ORIGINAL ARTICLE AESTHETIC

Borderline to Moderate Blepharoptosis Correction UsingRetrotarsal Tucking of Muller Muscle: Levator Aponeurosisin Asian Eyelids

Seungil Chung • Byungjoon Ahn • Wonyong Yang •

Jinsik Bum • Kiyup Kim • Sangyoon Kang

Received: 28 May 2014 / Accepted: 16 October 2014

� Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014

Abstract

Background The purpose of this paper is to report the

outcome of retrotarsal tucking of Muller muscle-levator

aponeurosis for the correction of borderline to moderate

ptosis in conjunction with esthetic blepharoplasty in Asian

eyelids and to explore the relationship between the extent

of advancement and change in the eyelid position (MRD1).

Methods The medical records of 290 consecutive patients

who underwent retrotarsal tucking of Muller muscle-leva-

tor aponeurosis from February 2005 to November 2011

were reviewed. Of those, 26 patients (51 eyelids) were

statistically analyzed. The correction was performed

through an external upper blepharoplasty approach. Once

the orbital septum was opened, the Muller muscle-levator

aponeurosis was advanced and tucked under the posterior

surface of the tarsus by a single lifting suture. The average

follow-up period was 20.6 months, with a range of

3–68 months.

Results In 26 patients (51 eyelids), satisfactory results were

recorded for 49 of 51 eyelids (96.1 %). The margin reflex

distance-1 (MRD1) increased from 1.56 ± 0.70 mm pre-

operatively to 3.86 ± 0.94 mm postoperatively (p \ 0.001,

Wilcoxon signed rank test). When 6.1 mm of advancement

was implemented, an average MRD1 of 1 mm was achieved.

For 7.2 and 8.3 mm of advancement, the average MRD1

achieved was 2 and 3 mm each. A noteworthy complication,

although not included in statistical analysis, was one patient

who had developed corneal irritation caused by the con-

junctival exposure to the non-absorbable suture 3 years after

the surgery, which led the subject to have the suture removed.

Conclusion The author concludes that this procedure is

one of the most effective surgical options in correcting

borderline to moderate blepharoptosis in conjunction with

esthetic blepharoplasty. The main advantage of such a

method is that once the orbital septum is opened, Muller

muscle-levator aponeurosis is easily advanced and tucked

under the posterior surface of the tarsal plate without

extensive dissection or resection, which is less traumatic

and gives a more vertical lifting vector, thus producing

excellent cosmetic results and quick recovery.

Level of Evidence V This journal requires that authors

assign a level of evidence to each article. For a full

description of these Evidence-Based Medicine ratings,

please refer to the Table of Contents or the online

Instructions to Authors www.springer.com/00266.

Keywords Sleepy eye � Blepharoptosis correction �Muller tucking

Introduction

While performing esthetic blepharoplasty in Asians, the

levator complex must be manipulated for patients with

blepharoptosis, as well as for patients within the normal

margin reflex distance (MRD) range, but exhibit poor

folding of the double eyelid and want to obtain brighter

eyes [1–3].

E-Poster presented at the Annual Meeting of the ASAPS (The

American Society for Aesthetic Plastic Surgery) & ASERF (Aesthetic

Surgery Education and Research Foundation), New York, April

11–16, 2013.

S. Chung (&) � W. Yang � J. Bum � K. Kim � S. Kang

Department of Plastic and Reconstructive Surgery, Graduate

School of Medicine, Kyung Hee University, #1 Hoegi-dong,

Dongdaemoon-gu, Seoul 130-702, Korea

e-mail: bepos@hanmail.net

B. Ahn

Secret Plastic Surgery Clinic, Seoul, Korea

123

Aesth Plast Surg

DOI 10.1007/s00266-014-0420-5

Based on the levator function, the amount of ptosis and

the surgeon’s preference, various techniques including

levator complex plication, advancement or shortening via a

percutaneous anterior or a posterior conjunctival approach

have been introduced over the years [4–10].

In recent days, the importance of the Muller muscle has

been emphasized in eyelid surgeries in light of the theory

that the Muller muscle, rather than the levator aponeurosis,

plays the primary role in the transmission of the force of

the levator muscle during eyelid lift [11–13]. By consid-

ering the functional reduction of the Muller muscle caused

by its resection, techniques such as advancement or tucking

of the Muller muscle-levator aponeurosis to the anterior

surface of the tarsal plate via limited resection or plication

have become mainstream [14–17].

However, when using the methods described above, it is

necessary that either the anatomical layers between the

Muller muscle and levator aponeurosis or conjunctiva be

dissected to form a flap, or that the Muller muscle be

separated from the tarsal plate. Thus, these methods have

disadvantages, such as the long time it takes to perform

such procedures and the difficulty of obtaining symmetry

when conducting a simultaneous esthetic double eyelid

operation. To overcome these disadvantages, it is necessary

to shorten the operation time using a less invasive and

simpler technique, which effectively reduces the intraop-

erative change of the eyelid caused by swelling or

bleeding.

To this end, the authors devised a technique that mini-

mizes dissection by avoiding the separation of the Muller

muscle from the upper margin of the tarsus, levator apo-

neurosis or conjunctiva; and this technique fixes the Muller

muscle and levator aponeurosis via posterior rather than

anterior advancement to overcome the increased possibility

of eversion of the tarsal plate [18].

Although similar techniques that advance the Muller

muscle and levator aponeurosis to the tarsal plate have

been reported, the study of retrotarsal tucking of the Muller

muscle-levator aponeurosis has not been reported yet.

Therefore, based on the past 5-year experience in the sur-

gery of borderline to moderate blepharoptosis, the out-

comes of retrotarsal tucking of the Muller muscle-levator

aponeurosis were clinically and statistically analyzed.

Materials and Methods

Subjects

This study was retrospectively conducted on 290 patients

(34 men and 256 women) who underwent retrotarsal

tucking (advancement) of the Muller muscle-levator apo-

neurosis in conjunction with esthetic blepharoplasty from

February 2005 to November 2011. Subject ages ranged

from 15 to 70 years (Mean age: 26.0 years). Of patients

who had mild to moderate blepharoptosis (amount of ptosis

B3 mm) based on the Berke method and patients who had

‘borderline blepharoptosis’ prior to treatment, those who

underwent retrotarsal tucking (advancement) of the Muller

muscle-levator aponeurosis because of the pathological

status of the levator palpebrae muscle during the treatment

were included in the study. For the preoperative plan, a

amount of ptosis using MRD, and levator function using

Berke method were measured. The levator function was

shown to be greater than 8 mm in 282 patients and modest

(5–7 mm) in 8 patients.

Methods

Of the subjects, the condition of 26 subjects (51 eyelids)

was followed up for 3 months or longer. For each of these

subjects, the MRD1 (margin reflex distance: distance

between pupil center and upper eyelid margin) of their

preoperative and postoperative digital photos was objec-

tively measured using Adobe Photoshop for statistical

analysis.

Measurement Using the Digital Photos (The Outcome

Measurements)

The subject’s MRD1, which was measured using the Berke

method before and after the surgery, varies depending on

the measurer’s experience and bias. To rule out the

aforementioned problem, the MRD1 was obtained using the

photos of the subjects who were followed up for 3 months

or longer and whose preoperative and postoperative photos

were all available. From among the digital photos of each

subject, only the front shots were used. To increase mea-

surement accuracy, these photos were uniformly magnified

and adjusted for size ratio, and then the MRD1 was mea-

sured using Adobe Photoshop CS5 Portable. The distance

from the reflex point of the pupil center to the upper eyelid

margin shown in the photos was determined as the MRD1.

The corneal length, which is relatively constant in the eyes,

was also measured. The mean corneal length of Koreans is

known to be 11.5 mm, and the MRD1 was adjusted based

on the mean corneal length (Fig. 1) [19, 20]. In cases in

which photos were unavailable, the corresponding subject

was excluded from statistical analysis even though his/her

MRD1 was recorded in the chart.

Evaluation of the Results

The position of the upper eyelid margin in their frontal

gaze was compared with the normal range of the height of

the upper eyelid margin for bilateral blepharoptosis, and

Aesth Plast Surg

123

with the normal eyelid for unilateral blepharoptosis. When

all of the following four criteria were met, the surgery was

assessed to be successful: Postoperative MRD1 of 3–5 mm;

difference in the MRD1 between both eyes B1 mm; dif-

ference in the size and shape of the double eyelids between

the two eyes B1 mm; symmetrical size and shape of the

double eyelids. Contrarily, in case any of the four criteria

was unmet or resurgery was required, the surgery was

determined to be unsuccessful.

Anatomical & Physical Considerations: Surgical

Concept and Schematic Diagram

During eyelid lift, the levator aponeurosis is known to not

only suspend the preaponeurotic fat and lift the eyelid

margin with slight eversion, but also control the tension of

the anterior lamella, as the Muller muscle controls the

tension of the posterior lamella [11–13].

As the eyelid is lifted up while rotating around the eye, it

is most efficiently lifted up when the force is transmitted to

the tangential direction of the eye. In other words, the

corresponding direction becomes the axial direction of the

tarsal plate. In light of this, the authors believe that an

eyelid lift using the middle layer and posterior surface of

the tarsal plate is a good alternative, since it causes less

friction (Fig. 2) [18].

Surgical Technique

For surgery, double eyelid incision is performed under

local anesthesia, and a small dose of a local anesthetic

agent (2 % lidocaine containing 1:100,000 epinephrine) is

applied to minimize the stimulation of the Muller muscle.

The skin and orbicularis oculi muscle are incised, and the

anterior muscle and fat of the tarsal plate are partially

removed to expose the orbital septum. The orbital septum

is inferiorly incised, which is close to the conjoined fascia,

to expose the levator aponeurosis. The orbital fat is also

removed, if necessary. Then, factors that inhibit the eye

from opening, such as excessive skin or orbicularis oculi

muscle, preaponeurotic fat, connective tissues around the

lower transverse ligament, and lateral horn of aponeurosis

are also removed (Fig. 3).

A pore is made using an iris scissor with a sharp tip

2 mm beneath the upper margin of the tarsal plate, and then

Fig. 1 Method of real MRD1 measurement. X measured diameter of

cornea, Y measured MRD1 in Adobe Photoshop) Method to obtain the

real MRD1 value 11.5 mm: real MRD1 = X: Y real

MRD1 = 11.5 mm 9 Y/X

Fig. 2 Because the upper lid is elevated over the surface of an

eyeball, the force of elevating the upper lid is transferred most

effective when the force is redirected tangentially to an eyeball and in

parallel to the axis of tarsal plate. While lifting an eyelid, the force of

friction is proportional to the force applied to an eyeball, which needs

to be minimized. In this case, the fixation of the Muller’s muscle-

levator aponeurosis to the posterior surface of tarsal plate requires less

force of friction and force to elevate the upper lid than the fixation to

the anterior surface of it. The torque ( _s) acting on the plate relative to

the fixed point ‘O’ is a vector quality defined as _s ¼ _r � _F. The

curved arrow shows the direction of the ‘torque ( _s)’. The small arrow

on the component indicates the ‘ _r’ vector (radius), and the long arrow

indicates the ‘ _F’ vector (the force). (Left) When fixed at the anterior

surface of tarsal plate, a clockwise torque is developed. Thus, the

upper lid tends to be everted. (Center) On the other hand, when

fixated at the posterior surface, a counter-clockwise torque is

developed. (Right) This illustrates the tendencies of eversion or

inversion with fixations at either position. Consequently, eversion of

the upper lid is minimized

Aesth Plast Surg

123

the region between the levator aponeurosis and Muller

muscle is partially dissected while checking the peripheral

arterial arcade (Fig. 4a–c). After the amount of advance-

ment from the incised site was determined according to the

preoperative plan, a 6-0 nylon suture is used to simulta-

neously penetrate the levator aponeurosis and Muller

muscle medially to the midpupilary line, with caution not

to expose the conjunctiva, and then again 2 mm beneath

the upper margin of the tarsal plate toward the anterior

surface of the tarsal plate from the posterior surface

(Fig. 4d–f). The suture is then pulled out of the anterior

surface of the tarsal plate and knitted to pass through a

Fig. 3 Schematic diagram of

surgical technique. (Left)

Needle passage. 6-0 nylon

suture is placed through the

aponeurosis—Muller muscle

and full-layered tarsus from

posterior to anterior surface

followed by penetration of the

mid-lamella of the upper tarsal

border. (Right) Knot is tied after

Muller muscle-levator

aponeurosis is advanced and

tucked under the posterior

surface of the tarsal plate

Fig. 4 a–c shows the dissection

of the levator aponeurosis and

the superior portion of the tarsal

plate. Here, the Muller muscle is

not detached from the tarsus and

lower conjunctiva. By grasping

the soft tissues over the tarsal

plate upward, it is possible to

obtain the hole necessary for

needle passages. c–i Muller

muscle-levator aponeurosis is

advanced (tucked) under the

posterior surface of the tarsal

plate, while making the mattress

suture just off the medium to the

mid-pupillary line with 6-0

nylon at 2 mm inferior from the

upper margin of the tarsus

Aesth Plast Surg

123

horizontal width of 3 mm, and then pulled out of the mid-

lamella of the tarsal plate (Fig. 4g). An assistant proceeds

to lift the tarsal plate with a forceps to secure the posterior

surface of the tarsal plate, followed by transient suturing.

The height of the upper eyelid margin is then adjusted to

be positioned 1 mm beneath the upper corneal limbus at

primary gaze, and the suture is ligated (Figs. 4h, i).

If the margin of the upper eyelid appears to be unnatural

or insufficient, an additional lifting suture is medially and

laterally performed. The orbital septum of the distal region

of the sutured site and levator aponeurosis stump are

trimmed to have a proper length to form double eyelids that

are natural in appearance. After trimming, the stump and

the muscle or the dermis of the lower eyelid flap are fixed

at 5–7 sites to form the double eyelid. This is followed by

skin suturing.

Statistical Analysis

For statistical analysis, the Wilcoxon signed rank test,

Mann-Whiteney test, and Kruskal Walis tests were con-

ducted as nonparametric tests for univariate analysis. In

addition, linear regression analysis and multiple regression

analysis were also conducted. Statistical analysis was

conducted using SPSS 18.0 at a significance level of\0.05.

Results

Statistical analysis was conducted on 51 eyelids (26 sub-

jects) out of 577 eyelids (290 subjects: 34 men and 256

women). The mean age of the subjects who underwent the

statistical analysis was 25.4 ± 8.0 years, and the mean

follow-up period was 20.6 ± 19.8 months, with a range of

3–68 months. The subjects consisted of 7 men and 19

women. They had 36 eyelids of borderline blepharoptosis

and 15 eyelids of mild to moderate blepharoptosis

(B3 mm). Among the 51 eyelids, epicanthoplasty was

additionally conducted on the 20 eyelids and the surgery

outcomes were assessed by comparing preoperative and

postoperative MRD1 values (Table 1).

Among the 26 subjects (51 eyelids) who underwent the

statistical analysis, 24 eyelids (47.1 %) were assessed to be

‘excellent’ (MRD1 4.1–5.0 mm) and 25 eyelids (49.0 %)

were assessed to be ‘good’ (MRD1 3.1–4.0 mm), which

showed that the satisfactory results of good or higher levels

were observed in 49 eyelids (96.1 %) (Figs. 5, 6).

As for postoperative complications, one subject (2

cases) had under-correction and three subjects had asym-

metry, of which one case was misdiagnosed before the

surgery, but had pseudoptosis due to preoperative hyper-

tropia of the left eye.

In the data excluded from the statistics, the complica-

tions from 290 total patients were minor, with the most

common occurrence being a slight asymmetry in 16

patients (5.5 %), mostly related to under-correction (17

patients; 5.9 %).

Moreover, the cases in which corneal irritation occurred

in 7 patients (2.4 %) who were excluded from statistical

analysis. Six of these patients underwent correction as the

condition occurred in the early postoperative period. The

one remaining patient had corneal irritation caused by

conjunctival exposure of the non-absorbable suture 3 years

after the surgery, forcing the subject to have their suture

removed.

The other complication was over-correction in 2 patients

(0.7 %).

No symptoms of dry eye, exposure keratopathy, or other

complications were encountered in any patient. No contour

abnormalities, infections, hematomas, or other complica-

tions were noted.

Results of Statistical Analysis

The mean preoperative and postoperative values were

shown to be 1.56 ± 0.70 and 3.86 ± 0.94, respectively. To

test the significance of the difference between the preop-

erative and postoperative values, the Wilcoxon signed rank

test, a nonparametric paired comparison, was conducted.

As a result, the difference was shown to be statistically

significant (p \ 0.001).

Table 1 Case summary

Variables n (51)

Age (year)

10–19 10

20–29 29

30 12

Sex

Male 14

Female 37

Follow-up duration (months)

3–12 28

13–36 12

37 11

Diagnosis

Borderline ptosis 36

True ptosis 15

Additional procedure

None 31

Medial epicanthoplasty 20

Aesth Plast Surg

123

Discussion

Various surgery methods for blepharoptosis have been

reported according to levator function, degree of ptosis, or

surgeon’s experience or preference. They include a tech-

nique that advances the levator muscle-aponeurosis and

Muller muscle to the anterior surface of the tarsal plate or

shortens them by resection via an external anterior, trans-

conjunctival posterior approach, or frontalis transfer.

However, surgery for mild to moderate blepharoptosis is

still controversial [4–10, 21–26].

In the past, it was thought that the levator aponeurosis

plays a leading role in transmitting levator functions.

However, the Muller muscle is currently thought to be

more significant. Since arriving at this conclusion, more

techniques using the Muller muscle have been actively

reported [11].

Haramoto et al. reported the eyelid lift mechanism as a

dual elastic suspension system where the anterior levator

aponeurosis, which attaches to the soft tissue of the anterior

tarsal plate, indirectly suspends the tarsal plate via this soft

tissue, and the Muller muscle, which not only directly

attaches to the upper margin of the tarsal plate but also

attaches to the anterior tarsal plate via the pretarsal fascia,

directly suspends the tarsal plate [12]. In addition, the

Muller muscle, which is governed by the sympathetic

nervous system, plays a main role in 2–3 mm lift of the

eyelid, maintaining the elevated eyelid at the constant

height and making the eyelid blink naturally [9, 12, 21, 27].

Thus, the aforementioned roles of the Muller muscle sug-

gest that the Muller muscle and the levator aponeurosis

should be simultaneously advanced for maintaining long-

term stability in the conduct of blepharoptosis surgery.

The Muller muscle was first included in a blepharoptosis

surgery conducted by Fasanella-Servat, upon which a small

amount of the Muller muscle was resected. In a study

conducted by Putterman et al., 4, 6, 8, and 10 mm of the

Muller’s muscle and conjunctiva were resected for 1, 1.5,

2, and 3 mm of ptosis amount, respectively [7, 8].

As for the surgery outcome of Muller muscle-conjunc-

tiva resection, Putterman et al., and Dresner reported a

success rate of 90 and 95 %, respectively. The good sur-

gery outcomes were explained by the following mecha-

nisms. First, the shortening of the Muller’s muscle

reinforces the tensile strength of it and improves the stretch

reflex as Matsuo suggested, which results in functional

improvement as the terminal tissue of the levator muscle.

Second, the shortening of the Muller muscle causes the

plication or advancement of the anterior levator aponeu-

rosis, which results in the good transmission of the force of

the levator muscle to the tarsal plate [8, 10, 28].

However, the aforementioned methods that resect the

conjunctiva, tarsal plate, and Muller muscle via a posterior

approach through the conjunctiva are inappropriate for

Asians who undergo blepharoptosis correction in con-

junction with double eyelid operation for esthetic purposes

rather than for the correction of vision disorders. The

reason for this is that the anterior approach is more

advantageous than the posterior approach in removing

factors that restrict eyelid lift such as skin, orbicularis oculi

muscle, orbital fat, lower transverse ligament, or connec-

tive tissues around the lateral horn of levator aponeurosis,

etc. Furthermore, if more of the Muller muscle is resected,

it increases the possibility of injury to the mechanorecep-

tors or the stretch reflex, which deviates from the recent

trend in which the Muller muscle is preserved as much as

possible [14, 15].

Accordingly, in recent days, techniques using the Muller

muscle have been mainly used in mild to moderate

blepharoptosis patients. They include advancement of the

Muller muscle-levator aponeurosis composite flap; Muller

tucking that advances the Muller muscle to the anterior

surface of the tarsal plate after the separation of the Muller

muscle from the levator aponeurosis; and balanced tucking

that advances the levator aponeurosis and fixes it to the

tarsal plate, pretarsal orbicularis oculi muscle, or dermis

without tension together with Muller tucking [14–17, 25].

Generally, in the methods described above, the Muller

muscle must be dissected from the levator aponeurosis,

Fig. 5 (Left) Preoperative view of a 22-year-old male with mild

blepharoptosis. (Right) Six months postoperative photo after 8 mm of

retrotarsal advancement of the Muller muscle-levator aponeurosis on

the right side and 6 mm of advancement on the left side and

simultaneous double eyelid surgery on both sides

Fig. 6 (Left) Preoperative view of a 28-year-old male with borderline

blepharoptosis. (Right) Fourteen months after 6 mm of retrotarsal

advancement of the Muller muscle-levator aponeurosis and simulta-

neous double eyelid surgery on both sides

Aesth Plast Surg

123

conjunctiva or the tarsal plate to form a flap. As such, these

methods have disadvantages because of the significant

amount of time they require, the relatively significant

edema, and the difficulty of obtaining symmetry when

performing an esthetic double eyelid operation. Further-

more, all of these methods fix the Muller muscle and

levator aponeurosis to the anterior surface of the tarsal

plate via shortening or advancement. Thus, due to the

occurrence of clockwise torque, the possibility of eversion

of the tarsal plate increases. This tendency particularly

increases as the fixation point is lower than the upper

margin of the tarsal plate. In addition, as the eyelid is lifted

up while rotating around the eyes, it is most efficiently

lifted up when the force is transmitted to the tangential

direction of the eyes. Thus, the corresponding direction

becomes the axial direction of the tarsal plate. The authors

believe that an eyelid lift using the middle layer and pos-

terior surface of the tarsal plate can be effective as a

smaller force is transmitted to the eyeball, which causes

less friction (Fig. 2) [18].

Accordingly, the authors developed retrotarsal tucking

(advancement) of the Muller muscle-levator aponeurosis

without dissection between the Muller’s muscle and levator

aponeurosis.

Particularly, in cases of sleepy-looking eyes, exhibiting

borderline blepharoptosis or in cases which, even after

removing all factors restricting the movement of the upper

eyelids, significant drooping of the eyelids is still observed,

the authors’ technique can easily be conducted by mini-

mally dissecting the site between the levator aponeurosis

and Muller muscle. Thus, obtaining symmetry is easier due

to the minimization of edema and bleeding. This is based

on our experience that the tissue trauma or edema occurred

less using our method in comparison to the cases of pro-

cedures that were done using preexisting techniques with

extensive dissection. In general, an eyelid lift is sufficiently

performed by a single lifting suture. The eyelid margin

with the most natural arc is obtained by positioning the

suture slightly nasally rather than the mid-pupillary line

[6]. In addition, eyelid peaking is significantly observed in

the cases of the weak tarsal plate, lowered fixation point

from the upper margin of the tarsal plate, penetration of

only the partial layer of the anterior surface by the suture,

and improper interval of the transverse matrix suture. In

this study, the suture was inserted through the entire layer

of the tarsal plate, and then pulled out via the mid-lamella

of the upper margin of the tarsal plate to prevent eyelid

peaking [26, 29].

As for the outcome of surgery, the success rate was

shown to be 96.1 % in this study, which was similar to that

of the previous studies. The mean preoperative MRD1 was

1.56 ± 0.70 and the mean postoperative MRD1 was

3.86 ± 0.94 in this study. Also, the difference in the MRD1

before and after the surgery was statistically significant

(p \ 0.001). Conventionally, 4 mm of levator muscle has

been resected for 1 mm of ptosis, or methods reported by

Putterman et al. have been used [7, 8, 24]. In this study,

however, when the difference in the values measured

before and after the surgery was analyzed based on the

relationship of the values measured before and after the

surgery rather than using the regression equation and sta-

tistical analysis, the advancement of 6.1, 7.2, and 8.3 mm

was estimated to be required for improving the MRD1 of 1,

2, and 3 mm, respectively. However, with the limited

sample size, this does not carry significant meaning and

with more cases to consider, the result is thought to con-

verge to a similar value.

In the analyzed group, one subject had under-correction

and three subjects exhibited asymmetry. As under-correc-

tion occurred even though the bilateral Muller muscle-

levator aponeuroses were advanced by approximately

10 mm, other methods including levator muscle resection

should have been considered for the correction of moderate

blepharoptosis with levator function 5–7 mm. Based on

previous experience, the maximum advancement that can

be achieved by the above method was approximately

12 mm. If the advancement exceeds 12 mm, the patient

may suffer discomfort during lid movement due to the

excessive plication of the conjunctiva. If blepharoptosis

correction is insufficient via this technique, however,

levator muscle resection may be conducted anytime, and

under-correction can be resolved as it is reversible. In the

case of asymmetrical results, it may occur due to improper

preoperative design, different skin resection amount or fat

removal amount, unstable fixation between the levator

aponeurosis and dermis, intraoperative bleeding or edema,

or levator palsy caused by local esthesis. In this study,

asymmetry occurred because of insufficient correction on

one side. Although no other complications were observed,

one subject, who was excluded from statistical analysis,

had corneal irritation caused by conjunctival exposure of

the non-absorbable suture 3 years after the surgery, in

which case the subject had to have the suture removed.

Conclusion

The retrotarsal tucking (advancement) of Muller muscle-

levator aponeurosis without the separation of the Muller

muscle from the upper margin of the tarsal plate achieves

efficient eyelid lift without the eversion of the tarsal plate.

In addition, this technique has many advantages including:

less bleeding and edema due to less extensive tissue dis-

section, increased ease of obtaining bilateral symmetry

during the surgery, and the relative simplicity to perform.

Thus, this procedure is suitable for correcting borderline to

Aesth Plast Surg

123

moderate blepharoptosis in conjunction with esthetic

blepharoplasty. However, conjunctival suture erosion is

theoretically possible, so we need to prevent it by carefully

checking the suture exposure in the conjunctival side and

making the intraoperative knot toward the skin. Moreover,

because data from this procedure are only available from a

limited sample size, this novel technique clearly needs

further study to evaluate long-term safety and efficacy.

Conflict of interest The authors declare that they have no conflict

of interest.

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