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Original Investigation
May 4, 2017

Role of Algorithm-Based Levator Aponeurectomy in Small-Incision External Ptosis Surgery for Involutional Ptosis

Author Affiliations
  • 1Allure Laser Center and Medispa, Kirkland, Washington
JAMA Facial Plast Surg. Published online May 4, 2017. doi:10.1001/jamafacial.2017.0172
Key Points

Question  How well can an algorithmic approach to external repair of involution ptosis with normal levator function achieve a postoperative margin reflex distance-1 (MRD1) that approximates the desired goal?

Findings  In a 26-eyelid retrospective cohort study, a technique using a 2:1 levator aponeurectomy for each millimeter of desired eyelid lift, consistent intercase tension on the aponeurosis, and standardized suture placement elevated eyelids to a mean MRD1 of 3.2 mm compared with the mean goal of 3.4 mm.

Meaning  The technique achieved a desired postoperative MRD1 based on a preoperative goal in external levator repair.


Importance  External surgical treatment of involutional ptosis with normal levator function is challenging owing to lack of an established algorithm. Developing an algorithm-based technique could improve postoperative results while limiting intraoperative inefficiencies.

Objective  To investigate the postoperative success of an algorithmic external levator aponeurosis resection technique for aponeurotic ptosis with good levator function.

Design, Setting, and Participants  This retrospective cohort study included patients with involutional ptosis and normal levator function who were treated from July 1, 2015, through November 30, 2016, at a private ophthalmic plastic surgery clinic.

Interventions  The technique involved a small incision in the eyelid crease, with dissection through the orbital septum to expose the levator aponeurosis. The leading edge of the aponeurosis was then clamped to a medical-grade spring scale to standardize the stress on the eyelid between patients. Two millimeters of aponeurosis were resected for every 1 mm of desired ptosis correction. Two sutures were then placed to connect the aponeurosis to the tarsus at predetermined locations.

Main Outcomes and Measures  Preoperative predicted (goal) vs actual margin reflex distance-1 (MRD1).

Results  Twenty-six eyelids of 15 patients (6 men and 9 women; mean [SD] age, 65 years [range, 17-84 years]) met inclusion criteria. The mean follow-up was 189 days (range, 63-343 days). The mean preoperative MRD1 was 0.44 mm (range, −0.5 to 2 mm; 95% CI, 0.18-0.70 mm) compared with the final mean MRD1 of 3.2 mm (range, 2.5-4.0 mm; 95% CI, 3.1-3.4 mm; P < .001). The mean predicted goal MRD1 was 3.4 mm (range, 2.5-4.0 mm; 95% CI, 3.2-3.5 mm). The final MRD1 of all eyelids was within 1 mm of the goal MRD1. The mean surgical time per eyelid was 14.6 minutes (range, 10.5-34.0 minutes). Twelve eyelids (46%) did not have intraoperative suture adjustments.

Conclusions and Relevance  In correcting aponeurotic ptosis, a small-incision levator aponeurectomy incorporating an algorithm and consistent stress on the aponeurosis during resection achieves the goal MRD1 efficiently. The algorithm closely estimates the desired height intraoperatively such that only small intraoperative suture height revisions, if any, are needed. No intraoperative adjustments were made in 12 eyelids, necessitating future studies to determine whether any adjustments are needed.

Level of Evidence  3.