"Were you recommended surgery but confused after being told there are 3 types?"
What you'll learn from this article
- Ptosis (blepharoptosis)Differences and mechanisms of the 3 representative surgical approaches
- How to choose the right surgery for your eyelid condition (severity and levator function)
- Downtime for each technique, and comparisons of "re-operation rates" and cosmetic outcomes based on research data
- The truth about material selection to prevent recurrence and surgical difficulty
Heavy eyelids that cover the pupil, narrowed field of vision, fatigue in the forehead and neck by evening, headaches... Many people suffering from these ptosis symptoms visit a clinic, only to be told "there are several surgical methods available" and feel confused. It's natural to worry when faced with technical terminology that makes it unclear which to choose, and to have concerns about post-operative appearance, scarring, and the risk of recurrence. In fact, according to one study, a specific surgical method achieved a re-operation rate as low as 2.6% (Ben Simon et al. 2005), while another approach reported a re-operation rate of 18% (Blair et al. 2018). What causes this difference? This article thoroughly compares each ptosis surgical technique based on scientific research data to answer your questions.
What is ptosis surgery in the first place — the full picture of the 3 surgical approaches
Ptosis refers to a condition in which the margin of the upper eyelid drops to an abnormally low position, partially or completely covering the pupil. This includes "congenital ptosis," where the muscle that lifts the eyelid is inherently weak, and "acquired (aponeurotic) ptosis," which occurs due to aging or prolonged hard contact lens use, causing the tissue connecting the muscle and eyelid cartilage to stretch or detach.
The main goal of treatment is to lift the lowered eyelid margin to the correct position and improve vision problems, especially in the upper field of view. To raise the eyelid, there are currently three main types of surgical methods performed worldwide:
- Levator advancement (Levator advancement / resection)
- Müller's muscle resection (Muller's muscle-conjunctival resection / Fasanella-Servat)
- Frontalis suspension (Frontalis suspension)
Are you aware that in addition to the standard "levator advancement," which involves cutting the skin surface and suturing the internal muscle together, there is an alternative "Müller's muscle resection" approach that accesses from the back of the eyelid (conjunctival side) and leaves no scars on the skin? The applicable surgical approach depends entirely on how much strength remains in the muscle that lifts the eyelid (levator function).
Levator advancement — the standard for acquired ptosis
Who is it right for?
Levator advancement (and levator resection) is the most common standard treatment performed worldwide for acquired aponeurotic ptosis caused by aging or contact lens use. This technique is suitable for patients who have "moderate to good levator function (4mm or more)" remaining in the "levator palpebrae superioris," the main muscle that pulls the eyelid upward. When the muscle's contractile force itself is normal but the "levator aponeurosis," the tissue that transmits the muscle's force to the eyelid margin (tarsal plate), has loosened or detached, repairing and advancing the junction restores force transmission.
Surgical procedure and downtime
Most surgeries are performed under local anesthesia. The eyelid skin is incised along the planned double eyelid line, the orbital septum is opened, and the levator aponeurosis deep within is located. The levator aponeurosis is then sutured to the tarsal plate (the cartilaginous tissue that forms the core of the eyelid) and firmly re-fixed.
The advantage of this surgery is that anatomical structures can be confirmed under direct visualization while fixing the muscle. Additionally, because the skin is incised, excess and sagging eyelid skin due to aging (dermatochalasis) and excess fat can be simultaneously removed for a cleaner appearance. However, because the skin is cut, post-operative swelling (downtime) and bruising are likely, and visible incision scars may remain on the surface.
Effects and re-operation rates shown in research
Levator advancement surgery is highly effective, improving visual field and cosmetic appearance. However, post-operative re-operation rates have been verified in several papers. A study by Ben Simon and colleagues at Jules Stein Eye Institute (USA) investigated the post-operative course of 51 patients who underwent external levator advancement (Ben Simon et al. 2005). The results showed that pre-operative eyelid height (MRD1) improved significantly from an average of 0.5mm to an average of 2.0mm post-operatively (Ben Simon et al. 2005). However, 18% of patients required re-operation (revision surgery) due to insufficient eyelid elevation (residual ptosis) or excessive elevation.
Additionally, a randomized controlled trial (RCT) by Saonanon and colleagues reported a re-operation rate of 7.7% (Blair et al. 2018) in the group that underwent levator advancement. As such, data shows that while levator advancement is an effective approach, fine intra-operative adjustments are difficult, and there is a certain risk of re-operation.
Müller's muscle resection — a less conspicuous scar option
What is the phenylephrine test?
"Müller's muscle-conjunctival resection," an approach from the back of the eyelid, is an effective option for patients with mild to moderate ptosis and well-preserved levator function. A critical pre-operative test that must always be performed to determine whether this surgery is appropriate is the "phenylephrine test."
When phenylephrine (an eye drop that stimulates the sympathetic nervous system) is instilled into a patient's eye, the "Müller's muscle"—a supplementary muscle on the underside of the eyelid controlled by sympathetic nerve activity—contracts. The eyelid height (MRD1) is measured before and after instillation, and if the eyelid lifts 2mm or more after the drops are applied and the opening improves, the patient is judged as "phenylephrine test positive." Patients who show a positive response on this test can be predicted to achieve excellent results—with eyes opening wide and alert, just as when the eye drops are applied—through surgery to shorten the Müller's muscle.
Result comparison with levator advancement
The maximum distinguishing feature of Müller's muscle shortening is the approach of grasping the conjunctiva and Müller's muscle with a specialized instrument from the inside of the eyelid (conjunctival side) and then suturing and resecting them. Because the skin side is not incised at all, there is an overwhelming advantage: no scar remains on the eyelid surface.
In the randomized controlled trial (RCT) by Saonanen and colleagues, there was no statistically significant difference between the two groups in the degree of MRD1 improvement, and both effectively lifted the eyelid. However, the cosmetic outcome score was statistically significantly higher in the Müller's muscle shortening group (3.07) compared to the levator advancement group (2.69) [Blair et al. 2018]. The reoperation rate for Müller's muscle shortening was also extremely low at 2.6% (3% in a study by Ben Simon and colleagues), compared to 7.7–18% for levator advancement.
Frontalis suspension—the gold standard for severe and congenital cases
When levator function is poor (less than 4mm), no amount of suturing and tightening of the eyelid muscles will open the eye. In such cases, a technique is used in which the eyelid tissue and the forehead muscle (frontalis) are connected with a cord-like material called a "sling," and the eyelid is mechanically suspended by the power of raising the eyebrow.
Material selection (autologous fascia vs. synthetic materials)
The gold standard is "autologous fascia lata" harvested from the patient's own thigh. It has no rejection risk and excellent long-term stability, but it leaves a scar on the leg. Synthetic materials such as silicone rods and Gore-Tex are simpler to use, but long-term recurrence risk is a concern.
A 10-year follow-up study by Ho and colleagues from Taiwan showed that the recurrence rate for frontalis suspension was 37.2% (compared to 6.8% for levator shortening [Ho et al. 2017]). In cases using silicone tubing, 87.5% experienced recurrence [Kim et al. 2017]. In Kim and colleagues' research, the extracted silicone rods showed innumerable cracks and structural collapse [Kim et al. 2017].
Guidelines for surgical technique selection by severity level
"Is the result the same regardless of where it's done?" The reality of a surgery where technical skill differences emerge
Ptosis surgery is a delicate procedure requiring a high level of achieving "bilateral symmetry." In research by Suga and colleagues (2017), it became clear that "preoperative bilateral asymmetry" is a powerful risk factor for reoperation [Suga et al. 2017]. Patients with large preoperative asymmetry between the eyes have a higher probability of requiring revision surgery. The skill to fine-tune eyelid height in 1mm increments is in the realm of craftsmanship, and it is essential to choose a specialist with anatomical knowledge and extensive experience.
If you're wondering, "What about my case?"
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Summary of this article
Which surgical technique is appropriate requires professional evaluation during a consultation. If you have any concerns, please feel free to reach out.
References
- Ben Simon et al. 2005. External Levator Advancement vs Muller's Muscle-Conjunctival Resection for Correction of Upper Eyelid Involutional Ptosis. Am J Ophthalmol. 2005DOI
- Unknown et al. 2018. External Levator Advancement versus Muller Muscle-Conjunctival Resection for Aponeurotic Blepharoptosis: A Randomized Clinical Trial. Plast Reconstr Surg. 2018DOI
- Yang et al. 2014. Comparison of levator-based procedure and frontalis suspension technique. Ann Plast Surg. 2014DOI
- Scuderi et al. 2008. Surgical Correction of Blepharoptosis using the levator aponeurosis-Muller's muscle complex readaptation technique. Plast Reconstr Surg. 2008DOI
Author of this article
Hiromitsu NakamuraPhysician
Zetith Beauty Clinic Ginza, Osaka, Fukuoka
With a track record of research presentations at domestic and international academic conferences, he is also involved in technical instruction and education across Zetith Beauty Clinic. He specializes in precision aesthetic medicine based on anatomical evidence, pursuing natural results tailored to each patient's bone structure and tissue.