involutional ptosis is corrected by aponeurosis advancement; moderate or severe ptosis by using Müller's muscle and aponeurosis together; skin excision should be limited (PMID 32718105).
• Phenylephrine testing, 270 eyelids: outcomes were the same with or without the test; the test predicted the final lid height within 1 mm in 60.2% (PMID 39752473).

Results and evidence

• Meta-analysis, 7 studies, 1,038 eyelids: lid height and undercorrection did not differ; levator advancement had more overcorrection (OR 0.17) and reoperation (OR 0.26) than Müller muscle surgery, which also scored better cosmetically and took 10.96 minutes less (PMID 36692699).
• Randomized trial with upper blepharoplasty, 40 patients: final MRD1 3.0 mm after levator advancement and 3.2 mm after Müller muscle surgery; cosmetic score 2.69 against 3.07; reoperation 7.7% against 2.6% (PMID 29369985).
• Severe ptosis, 372 eyelids: success 97.2% after Müller muscle surgery against 77.4% after levator surgery; adding blepharoplasty did not change results (PMID 32387434).
• Müller muscle surgery as a first step in 56 eyelids of varied severity: MRD1 1.3 mm to 3.2 mm; asymmetry 5.9%; dry eye 2.9% (PMID 38887214).
• Front against back approach for levator advancement, 78 patients (43 and 35 eyelids): success 69.8% against 57.1%; reoperation 6.9% against 31.4% (PMID 31934962).
• Levator aponeurosis advancement, 96 eyelids: recurrence 4.2% at a mean 12.2 months (PMID 33994326).
• Blepharoplasty plus ptosis correction, 109 cases: revision 9.2% against 3.8% after blepharoplasty alone; no difference between Müller muscle (60) and levator (49) techniques (PMID 38315110).
• American Academy of Ophthalmology review: 3 studies found continued quality-of-life benefit 1.5-3.6 years after ptosis correction (PMID 40913605).

Risks and complications

• Reoperation after levator surgery for bilateral involutional ptosis, 274 patients: 32.5%; preoperative asymmetry over 1 mm raised the odds (42.7% against 28.1%, OR 1.90) (PMID 28259643).
• Obstructive sleep apnea, 577 patients: failure 20.5% with sleep apnea against 13.1% without (PMID 37995148).
• Herring's law, a natural balancing between the two upper lids, influences the outcome of ptosis repair (PMID 19336167); one unilateral case in a 19-patient series became asymmetric from a Herring response (PMID 30844915).
• Dry eye, 54 patients: symptom score rose from 17.24 to 25.38 and staining increased after blepharoplasty with Müller muscle surgery; blepharoplasty alone did not change dry eye tests (PMID 31770512).
• Dry eye, 92 patients with levator advancement: temporary increase at 1 and 3 months, greatest when combined with blepharoplasty; near baseline by 6 months (PMID 40141678).
• Lower lid position, 47 patients: the lower lid rose 0.38-0.39 mm after Müller muscle surgery (PMID 38868860).
• Brow position: ptosis correction lowered the brow by 2.10 mm in pooled data (PMID 36890345).
• Revisions after combined surgery were for overcorrection, residual skin and asymmetry (PMID 38315110).

Recovery

• Jones advised local anesthesia for aponeurotic repair (PMID 1156224); the central suture series operated under local anesthesia in a minor procedure room (PMID 40326565).
• After sutureless Müller muscle surgery, lid height at 8 weeks matched the height seen after phenylephrine before surgery (PMID 40577206).
• Dry eye symptoms after levator advancement were increased at 1 and 3 months and near baseline by 6 months (PMID 40141678).
• Subcutaneous tranexamic acid reduced bruising on day 0 and at 1 week in 69 levator advancement procedures (PMID 38624153).

Combined procedures

• Published facial rejuvenation results often show uncorrected ptosis; 57.6% of facial rejuvenation patients had it (PMID 32356151).
• Forehead lines from compensating frontalis: forehead rejuvenation may fail to remove them, and neuromodulator injections can reduce the visual field by blocking that compensation (PMID 30030561).
• Brow lift was added in 31.7% of 533 upper blepharoplasties in a series where 20.5% had ptosis correction (PMID 38315110).
• High-volume blepharoplasty surgeons more often combine brow lift and ptosis repair (PMID 33346340).
• The brow may descend after ptosis surgery; a sub-brow lift or forehead lift may be needed before or after (PMID 32718105).

Current questions

• Müller muscle surgery or levator advancement: pooled data favor Müller muscle surgery for predictability (PMID 36692699), while most surveyed aesthetic surgeons use levator advancement (PMID 33346340).
• The phenylephrine test: two recent series found outcomes unchanged without it (PMID 39752473), (PMID 40326565).
• Revision rates range from 1.42% (PMID 40326565) to 32.5% (PMID 28259643), depending on technique, patient selection and definitions.
• Eyedrops: oxymetazoline 0.1% raised the lid 0.65 mm against 0.26 mm with placebo in 4 randomized trials, 448 patients (PMID 40881581); effects beyond 6 weeks need study (PMID 33001144).
• Visual field with drops: oxymetazoline increased points seen on the Leicester field test by 7.1 against 2.4 with placebo at day 14, 304 patients (PMID 33001144).

Terms

• Blepharoptosis (ptosis): an upper lid margin that sits too low (PMID 33927356).
• MRD1: distance from the corneal light reflex to the upper lid margin (PMID 29369985).
• Levator aponeurosis: the tendon of the main lid-lifting muscle (PMID 1156224).
• Müller's muscle: a smaller lid-lifting muscle under the levator that responds to phenylephrine (PMID 1156223).
• Levator function (excursion): how far the lid travels from down gaze to up gaze (PMID 1156224).
• Phenylephrine test: eyedrops that lift the lid to preview the effect of Müller muscle surgery (PMID 1863563).
• MMCR: Müller muscle-conjunctival resection, the inside approach (PMID 36692699).
• External levator advancement: reattaching the aponeurosis through a lid crease incision (PMID 29369985).
• Herring's law: equal nerve drive to both lids, so fixing one lid can reveal ptosis in the other (PMID 19336167).
• Frontalis compensation: raising the brows to lift ptotic lids, seen as forehead lines (PMID 30030561).
• Oxymetazoline 0.1%: an alpha-adrenergic eyedrop that raises the lid temporarily (PMID 40881581).

Papers