Key surgical approaches for ptosis repair

Surgical techniqueKey features AdvantagesDisadvantagesReferences
Levator advancement

  • The levator aponeurosis is advanced and sutured to the superior tarsus

  • Mainly recommended for aponeurotic and involutional ptosis

  • No material needed

  • Small-incision techniques exist

  • Possibility of performing simultaneous blepharoplasty

  • Reoperation is easy to perform

  • Minimal changes in eyelid anatomy

  • Does not correct dermatochalasis or lash ptosis

  • Recurrence rate between 9–12%

  • Entropion of the upper lid

  • Possibility of over- or under correction of the ptosis

  • Risk of asymmetry in upper eyelid height

[30, 40, 41, 56–61]
Muller’s muscle-conjunctival resection (MMCR)

  • Muller’s muscle and conjunctiva are excised after everting the upper eyelid

  • Mainly for mild to moderate ptosis with good LPS muscle function

  • No material needed

  • Less risk of injury to sensory nerves and the distal branch of the facial nerve

  • No visible scar

  • Short operating time and learning curve

  • Avoidance of dry eyes and floppy eyelid

  • Need for an additional incision for blepharoplasty

  • Not indicated for poor levator function

  • May increase symptoms in patients with dry-eye syndrome

  • Avoided in patients with corneal disease or filtering blebs

[42, 61–63]
Frontalis flap

  • Consists of releasing the frontalis muscle and suturing it to the upper tarsus

  • No material needed

  • No need for alloplastic or autologous tissue

  • Improves the direction of the pull

  • Minimal ptosis on upward gaze compared to frontalis sling

  • Can be done at a younger age

  • Low risk of facial nerve injury

  • Possibility of severe lagophthalmos, lid lag, and nocturnal exposure keratopathy

  • Eyebrow asymmetry

  • Overcorrection not reversible

  • Not indicated in patients with poor levator function

[64–66]
Frontalis sling

  • Linkage of the frontalis muscle to the eyelid tarsus using a sling material

  • Material of choice: autogenous fascia

  • Other materials used: banked fascia, nylon monofilament, polyester, PTFE, polypropylene, ETHIBOND, and silicone

  • Better eyelid position in primary gaze

  • Possibility of reversibility if overcorrection

  • Lagophtalmos

  • Eyelid lag in downgaze

  • Scarring and loss of eyelid crease

  • 26% recurrence rate

  • Foreign body sensation

  • Granuloma or eyelid infections

[44–51, 67]