Oculoplastic Surgery

Aesthetic Surgery Journal

2021, Vol 41(10) 1120–1129
A Comprehensive Approach to Asian © The Author(s) 2021. Published
by Oxford University Press on behalf
Upper Eyelid Ptosis Correction: The Levator of The Aesthetic Society. All rights
reserved. For permissions, please
Musculo-Aponeurotic Junction Formula e-mail: journals.permissions@oup.com
DOI: 10.1093/asj/sjab039
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Chin-Ho Wong, M.Med (Surg), FAMS (Plast Surg);
Michael Ku Hung Hsieh, MD, MRCS (Ed), M.Med (Surg); and
Bryan Mendelson, FRCS (Ed), FRACS, FACS

Abstract
Background: The unique anatomy of the Asian upper eyelid requires specific adaptation to the levator advancement
technique for ptosis correction to achieve predictable and reproducible outcomes.
Objectives: The levator musculo-aponeurotic junction was employed as they key landmark. With a formula developed by
the authors, the location of fixation relative to this landmark can be predicted preoperatively. The authors’ clinical experi-
ence and outcomes with this technique are presented.
Methods: Inclusion criteria were Asian patients with mild to severe ptosis with at least fair levator function. Patients with
acquired or congenital ptosis and primary and revisional cases were all included. The location for placement of the ad-
vancement sutures was measured from the musculo-aponeurotic junction of the upper eyelid levator. This distance was
determined by a formula that considers (1) the amount of elevation of the upper eyelid margin needed, (2) the degree of
compensatory brow elevation present, and (3) eye dominance.
Results: A total 156 Asian patients were included in this prospective study. Of these, 148 were bilateral and 8 were uni-
lateral corrections. The technique was predictable with resolution of symptoms of eyelid ptosis post-surgery and good
long-term symmetry of the palpebral aperture and crisp upper eyelid creases. The formula for estimating the fixation point
on the levator was accurate to within ±1 mm in the majority of patients. The aperture revision rate was 2%.
Conclusions: This novel technique provides a predictable and reliable approach for upper eyelid ptosis correction in
Asian patients.

Level of Evidence: 4

Editorial Decision date: December 2, 2020; online publish-ahead-of-print February 28, 2021.

Upper eyelid ptosis correction is a highly complex func-

tional and aesthetic surgical procedure. The levator ad-
vancement is the most commonly employed technique
for ptosis correction and is effective for most patients with
upper eyelid ptosis, arising from a wide range of causes,
who have at least fair levator function. However, con-
ventional approaches to performing this procedure tend
to require a significant amount of intraoperative trial and
error adjustments of the fixation. This is due to a variety of
contributory factors, including diverse recommendations
in the literature regarding the amount of levator advance-
ment necessary for a required degree of ptosis correction
Dr Wong is a plastic surgeon in private practice in Singapore.
Dr Hsieh is a senior resident, Department of Plastic Reconstructive
and Aesthetic Surgery, Singapore General Hospital, Singapore.
Dr Mendelson is a plastic surgeon in private practice
in Toorak, Victoria, Australia.
Corresponding Author:
Dr Chin-Ho Wong, 38 Irrawaddy Road, 329563, Singapore.
E-mail: drwong@waesthetics.com
Presented in part at: 3rd Asian Blepharoplasty Forum in Seoul, South
Korea on November 10, 2019; 2020 Chang Gung Aesthetic Conference
on October 31, 2020; and PRS Korea 2020 on November 14, 2020.
Wong et al1121
Figure 1. Anatomy of the Asian upper eyelid. Features
unique to Asian upper eyelids include the thick, multi-
lamellated orbital septum, which fuses with the levator
aponeurosis at a relatively lower position, approximately
at the level of the upper anterior edge of the tarsus. The
septum also bulges forward and prolapses inferiorly (over the
fusion point with the lower edge of the levator aponeurosis).
The tarsus is slightly smaller (on average 8-9 mm in height)
compared with the tarsus in the Caucasian upper eyelids.
Also, the pretarsal area has a distinct layer of fibrofatty tissue
that obscures the upper edge of the tarsus.
and the lack of a consistent anatomical reference point
from which this tightening should be referred. The lower
edge of the levator is the most commonly utilized land-
mark, although this is quite a variable anatomical structure
and would have been altered in revision cases. A further
compounding factor is the varying degree of compensa-
tory frontalis activation assisting eye opening secondary
to levator insufficiency.1-3 Effective ptosis correction elim-
inates the need for compensatory frontalis activation. The
subsequent relaxation of the brow results in a lowering of
the eyelid margin, thereby unmasking a greater degree
of lid ptosis than was previously apparent, which in turn
necessitates more tightening than expected from eyelid
aperture analysis alone. Finally, eye dominance, a factor
not previously discussed in ptosis correction, should be
considered. As is commonly known, the non-dominant or
“lazy-eye” requires more tightening to achieve a satisfac-
tory result compared with the dominant eye.4 To maximize
surgical precision and minimize intraoperative trial and
error fixation, the ability to preoperatively determine the
fixation point on the levator to achieve the desired ptosis
correction would be a profound technical advancement. To
develop such a formula, all the factors discussed above
should be considered.
The unique upper eyelid anatomy of Asian patients re-
quires specific technical adjustments in surgical dissection
for identification of key anatomical structures (Figure 1).
More secure and robust fixation of the eyelid crease and
greater tension on the levator advancement is needed
because of the generally thicker and heavier tissues in
the Asian upper eyelids, which are also predisposed to
more severe and prolonged postoperative swelling.3,4 We
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employed a novel method of performing the levator ad-
vancement procedure by referencing the advancement, in
millimeters, from a constant landmark in the upper eyelid.
This landmark is the junction of the levator muscle and
its aponeurosis (musculo-aponeurotic junction [MAJ]).1,2,5
A formula for preoperatively determining the fixation point
from the MAJ was developed. This paper details our clin-
ical experience and long-term results utilizing this tech-
nique in an Asian population.
METHODS
Upper eyelid ptosis was diagnosed from a detailed his-
tory and physical examination. The symptoms of eyelid
ptosis, such as heaviness and difficulty opening the
upper eyelid, were noted. On examination, the severity
of upper eyelid ptosis was measured employing the
margin-reflex distance 1 (MRD 1). The MRD 1 is the dis-
tance from the pupillary eye reflex in primary gaze to
the upper lid margin. Measurement of less than 5 mm
was taken as the clinical threshold for the diagnosis of
upper eyelid ptosis in symptomatic patients.6 The le-
vator function was measured as excellent, good, fair, or
poor employing Berke’s method. Upper eyelid excur-
sion was measured from downward to upward gaze with
the negation of brow elevation due to the frontalis.3,4
Compensatory mechanisms, as a result of levator insuf-
ficiency, were noted preoperatively, with frontalis hyper-
activity indicated by brow elevation, forehead wrinkles,
and supraorbital hollowing.4,7-9 Ocular dominance was
determined by the Dolman method (hole in a card test),
where a distant object is viewed through a hole in a card
with binocular vision and each eye is alternately closed.
The eye that retains the centralized object through the
hole via monocular vision is the dominant eye.3,4,10 The
inclusion criteria for this study were the following: (1)
Asian patients with symptomatic upper eyelid ptosis; (2)
with mild, moderate, or severe upper eyelid ptosis; (3)
excellent to fair levator function (a levator function of
at least 5 mm); and (4) a minimum follow-up of at least
1 year. Cases with the ptosis from medical causes (such
as myasthenia gravis) were included if they had been
1122
Table 1. Preoperative Determination of the Estimated Loca-
tion of Suture Placement on the Levator of the Upper Eyelid
for Ptosis Correction
Ptosis correction Brow elevation Eye dominance (C)
needed mm: distance with eye opening (B)
from the MAJ (A)
0 mm: −5 Absent: +0 Dominant eye: +0
1 mm: −4 Mild: +1 Co-dominant eye: +0
2 mm: −3 Moderate: +2 Non-dominant eye: +1
3 mm: −2 Severe: +3 —
4 mm: −1 — —
5 mm: 0 — —
Estimated distance (in mm) for levator advancement from the MAJ to anterior
tarsus: A + B + C. A was determined by taking the “ideal” MRD1 of +5 mm minus
preoperative MRD 1. B was assessed as mild when only the medial brow ele-
vates with eye opening, moderate when the medial and middle brow elevates
with eye opening, and severe when the entire brow elevates with eye opening
(Video 1). The non-dominant eye requires more tightening than the non-
dominant eye, accordingly assigned a further value of +1 mm. MAJ, musculo-
aponeurotic junction; MRD, margin-reflex distance 1.
optimally treated before surgery. Patients who had poor
levator function were excluded from the study. This
study recruited patients from July 2012 to June 2019.
No IRB approval for this prospective study was ac-
quired. Informed consent and photo release to participate
in this study were obtained from all patients. The study fol-
lowed the tenets of the Declaration of Helsinki.
Preoperative Estimation of Location of
Suture Placement on the Levator for
Ptosis Correction
A detailed explanation of our formula for preoperative es-
timation of the fixation point on the levator has been pre-
viously described.11 Table 1 shows our formula. Factors in
determining the advancement needed include (1) the amount
of upper lid margin elevation required, in millimeters, which
is calculated by taking the target “ideal” MRD 1 of +5 mm
minus the preoperative MRD 1; (2) the degree of compen-
satory brow elevation present preoperatively (Video 1); and
(3) eye dominance. These factors were summated into an
estimated fixation point, in millimeters, from the MAJ. This
was then sutured to the tarsal plate, 1 mm, below its upper
edge.1,2,5 Video 2 shows the preoperative estimation of fix-
ation points for the patient shown in our operative video.
Surgical Technique
Our surgical technique has previously been described11
and is demonstrated in Video 3.
Aesthetic Surgery Journal 41(10)
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RESULTS
A total 156 Asian patients were included in this study. Of
these, 148 patients underwent bilateral upper eyelid ptosis
correction and 8 patients underwent unilateral ptosis cor-
rection. There were 111 primary cases (71%) and 45 (29%)
revision cases; 108 patients were female and 48 were
male. Three patients with myasthenia gravis were treated
with this approach after their condition was optimally
treated medically. The mean follow-up was 19 months
(range, 12-59 months). The mean age of the patients was
42 years (range, 14-78). The mean operative time (for pa-
tients undergoing bilateral upper eyelid ptosis correction)
was 72 minutes (range, 56-105 minutes). The majority of
patients were pleased with the outcome of their surgery
with good stability of their long-term result. Aesthetically,
a wider palpebral aperture gave the eyes a refreshed and
brighter appearance. Functionally, all patients reported
that their postoperative eye opening was easier, with un-
hindered vision, and that the forehead felt lighter and more
relaxed.
Video 4 demonstrates the recovery and long-term re-
sults of the patient shown in our operative video. This
patient demonstrates the typical recovery process for
Asian patients and illustrates the following: (1) postoper-
ative swelling is generally more pronounced and more
prolonged in the upper eyelids of Asian patients; (2) with
more significant levator advancements (0 or + from the
MAJ), it is usual to have some degree of lagopthalmos
intraoperatively, which generally resolves within 1 week with
complete lid closure; (3) slight narrowing of the palpebral
aperture in the early postoperative period due to the signif-
icant swelling of the upper eyelids. With the robust crease
fixation, the aperture gradually widens as the swelling sub-
sides; and (4) adequate correction of the ptosis restores
the intrinsic eye-opening function of the upper eyelid,
thereby eliminating the compensatory frontalis contraction
with eye opening in the long-term results. Therefore, in ad-
dition to symmetry and height of the palpebral aperture,
Wong et al1123
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relaxation of the frontalis with eye opening post-surgery is
a primary endpoint of ptosis correction.
The formula accurately predicted the correct fixation
point in 205 (67%) of the 304 lids we analyzed in this study.
In 87 lids (29%), the intraoperative fixation point was ±1 mm
from the preoperatively planned fixation point. That is, in
96% of cases, the correct fixation point was within ±1 mm
of the preoperative fixation point. In only 12 lids (4%) is
the fixation point greater than 1 mm from the predicted
fixation point.
This technique was effective for Asian patients pre-
senting with a wide range of conditions associated with
eyelid ptosis. The most common group of patients in our
series were older patients with involutional (senile) ptosis
due to levator dehiscence (Figures 2, 3). Young patients
with congenital upper eyelid ptosis were also effectively
treated with the technique (Figure 4). In revision cases, it
may be employed for young patients with exacerbation
of eyelid ptosis after previous blepharoplasty (Figure 5)
and patients having multiple previous upper eyelid sur-
geries presenting with upper eyelid ptosis (Figure 6).
The procedure was also effective for patients with sub-
clinical upper eyelid ptosis presenting primarily with the
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symptoms of constant strain and heaviness in the fore-
head but with normal (+5 mm) or near normal (+4 mm)
palpebral apertures. In this group of patients, the ob-
jective of the surgery was to eliminate these symptoms.
This technique reliably delivers symptomatic relief and
elimination of frontalis strain with eye opening (Figure 7).
Patients with brow asymmetry due to unequal frontalis
activation were effectively treated, with the relaxation of
the brow that follows ptosis correction, obtaining better
brow symmetry (Figure 8). A case of unilateral ptosis cor-
rection with this technique is presented in Supplemental
Figure 1. It may also be utilized predictably in patients
with underlying medical conditions such as myasthenia
gravis (Supplemental Figure 2).
Our criteria for revision of the palpebral aperture were
asymmetry of the palpebral aperture >1 mm and/or patient
dissatisfaction. Minor asymmetries (<1 mm) that the patient
considered satisfactory and did not wish to undergo further
surgeries for were considered acceptable outcomes and
not included in analysis of postoperative aperture asym-
metry. Only 3 patients (2%) required revision of the ptosis
surgery to obtain symmetry of the palpebral apertures. Two
patients had been undercorrected and 1 was overcorrected.
A further 8 patients (5%) underwent minor revision surgery
of skin excision only to correct asymmetry of the lid crease.
The overall revision rate in our series was 7%.
DISCUSSION
Several anatomical features specific to the Asian upper
eyelid make the dissection quite different from Caucasian
eyelids. These include the following: thick and hyper-
trophic orbicularis oculi, and multi-lamellated orbital
septum, which fuses at a relatively lower location with the
levator aponeurosis, at approximately the upper edge of
the tarsus. The septum also prolapses forward and down-
wards over the fusion point with the levator aponeurosis.
1124 Aesthetic Surgery Journal 41(10)

A B

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Figure 2. (A) This 47-year-old female presented with bilateral involutional upper lid ptosis with heaviness and difficulty opening
her eyes. She had no previous eyelid surgery. Margin-reflex distance 1 on the right was 4 mm and on the left was 3 mm. She
was right eye dominant. Preoperative estimation of the fixation point for the right eye was −3 mm (−4, +1, +0) and for the left was
–2 mm (−3, +0, +1). Intraoperative symmetry was achieved at a fixation point of –3 mm from the musculo-aponeurotic junction
on the right and –2 mm on the left. (B) She is shown here at 2 years postoperation.

A B

Figure 3. (A) This 52-year-old female presented with heaviness and difficulty opening her eyes. She had no previous eyelid
surgery. On examination, her margin-reflex distance 1 was +4 mm bilaterally. She was right eye dominant. The estimated
fixation point for her right eye was −3 mm from the musculo-aponeurotic junction (−4, +1, +0) and on her left was –1 mm (−4, +2,
+1). Intraoperatively, symmetry and adequate correction of her eyelid ptosis were achieved at a fixation point of –3 mm from the
musculo-aponeurotic junction on the right and –1 mm on the left. (B) She is shown here at 3 years postoperation.

A B

Figure 4. (A) This 29-year-old female presented with bilateral congenital upper eyelid ptosis more severe on the left side.
Margin-reflex distance 1 on the right was +4 mm and on the left was +2 mm. She was right eye dominant. Preoperative
estimation of the fixation point for the right eye was –4 mm (−4, +0, +0) and the left was –0 mm (−2, +1, +1). Intraoperative
symmetry of the palpebral aperture was achieved at a fixation point of –3 mm on the right and 0 mm on the left. (B) She is
shown here 2 years postoperation, with good long-term stability of the result.
Wong et al1125

A B

Figure 5. (A) This 21-year-old female with an absent upper eyelid crease underwent a cosmetic upper blepharoplasty. She
presented 6 months after her initial blepharoplasty with complaints of heaviness and difficulty opening her eyes. Margin-reflex
distance 1 on the right was +3 mm and left was +3 mm. Preoperative estimation of fixation point was –2 mm (−3, +1, +0) on the

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right and –1 mm (−3, +1, +1) on the left. Intraoperatively, symmetry was achieved at –2 mm on the right and –1 mm on the left. (B)
She is shown here at 1 year postoperation with complete resolution of her symptoms of difficulty with eye opening.

A B

Figure 6. (A) This 70-year-old female with multiple previous upper blepharoplasties and upper eyelid fat grafting presented
with upper eyelid asymmetry and eyelid ptosis. Margin-reflex distance 1 on the right was +2 mm and left was +5 mm. The
preoperative estimation of fixation point was –1 mm (−2, +0, +1) on the right and –3 mm (−5, +2, +0) on the left. Intraoperative
symmetry was achieved at –1 mm on the right and –4 mm on the left. Extensive upper eyelid excision of injected fat was
performed. (B) She is shown here at 1 year postoperation.

This anatomy results in the presence of more fibrofatty
tissues consisting of the thick fusion area of the levator
aponeurosis-orbital septum and the reflected cut edges of
the orbital septum (when the septum has been opened) at
or below the upper edge of the tarsus (Figure 1). Careful
excision of these layers of fibrofatty tissue is required to
clearly visualize the upper edge of the tarsus.3,6,10-12 This
is important because to achieve consistent results, the
point of suture placement into the tarsus should be 1 mm
below the upper edge to optimally transfer the mechanical
tightening of the levator to the upper eyelid. Other ana-
tomical features specific to the Asian upper eyelid are the
levator aponeurosis, which may be partially dehisced off
the tarsus and retracted superiorly, and the tarsus, which is
smaller and less robust compared with Caucasian eyelids,
making it less distinct during surgery.3,5,10-13
Our technique was developed to address these spe-
cific challenges for Asian upper eyelids. The constant con-
tractions of the thick orbicularis oculi interfere with the
long-term stability of the upper eyelid crease. To achieve
a crisp and stable upper eyelid crease, it is necessary to
excise some of the interposing thick orbicularis oculi at the
location of the eyelid crease. This allows the formation of a
precise, linear zone of firm adhesion between the dermis
and the lower edge of the levator aponeurosis.4,14-19 This is
achieved by a trapezoidal excision of the orbicularis oculi
(Video 5). The resultant gap in the muscle enables the
dermis to be in direct contact with the edge of the levator
aponeurosis without interposing orbicularis muscle, where
it is secured with the placement of multiple dermal-levator
fixation sutures
A key step in the dissection is exposure of the levator
aponeurosis/MAJ by cutting across the orbital septum. The
multi-lamellated orbital septum requires cutting through
several layers of septum before the orbital septum has
been completely cut. The levator aponeurosis is usually
partially or completely detached from the tarsus (levator
dehiscence) and retracted superiorly.20-22 The lower edge
1126 Aesthetic Surgery Journal 41(10)

A B

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Figure 7. (A) This 42-year-old female with a margin-reflex distance 1 of +4 mm bilaterally presented with “subclinical” upper
eyelid ptosis. She complained of heaviness and difficulty opening her eyes with significant elevation of her medial brows with
eye opening. She was right eye dominant. Preoperative estimation of fixation point was –4 mm (−5, +1, +0) on the right and
–3 mm (−5, +1, +1) on the left. Intraoperatively, symmetry was achieved at –4 mm on the right and –4 mm on the left. (B) She
is shown here at 18 months postoperation with complete resolution of the sensation of straining to open her eyes. Note the
complete resolution of the peri-orbital strain that was evident in the preoperative photographs.

A B

Figure 8. (A) This 36-year-old female presented bilateral asymmetric upper eyelid ptosis with significantly greater degree of
brow elevation on the left side with eye opening. Her margin-reflex distance 1 on the right was +3 mm and +5 mm on the left
and she was right eye dominant. Preoperative estimation of fixation point was –3 mm (−3, +0, +0) on the right and –1 mm (−5,
+3, +1) on the left. Intraoperatively, symmetry was achieved at –3 mm on the right and –2 mm on the left. (B) She is shown here
at 18 months postoperation. Note that with the ptosis correction, intrinsic eye-opening ability was restored, and the need for
activation of the frontalis to assist in eye opening was eliminated. This brought about the relaxation of the frontalis, relieved the
sensation of constant straining to kept the eyes open, and restored symmetry in brow positioning.

of the levator must be identified early in the dissection by
looking for the distinct whitish, fibrous edge of the levator
aponeurosis. The levator is then retracted caudally to fa-
cilitate dissection in the correct surgical plane (Video 6).
The key identifying landmark is the preaponeurotic orbital
fat pad. Once this discrete lobular fat has been identified,
the levator aponeurosis is located directly below and the
orbital septum superficial to the fat pad may be safely cut
to expose the levator aponeurosis below. Retraction of the
orbital (pre-aponeurotic) fat pads cephalically will expose
the levator and the MAJ, the key reference landmark with
this technique.23-26 If correct traction is not applied to the
levator aponeurosis, the cephalically retracted levator (and
the overlying orbital fat pad) could be missed. Dissection
may then be inadvertently taken into Müller’s muscle and
the vascular arcade (the peripheral arterial arcade of the
upper eyelid) above the tarsus. This may result in bleeding
and hematoma in the Müller’s muscle, making subse-
quent assessment of adequacy ptosis correction very
difficult.6,10,27,28
Conventionally, levator advancement has been most
commonly referenced in terms of millimeters from the
lower edge of the levator.5,10,23,24,28 The commonly cited
recommendations range from 1:3 to 1:4 ratios; that is, for
every 1 mm of upper eyelid ptosis correction required,
the levator should be shortened 3 mm or 4 mm, respec-
tively.1-5,20,21 However, the correlation between the eleva-
tion of the upper eyelid margin and the amount of levator
advancement is not linear, with surgeons employing this
approach having to rely on significant amount of trial
and error and clinical experience to achieve the desired
correction. Furthermore, the lower edge of the levator
Wong et al1127
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aponeurosis itself is quite variable and inconsistent. It
is often stretched and attenuated in older patients. It
may also have been damaged iatrogenically during ex-
posure or shortened from previous surgery in revision
cases. Specifically, in the Asian eyelid, the fibrous multi-
lamellated orbital septum, when cut and reflected cau-
dally off its fusion point with the levator, appears as an
extension of the lower edge of the levator aponeurosis.
This makes accurate identification of the exact location
of the lower edge of the levator more difficult, adding to
poor predictability of this approach for ptosis correction
in Asian patients.10-13,22,29-31
To increase the precision of the surgery, it is critical to
have a fixed anatomical reference point. The junction of
the levator muscle with the levator aponeurosis (MAJ) is
a constant anatomical landmark. We have found utilizing
this landmark with our formula as presented in Table 1 is
an accurate preoperative predictor of the point of fixation
needed for the specific requirements of each individual
patient. Our formula is the summation of the 3 factors
important in achieving adequate ptosis correction. The
first factor (A) is the amount of upper eyelid margin ele-
vation required. Based on the ptosis correction needed,
the corresponding distances from the MAJ were devel-
oped and were validated in this study. The second factor
(B) is brow elevation. This was categorized as absent,
mild, moderate, or severe. Assuming that each of these
ascending categories reflects a progressively greater de-
gree of upper eyelid elevation that is a direct effect of the
frontalis contraction, greater degrees of levator advance-
ment would be necessary to achieve the desired aperture
on complete relaxation of the frontalis with adequate cor-
rection of the ptosis. This was the rationale for tightening
of +1, +2, and +3 assigned to patients with mild, moderate,
and severe elevation of the brow, respectively. Finally, eye
dominance (C) is a factor that is crucially important and not
discussed in ptosis correction. Conceptually, the central
stimulus for eye opening is primarily in response to input
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from the dominant eye. Once the dominant eye has been
corrected, the non-dominant eye will inevitably become
slightly more ptotic as the central innervation to the non-
dominant eye decreases. Accordingly, +1 mm was added
to the non-dominant eye to account for this expected drop
in eyelid margin in the non-dominant eye.
The provision of a predetermined fixation point has sig-
nificantly shortened our operating time by eliminating the
intraoperative trial and error needed. The limitations of util-
izing a prescribed formula to predict the response of a bi-
ological system as complex as eyelid opening to surgical
manipulations should also be acknowledged. The formula
was able to predict the correct location of suture placement
point in 67% of the eyelids we operated on and certainly
provides an excellent guide to the initial trial fixation point.
However, the surgeon should be flexible and be ready to
adjust the fixation point above the below the estimated fix-
ation point as required intraoperatively. In 96% of patients,
the correct location of fixation point was within ±1 mm of
the preoperative determined fixation location. One of the
keys to our low revision rate was intraoperatively sitting
the patient up and performing the necessary adjustment of
fixation as required to achieve adequate height and sym-
metry of the palpebral aperture.
The final intraoperative palpebral aperture should be ex-
actly what the surgeon intended. An aperture that is insuffi-
ciently wide intraoperatively is unlikely to improve or widen
with resolution of postoperative swelling. Equally important,
overcorrection, resulting in lid retraction, must be avoided.
The practice of producing a slight overcorrection to with-
stand the postoperative swelling and stretching is not ap-
propriate with this technique. The strong fixation achieved
with the technique reduces the likelihood of stretching or
the lid relaxing downwards in the postoperative period.
Some patients develop significant early postoperative
swelling, which may temporarily marginally narrow the ap-
erture. Provided the eye opening achieved intraoperatively
is adequate, gradual widening of the palpebral aperture
1128
would be expected as the swelling subsides. This may be
seen in our patient’s serial recovery photographs in Video 4.
With ptosis correction, the critical aim is to be able to pre-
dictably achieve palpebral apertures that are adequately
wide and symmetrical; revisions needing to adjust the ap-
erture are rare with our approach (2%). The majority of the
revisions were for correction of minor asymmetries in the
lid fold/pretarsal show without significant asymmetry of
the palpebral aperture (5%). These are relatively simple to
correct, with skin excision blepharoplasty alone producing
predictable results.
CONCLUSIONS
We have found this surgical technique produces predictable
and excellent long-term results for Asian patients presenting
with varying severity of upper eyelid ptosis. The MAJ is a con-
stant anatomical landmark that may be reliably employed,
even in patients having multiple previous blepharoplasties.
It is more predictable and reproducible than the more com-
monly utilized lower edge of the levator aponeurosis as the
key reference landmark. Employed as the key landmark
when utilizing our formula reliably predicts the level of the
intraoperative fixation needed for accurate ptosis correc-
tion. This technique has enabled us to maximally harness
the potential of the levator advancement technique for cor-
rection of upper eyelid ptosis in Asian patients.
Supplemental Material
This article contains supplemental material located online at
www.aestheticsurgeryjournal.com.
Disclosures
The authors declared no potential conflicts of interest with re-
spect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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