Blepharoptosis repair

What it is

• In ptosis the edge of the upper lid covers too much of the eye. Acquired ptosis is the most common form, and it can affect appearance, vision and quality of life (PMID 33927356).
• With age the main lifting muscle (the levator) keeps working, but its tendon stretches or comes loose from the lid; repair reattaches it (PMID 1156224).
• Ptosis is different from excess eyelid skin. The two often occur together in older patients, each needs its own assessment, and the two operations are often done together (PMID 3045728, PMID 32718105).
• Forehead lines can be a sign: people raise their brows to lift drooping lids, and lines on one side of the forehead matched ptosis on that side (PMID 30030561). Wrinkle injections in the forehead can block that lifting and narrow the field of vision (PMID 30030561).
• Ptosis also follows years of hard contact lens wear, and it can follow an earlier cosmetic eyelid operation when the tendon is caught in scar (PMID 25906332, PMID 31802837).

Two approaches, both from 1975

• In 1975 Jones and colleagues described reattaching the stretched levator tendon through an incision in the lid crease, the front (external) approach (PMID 1156224). Anderson refined it, keeping the deeper structures intact and setting the lid slightly high at surgery (PMID 375893).
• The same year Putterman described removing a strip of Müller's muscle and the lining of the lid from the inside, with no skin incision, for lids that rise well after phenylephrine eyedrops (PMID 1156223). Dresner later added a formula for how much to remove (PMID 1863563).
• Newer versions of the inside approach use a single central stitch or no stitch at all, and some surgeons now skip the eyedrop test with the same results (PMID 40326565, PMID 40577206, PMID 39752473).
• Most aesthetic surgeons who repair ptosis use the front approach as their main technique (PMID 33346340).

Who it suits

• Front approach (levator advancement): a lid with good lifting movement and a stretched or detached tendon, often with a high crease and thin lid (PMID 1156224, PMID 3045728).
• Inside approach (Müller muscle-conjunctival resection): mild ptosis with a normal crease, or a lid that rises after phenylephrine drops (PMID 3045728, PMID 1863563).
• Moderate or severe ptosis may need both muscle and tendon tightened; skin removal is kept limited (PMID 32718105).
• Both approaches can be combined with upper blepharoplasty at the same operation (PMID 3045728, PMID 32387434).

How it is done

• Front approach: through a crease incision a few millimetres above the lashes, the surgeon finds the levator tendon and stitches it back to the lid, planned before surgery and adjusted on the table for height and symmetry (PMID 1156224, PMID 37387609).
• Inside approach: a measured strip of Müller's muscle and lining is removed and closed from the inside of the lid, leaving no skin scar (PMID 1156223, PMID 40326565).
• Both are usually done under local anesthesia, often in a procedure room (PMID 1156224, PMID 40326565).

Results and how long they last

• Both approaches raise the lid to a similar final height. In pooled comparisons the inside approach gave fewer overcorrections and reoperations, a better look and a shorter operation (PMID 36692699).
• In a randomized trial with upper blepharoplasty, lid heights were similar and reoperation was needed in about 1 in 13 after the front approach against about 1 in 40 after the inside approach (PMID 29369985).
• For severe ptosis, the inside approach succeeded in nearly all lids and the front approach in about three in four in one large series; adding blepharoplasty did not change results (PMID 32387434).
• After the front approach, the lid dropped again in about 1 in 25 lids at about a year (PMID 33994326).
• Improvements in vision-related quality of life were still present 1.5 to 3.6 years after ptosis surgery (PMID 40913605).

Risks and how surgeons lower them

• Uneven lids and the need for a second operation are the main risks. After front-approach surgery on both lids for age-related ptosis, about 1 in 3 patients had a reoperation in one series, more often when the lids were uneven before surgery (PMID 28259643). Reported rates range from about 1 in 70 to 1 in 3, depending on technique, patient selection and definitions (PMID 40326565, PMID 28259643).
• Both lids share one nerve drive (Herring's law), so raising one lid can let the other drop; surgeons test for this before surgery (PMID 19336167, PMID 1863563).
• Sleep apnea raised the failure rate, about 1 in 5 against 1 in 8 without it (PMID 37995148).
• Dry eye: symptoms rose temporarily, most when ptosis repair was combined with blepharoplasty, and were near baseline by six months (PMID 40141678, PMID 31770512).
• The brow tends to settle about 2 mm lower after ptosis correction, and a brow lift may be needed before or after (PMID 36890345, PMID 32718105).
• Combining ptosis repair with blepharoplasty raised revision to about 1 in 11, against about 1 in 26 for blepharoplasty alone; revisions were for overcorrection, leftover skin and asymmetry (PMID 38315110).

Recovery

• Tranexamic acid injected under the skin reduced bruising on the day of surgery and at one week after front-approach repair (PMID 38624153).
• By eight weeks after the inside approach, lid height matched the height seen with the eyedrop test before surgery (PMID 40577206).
• Dry eye symptoms peak at one to three months and settle by six (PMID 40141678).

With a facelift and other surgery

• Uncorrected ptosis is common in published facial rejuvenation results (PMID 32356151).
• Surgeons who do many eyelid operations more often combine brow lift and ptosis repair (PMID 33346340). In one series about a third of upper eyelid patients also had a brow lift (PMID 38315110).
• Eyedrops: oxymetazoline 0.1% gives a small, temporary lift of under a millimetre and can widen the upper field of vision (PMID 40881581, PMID 33001144).

Questions to ask a surgeon

• Do I have ptosis, excess skin, a low brow, or more than one? (PMID 3045728)
• Which approach do you recommend for my lids, and why? (PMID 36692699)
• How often do your patients need a second operation? (PMID 28259643)
• Will fixing one lid change the other? (PMID 19336167)
• Do I need a brow lift as well? (PMID 32718105)

Open questions

• Inside or front approach: pooled data favor the inside approach for predictability (PMID 36692699), while most surveyed aesthetic surgeons use the front approach (PMID 33346340).
• The eyedrop test: recent series found the same results without it (PMID 39752473, PMID 40326565).
• Eyedrops: effects beyond six weeks need study (PMID 33001144).

Terms

• Blepharoptosis (ptosis): an upper lid edge that sits too low (PMID 33927356).
• MRD1: distance from the light reflex on the eye to the upper lid edge (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: 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 inside-approach surgery (PMID 1863563).
• MMCR: Müller muscle-conjunctival resection, the inside approach (PMID 36692699).
• External levator advancement: reattaching the tendon 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 drooping lids, seen as forehead lines (PMID 30030561).

Papers