Ptosis correction: cut from the front or back? How the method changes the final result and risks

Lower eyelid lowering surgery (ptosis correction) lowers the edge of the lower eyelid to make the eyes appear vertically larger. The method varies depending on whether the procedure is performed from behind the eyelid or involves cutting the skin from the front; analysis shows that cutting from the front is more prone to ectropion (outward turning of the eyelid) and excessive scleral show (white of the eye visible)[1]. However, this comparison is from fracture surgery, and no research directly comparing the two approaches for cosmetic purposes has been found.

What is the difference between cutting from the front and the approach from behind?

Analysis comparing the method of cutting the skin below the lashes and the approach through the back of the eyelid exists in fracture surgery of the eye area[1]. This is a summary of 19 studies involving 2,103 people[1].

In the method of cutting below the lashes, the likelihood (as measured by odds ratio) was approximately 2.9 times for ectropion, approximately 2.3 times for excessive scleral show, and approximately 5.6 times for visible scarring[1]. Conversely, the approach from behind showed a higher likelihood of entropion (inward turning of the eyelid)[1].

This is a result from fracture surgery, which has a different purpose from cosmetic ptosis correction. Nevertheless, the fact that complications present differently between the front and back approaches provides a clue for comparing methods.

What results are reported for cosmetic ptosis correction?

In cosmetic research, a method reported on 63 people in China involves lowering the tarsal plate (the foundation of the lower eyelid) by securing it with sutures to the membrane of the bone below the eye[2]. In all cases, the lower eyelid on the lateral side dropped, and the outer corner of the eye expanded vertically[2].

However, 5 people (7.9%) were not fully satisfied because the lowered shape partially reverted[2]. How well the lowered shape is maintained is an important point when comparing methods.

In this study, people with prominent eyes or weak lower eyelid elasticity were excluded from the study[2].

Why does ectropion or excessive scleral show occur?

When too much skin or muscle of the lower eyelid is removed, the eyelid edge may be pulled forward, leading to ectropion[3]. Conservatively cutting the lower eyelid skin is considered a basic approach to prevent excessive scleral show and ectropion[4].

Some people naturally have loose lower eyelid skin or tendon, which can lead to postoperative complications[3]. In the fracture surgery analysis as well, ectropion was more likely in older people and those with lax lower eyelids[1].

How do I choose the right method for me?

Lower eyelid surgery is fundamentally built on identifying where the issue lies—in the eyelid itself, the lateral canthus, or the cheek connection—and tailoring the method to each individual[5]. Lower eyelid surgery increasingly includes additional measures to support the lateral canthus[6].

Whether to cut from the front is determined by whether excess skin needs to be removed at the same time and how much risk of ectropion and scarring you are willing to accept[1][4]. People with prominent eyes or weak eyelid elasticity may not be suitable candidates for lowering surgery itself[2].

What should be confirmed during the consultation?

How much the eyelid can be lowered and which method is appropriate cannot be determined without examining eyelid elasticity and eye prominence. It is important to confirm eyelid laxity during the preoperative consultation.[3].

During your consultation, confirm with your doctor whether the procedure will be performed from the front or back, whether additional measures for the lateral canthus will be added, and what to do if the shape reverts or ectropion develops.