Surgical Approach to Blepharoptosis: Anatomical Reattachment of the Levator Palpebrae Superioris to Tarsus

Surgical Approach to Blepharoptosis: Anatomical Reattachment of the Levator Palpebrae Superioris to Tarsus | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Surgical Approach to Blepharoptosis: Anatomical Reattachment of the Levator Palpebrae Superioris to Tarsus Tunahan Berk Başol, Doğukan Yıldıztaş, Ersin Akşam This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8049911/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background Upper eyelid ptosis is defined as an abnormally low-lying margin of the eyelid in the primary gaze position, resulting in the narrowing of the palpebral aperture. We aimed to execute an anatomical repair that secures the adherence of the levator palpebrae superioris (LPS) to the superior border of the tarsus, with the goal of achieving optimal aesthetic and functional results. Method A total of 196 patients and 264 eyelids were treated using this technique. At 12 months postoperatively, the marginal reflex distance (MRD) and palpebral fissure height were assessed and compared with preoperative measurements. Results Out of the 264 eyelids, 193 (73%) achieved a MRD1 of 4–5 mm, which is considered within the normal range, and in 53 patients (20%) MRD1 ranged from 3–4 mm, resulting in mild residual ptosis. Analysis revealed a statistically significant difference between preoperative and postoperative measurements (p < 0,05). Conclusions This study demonstrates that our surgical technique, which emphasizes the anatomical reattachment of the levator palpebrae superioris to the upper edge of the tarsus, achieves significant improvements in eyelid position and function. Blepharoptosis Levator palpebrae superioris MRD 1 Re-attachment Re-insertion Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Introduction Ptosis is characterized by the drooping or sagging of a body part [ 1 ]. Specifically, upper eyelid ptosis is defined as an abnormally low-lying margin of the eyelid in the primary gaze position, resulting in the narrowing of the palpebral aperture, which can partially obstruct the visual axis [ 2 ]. Ptosis may be congenital or acquired [ 3 , 4 ]. It can affect one or both eyes, leading to a range of functional and aesthetic concerns [ 2 ]. The characteristic ‘sleepy’ appearance associated with ptosis, along with potential asymmetry, can be observed in both unilateral and bilateral cases [ 2 , 5 ]. Studies have demonstrated that ptosis can significantly affect patient well-being, including diminished independence as well as increased anxiety and depression related to appearance [ 6 , 7 ]. In severe cases, prolonged obstruction of the visual axis can impair the development of visual function. Therefore, timely and effective intervention for ptosis is essential to preserve both the physiological and psychological health of the patient [ 8 ]. Several surgical techniques are available for the correction of ptosis, including levator resection, levator plication, levator advancement, Müller’s muscle conjunctival resection, Whitnall’s sling, and frontalis suspension procedures [ 2 , 3 , 9 ]. Regardless of the chosen surgical approach, a successful outcome should aim to restore the eyelid’s original physiological function. The levator palpebrae superioris (LPS) muscle plays the primary role in eyelid elevation; therefore, the most effective surgical correction of ptosis should consider the function and anatomy of the LPS [ 8 ]. Building on this concept, we aimed to execute an anatomical repair that secures the adherence of the LPS to the superior border of the tarsus, with the goal of achieving optimal aesthetic and functional results. Materials and Methods Ethics committee approval was obtained from the *** University Ethics Committee, and the study was conducted in accordance with the Declaration of Helsinki. All patients with congenital or acquired ptosis who were scheduled for primary or revision surgery were included in the study. Consent for the use of photographs was obtained from all patients. A total of 264 eyelids from 196 patients, who were treated between 2017 and 2024 were included in this study. Of the 196 patients treated for blepharoptosis, 76 (38.8%) were male and 120 (61.2%) were female. Patient ages ranged from 19 to 63 years, with a mean age of 32 years. With the patient in an upright position, preoperative margin–reflex distance 1 (MRD1) and palpebral fissure height were measured and recorded. Postoperative follow-up visits were scheduled at 6 months and 12 months, during which photographs were taken and measurements of MRD1 and palpebral fissure heights were obtained. These data were analyzed using SPSS v26 (IBM; USA), and the presence of statistically significant differences was assessed. Surgical Technique The procedure was performed under local anesthesia in all patients. Local anesthesia was achieved by administration of a lidocaine and epinephrine combination (1 mL containing 20 mg of lidocaine HCl and 0.0125 mg of epinephrine; Jetokain, Adeka AS, Samsun, Turkey) using a 25-gauge cannula beneath the orbicularis oculi muscle. The use of cannulas is intended to minimize the risk of needle-related micro-hematoma formation and the associated disruption of dissection planes. Additionally, proparacaine eye drops (Alcaine, Alcon, Switzerland) were applied at the beginning of the procedure for topical anesthesia, and intraoperative pain relief was provided as needed. Blepharoplasty markings were performed in patients presenting with dermatochalasis accompanying blepharoptosis. Markings were initiated by measuring the patient's limbal diameter. This measurement was used to determine the distance between the ciliary margin and the lower border of the blepharoplasty incision. For the superior border of the excision, 1 mm more than limbal diameter is marked from the upper orbital rim. For example, with a limbal width of 9 mm, the lower incision was placed 9 mm above the ciliary margin and the upper incision 10 mm below the superior orbital rim. The lateral extent of the incision was planned with the patient seated and fixating in primary gaze, ensuring complete excision of excess lateral canthal skin; medially, the incision did not cross the medial canthus. In cases where there is no excess skin, an incision of approximately 2.5–3.0 cm was made at the level of the supratarsal fold. If the supratarsal crease was shifted upwards, the target crease level was determined by, again, adding the limbal diameter to the ciliary margin. Following the skin incision, the levator aponeurosis and the superior edge of the tarsal plate were exposed either by excising a strip of orbicularis oculi muscle at the level of the supratarsal crease when muscle excess was present, or by direct incision of the muscle ( Fig. 1 ) . Dissection of the anterior surface of the levator aponeurosis was continued until the LPS muscle belly was reached ( Fig. 2 ) . Reattachment was performed at the mid-pupillary line using horizontal mattress sutures with 7/0 polypropylene, securing the muscle-aponeurosis junction to the upper border of the tarsal plate. During this step, the conjunctival surface was carefully examined to ensure that the sutures did not penetrate the conjunctiva. Patients were seated for evaluation (Fig. 3 ). Unilateral blepharoptosis was assessed for symmetry, while bilateral blepharoptosis was evaluated to ensure an optimal MRD. Slight overcorrection was intended in all patients. If the postoperative outcome was satisfactory, reattachment was completed by placing two additional mattress sutures immediately medial and lateral to the initial suture ( Fig. 4 ) . If excessive correction occurred, the suture level was lowered to a more distal position on the levator aponeurosis. When the desired palpebral fissure height was not achieved, adequate palpebral fissure height was attempted by plicating the levator, once firm adherence of the levator to the tarsus had been confirmed. In refractory cases, the posterior surface of the levator aponeurosis was dissected from the conjunctiva to facilitate reattachment. After confirming hemostasis, the orbicularis oculi muscle and skin were approximated and sutured. Skin sutures were removed on the seventh postoperative day. Results The preoperative ptosis types and degrees are summarized in Table 1 . Table 1 Preoperative Degree and Etiology of Ptosis Ptosis Type Mild (n) Moderate (n) Severe (n) Total (n) Congenital 24 20 14 58 Acquired 34 56 48 138 Total 58 76 62 196 For the 264 operated eyelids, the preoperative mean MRD1 was 2.3 mm and the mean palpebral fissure height was 6.7 mm. Measurements at 12 months postoperatively demonstrated a mean MRD1 of 4.1 mm and a mean palpebral fissure height of 8.9 mm. Analysis with the paired sample t-test revealed a statistically significant difference between preoperative and postoperative measurements (p < 0,05). On the first postoperative day, complete eyelid closure was achieved in 161 eyelids (61%), while lagophthalmos ranging from 1 to 3 mm was observed in 103 eyelids (39%). During follow-up visits in the first week, mild massage was advised for patients with persistent lagophthalmos, and no cases persisted at the one-month follow-up. No major complications requiring surgical intervention were encountered. Some of our results are shown in Figs. 5 , 6 and 7 . The comparison of preoperative and postoperative data is summarized in Table 2 . Table 2 Statistical Analysis of Preoperative and Postoperative MRD1 and Palpebral Fissure Height Measurements Parameter Preoperative (mean ± SD) Postoperative (mean ± SD) Mean Difference (mm) p-value MRD1 (mm) 2.3 ± 0.7 4.1 ± 0.8 + 1.8 < 0.05 Palpebral fissure height (mm) 6.7 ± 1.0 8.9 ± 1.1 + 2.2 < 0.05 Out of the 264 eyelids, 193 (73%) achieved a MRD1 of 4–5 mm, which is considered within the normal range [ 10 ]. In 53 patients (20%), MRD1 ranged from 3–4 mm, resulting in mild-residual ptosis. Eighteen patients (7%) whose MRD1 remained below 3 mm at 6 months postoperatively despite levator reattachment were admitted to have insufficient levator function and were scheduled for reoperation using frontalis suspension techniques. Discussion Blepharoptosis is a frequently encountered condition in daily practice. Studies in the literature report a prevalence of blepharoptosis ranging from 4.7% to 13.5% [ 4 ]. According to a study conducted by Tan MC et al. at an oculoplastic clinic in Singapore, blepharoptosis was the most common condition among patients presenting to the clinic, with a prevalence of 11.7% [ 11 ]. Additionally, with the increasing use of botulinum toxin injections in the frontal region, there has been a rise in the incidence of eyelid ptosis caused by the elimination of compensatory mechanisms provided by the frontalis muscle in patients who were not adequately evaluated preprocedurally. When a detailed medical history was taken from the patients, it was learned that 7 patients (4% of all patients) had a history of recurrent eyelid ptosis after botulinum toxin injection. Examination of pre-injection photographs showed that their ptosis had been compensated by the frontalis muscle, recognizable by eyebrow asymmetry at rest. Patients who consented underwent ptosis repair using the above-described technique; postoperative follow-up demonstrated restoration of eyebrow symmetry, and these patients did not experience recurrent blepharoptosis with subsequent botulinum toxin injections (Fig. 8 ). The earliest studies on the correction of ptosis date back to 1897. In a study by Oliver CA., levator resection and advancement were performed on a patient with traumatic ptosis [ 12 ]. Since then, although numerous surgical techniques utilizing anterior or posterior approaches have been described for ptosis correction, a gold standard method has not been established. In a meta-analysis conducted by Karam M., Müller muscle resection performed via the posterior approach was compared with levator advancement techniques using the anterior approach. The analysis revealed no statistically significant differences between the two groups regarding patients' MRD and the surgeons' learning curves [ 13 ]. In a study by Scuderi et al., the levator aponeurosis-Müller's muscle complex was re-adapted onto the anterior surface of the tarsus as a single flap via an anterior approach [ 14 ]. In our technique, although a repair very similar to the one described in this article is accomplished, it should be noted that the levator aponeurosis or the levator aponeurosis-Müller's muscle complex is reattached to the superior edge of the tarsus to achieve a more anatomical reconstruction. Limitations of our study include the narrow ethnic diversity of the patient cohort. A larger series of patients with blepharoptosis masked by frontalis compensation that becomes apparent after botulinum toxin injection would allow a more detailed investigation in this area. Conclusion This study demonstrates that our surgical technique, which emphasizes the anatomical reattachment of the levator palpebrae superioris to the upper edge of the tarsus, achieves significant improvements in eyelid position and function, with complete correction or mild-residual ptosis observed in 93% of patients, and provides satisfactory aesthetic outcomes. Declarations Author Contribution E.A. conceived and designed the study.T.B.B. and D.Y. wrote the manuscript.E.A. supervised the project.T.B.B. and D.Y. collected and analyzed the data.E.A., T.B.B. and D.Y. prepared the figures.All authors reviewed and approved the final manuscript. Data Availability All data supporting the findings of this study are available within the paper. References Bron AJ, Tripathi RC, Tripathi BJ: Wolff’s anatomy of the eye and orbit. 2. The ocular appendages: Eyelids, conjunctiva and lacrimal apparatus. Chapman and Hall Medical, London, pp 30–72, 1997 Finsterer J. Ptosis: causes, presentation, and management Aesthetic Plast Surg 2003 May-Jun;27(3):193–204. doi: 10.1007/s00266-003-0127-5 . SooHoo JR, Davies BW, Allard FD, Durairaj VD. Congenital ptosis. Surv Ophthalmol. 2014 Sep-Oct;59(5):483 – 92. doi: 10.1016/j.survophthal.2014.01.005 . Bacharach J, Lee WW, Harrison AR, Freddo TF. A review of acquired blepharoptosis: prevalence, diagnosis, and current treatment options. Eye (Lond). 2021;35(9):2468–2481. doi: 10.1038/s41433-021-01547-5 . Zoumalan CI, Lisman RD. Evaluation and management of unilateral ptosis and avoiding contralateral ptosis. Aesthet Surg J. 2010;30:320–8. doi: 10.1177/1090820X10374108 . McKean-Cowdin R, Varma R, Wu J, Hays RD, Azen SP, Los Angeles Latino Eye Study Group. Severity of visual field loss and health-related quality of life. Am J Ophthalmol. 2007;143: 1013–23. doi: 10.1016/j.ajo.2007.02.022 . Richards HS, Jenkinson E, Rumsey N, White P, Garrott H, Herbert H, et al. The psychological well-being and appearance concerns of patients presenting with ptosis. Eye. 2014;28:296–302. doi: 10.1038/eye.2013.264 . Zuo L., Wang X.X. Huang X. Y., Zhang J.L., Du Y.Y., A Modified Levator Resection Technique Involving Retention of the Levator Palpebrae Superioris Muscle Suspension System for Treatment of Congenital Ptosis Aesthetic Plast Surg. 2017;41(4):856–862. doi: 10.1007/s00266-017-0840-0 . Baroody M, Holds JB, Vick VL (2005) Advances in the diagnosis and treatment of ptosis. Curr Opin Ophthalmol 16(6):351–355. doi: 10.1097/01.icu.0000186647.00413.21 . Koka K, Patel BC. Ptosis Correction. [Updated 2023 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539828/ Tan MC, Young S, Amrith S, Sundar G. Epidemiology of oculoplastic conditions: the Singapore experience. Orbit. 2012;31:107–13. doi: 10.3109/01676830.2011.638095 . Oliver CA. Resection and advancement of the levator palpebrae muscle in traumatic ptosis. Trans Am Ophthalmol Soc. 1897;8:103–7. Karam M, Alsaif A, Abul A, Alkhabbaz A, Alotaibi A, Shareef E, Behbehani R. Muller's muscle conjunctival resection versus external levator advancement for ptosis repair: systematic review and meta-analysis. Int Ophthalmol. 2023;43(7):2563–2573. doi: 10.1007/s10792-023-02633-1 . Scuderi N, Chiummariello S, De Gado F, Alfano C, Scuderi G, Recupero SM, Surgical correction of blepharoptosis using the levator aponeurosis-Müller's muscle complex readaptation technique: a 15-year experience Plast Reconstr Surg. 2008;121(1):71–78. doi: 10.1097/01.prs.0000293878.26535.de . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 07 Dec, 2025 Reviewers agreed at journal 26 Nov, 2025 Reviewers invited by journal 25 Nov, 2025 Editor assigned by journal 07 Nov, 2025 Submission checks completed at journal 07 Nov, 2025 First submitted to journal 06 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8049911","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":551559905,"identity":"7fb4dba0-6ebd-44b1-82d0-8aa48d23160d","order_by":0,"name":"Tunahan Berk 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09:25:27","extension":"png","order_by":27,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":125748,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefigure5.png","url":"https://assets-eu.researchsquare.com/files/rs-8049911/v1/7a071073948e761ab59c68d1.png"},{"id":97668598,"identity":"ee56cc14-13b2-43a0-9255-b68867cea4d4","added_by":"auto","created_at":"2025-12-08 09:25:50","extension":"png","order_by":28,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":233202,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefigure6.png","url":"https://assets-eu.researchsquare.com/files/rs-8049911/v1/bde3774149d93d5978825e80.png"},{"id":97669486,"identity":"14ad31fb-79c9-43c1-8d44-912be4c8f31b","added_by":"auto","created_at":"2025-12-08 09:28:05","extension":"png","order_by":29,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":263077,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefigure7.png","url":"https://assets-eu.researchsquare.com/files/rs-8049911/v1/909dba9f2a9ef0630438472a.png"},{"id":97460334,"identity":"57b45393-3c63-4904-8e49-1fb5651c3b77","added_by":"auto","created_at":"2025-12-04 15:21:34","extension":"png","order_by":30,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":154213,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefigure8.png","url":"https://assets-eu.researchsquare.com/files/rs-8049911/v1/56386a88f29f3940c9c088f8.png"},{"id":97460330,"identity":"3860b7cf-ea8e-4d0b-886b-23baafa0e87a","added_by":"auto","created_at":"2025-12-04 15:21:34","extension":"xml","order_by":31,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":50068,"visible":true,"origin":"","legend":"","description":"","filename":"eb35d9b2183a4a26a87032e5bd77c9ca1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8049911/v1/4dea6849a3219a6264c632c4.xml"},{"id":97460339,"identity":"5e13b137-59a8-444b-a0db-f994778b27a1","added_by":"auto","created_at":"2025-12-04 15:21:34","extension":"html","order_by":32,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":58687,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8049911/v1/e246149f39590530e7a6b674.html"},{"id":97460302,"identity":"85e9280a-5510-488e-acaa-fa2aa7e2fa59","added_by":"auto","created_at":"2025-12-04 15:21:33","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2316631,"visible":true,"origin":"","legend":"\u003cp\u003eExposition of the upper border of tarsus\u003c/p\u003e","description":"","filename":"figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8049911/v1/620386b99ea4efb22750911b.jpg"},{"id":97668296,"identity":"08974a1a-3455-4546-ac9c-5e20ddfc75c8","added_by":"auto","created_at":"2025-12-08 09:25:16","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2275260,"visible":true,"origin":"","legend":"\u003cp\u003eLevator aponeurosis dissection\u003c/p\u003e","description":"","filename":"figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8049911/v1/155483d9a1cf68be2d87affe.jpg"},{"id":97669174,"identity":"4d79b288-eda4-44e6-a117-3cdc5cb5769f","added_by":"auto","created_at":"2025-12-08 09:27:31","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2308501,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative evaluation. Note that the patient's frontal muscle compensation is still present.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8049911/v1/2a65d27fe238ec60d77b7f1b.jpg"},{"id":97668324,"identity":"25038332-8428-4890-9650-e8a4f5f5fce0","added_by":"auto","created_at":"2025-12-08 09:25:21","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":2370959,"visible":true,"origin":"","legend":"\u003cp\u003eAnatomical reattachment of the levator palpebrae superioris to tarsus\u003c/p\u003e","description":"","filename":"figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8049911/v1/4503e6b4c5fe0bb547426ef2.jpg"},{"id":97669773,"identity":"2d115e53-0f90-4256-bd7e-ab4ab18a9920","added_by":"auto","created_at":"2025-12-08 09:28:51","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1163045,"visible":true,"origin":"","legend":"\u003cp\u003eA 23-year-old female patient presented with mild blepharoptosis in the left eye (left). Note that frontal muscle compensation has significantly reduced at the 12-month postoperative follow-up (right).\u003c/p\u003e","description":"","filename":"figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8049911/v1/c27692bda71434fc4fc429ef.jpg"},{"id":97667977,"identity":"ff31cfea-1c2d-4895-844a-9b3bcfc772c9","added_by":"auto","created_at":"2025-12-08 09:24:34","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":2230269,"visible":true,"origin":"","legend":"\u003cp\u003eA 62-year-old female patient presented with severe blepharoptosis in the left eye (left). Note that frontal muscle compensation has significantly reduced at the 12-month postoperative follow-up (right).\u003c/p\u003e","description":"","filename":"figure6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8049911/v1/49e37e7b8abb3a4bc4b1ea68.jpg"},{"id":97460313,"identity":"129754e8-a3c7-4b6f-97f0-ad3826e5d8fb","added_by":"auto","created_at":"2025-12-04 15:21:33","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":2373858,"visible":true,"origin":"","legend":"\u003cp\u003eThe 56-year-old female patient presented with moderate ptosis in the left eye and mild ptosis in the right eye. Notably, there was a slight elevation of the left eyebrow due to frontalis muscle compensation (left). At the 12-month postoperative follow-up, optimal palpebral fissure height and eyebrow symmetry were achieved (right).\u003c/p\u003e","description":"","filename":"figure7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8049911/v1/50a682bd84e5d17985d494df.jpg"},{"id":97669053,"identity":"d3c79eac-b6c0-42d2-9c90-29fa6f89a8a7","added_by":"auto","created_at":"2025-12-08 09:27:09","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":1436794,"visible":true,"origin":"","legend":"\u003cp\u003eA 48-year-old female patient with a history of recurrent blepharoptosis following botulinum toxin injections presented with mild ptosis in both eyes (above, left). At the time of presentation, she was not under the effect of botulinum toxin (above, right). At the 12-month postoperative follow-up, optimal palpebral fissure height and brow symmetry were achieved (below, left). The patient received botulinum toxin injections after surgery, and ptosis was not observed during follow-up (below, right).\u003c/p\u003e","description":"","filename":"figure8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8049911/v1/ad05ebe041e47d2bae85247e.jpg"},{"id":97893036,"identity":"97c545f2-8933-4590-8be0-33daccdabaa3","added_by":"auto","created_at":"2025-12-10 15:26:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":19382329,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8049911/v1/843d56de-5051-45c6-b5cd-b2514e0171e9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eSurgical Approach to Blepharoptosis: Anatomical Reattachment of the Levator Palpebrae Superioris to Tarsus\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePtosis is characterized by the drooping or sagging of a body part [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Specifically, upper eyelid ptosis is defined as an abnormally low-lying margin of the eyelid in the primary gaze position, resulting in the narrowing of the palpebral aperture, which can partially obstruct the visual axis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Ptosis may be congenital or acquired [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. It can affect one or both eyes, leading to a range of functional and aesthetic concerns [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The characteristic \u0026lsquo;sleepy\u0026rsquo; appearance associated with ptosis, along with potential asymmetry, can be observed in both unilateral and bilateral cases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eStudies have demonstrated that ptosis can significantly affect patient well-being, including diminished independence as well as increased anxiety and depression related to appearance [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In severe cases, prolonged obstruction of the visual axis can impair the development of visual function. Therefore, timely and effective intervention for ptosis is essential to preserve both the physiological and psychological health of the patient [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSeveral surgical techniques are available for the correction of ptosis, including levator resection, levator plication, levator advancement, M\u0026uuml;ller\u0026rsquo;s muscle conjunctival resection, Whitnall\u0026rsquo;s sling, and frontalis suspension procedures [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Regardless of the chosen surgical approach, a successful outcome should aim to restore the eyelid\u0026rsquo;s original physiological function. The levator palpebrae superioris (LPS) muscle plays the primary role in eyelid elevation; therefore, the most effective surgical correction of ptosis should consider the function and anatomy of the LPS [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBuilding on this concept, we aimed to execute an anatomical repair that secures the adherence of the LPS to the superior border of the tarsus, with the goal of achieving optimal aesthetic and functional results.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e Ethics committee approval was obtained from the *** University Ethics Committee, and the study was conducted in accordance with the Declaration of Helsinki. All patients with congenital or acquired ptosis who were scheduled for primary or revision surgery were included in the study. Consent for the use of photographs was obtained from all patients.\u003c/p\u003e\u003cp\u003eA total of 264 eyelids from 196 patients, who were treated between 2017 and 2024 were included in this study. Of the 196 patients treated for blepharoptosis, 76 (38.8%) were male and 120 (61.2%) were female. Patient ages ranged from 19 to 63 years, with a mean age of 32 years. With the patient in an upright position, preoperative margin\u0026ndash;reflex distance 1 (MRD1) and palpebral fissure height were measured and recorded. Postoperative follow-up visits were scheduled at 6 months and 12 months, during which photographs were taken and measurements of MRD1 and palpebral fissure heights were obtained. These data were analyzed using SPSS v26 (IBM; USA), and the presence of statistically significant differences was assessed.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSurgical Technique\u003c/h2\u003e\u003cp\u003eThe procedure was performed under local anesthesia in all patients. Local anesthesia was achieved by administration of a lidocaine and epinephrine combination (1 mL containing 20 mg of lidocaine HCl and 0.0125 mg of epinephrine; Jetokain, Adeka AS, Samsun, Turkey) using a 25-gauge cannula beneath the orbicularis oculi muscle. The use of cannulas is intended to minimize the risk of needle-related micro-hematoma formation and the associated disruption of dissection planes. Additionally, proparacaine eye drops (Alcaine, Alcon, Switzerland) were applied at the beginning of the procedure for topical anesthesia, and intraoperative pain relief was provided as needed.\u003c/p\u003e\u003cp\u003eBlepharoplasty markings were performed in patients presenting with dermatochalasis accompanying blepharoptosis. Markings were initiated by measuring the patient's limbal diameter. This measurement was used to determine the distance between the ciliary margin and the lower border of the blepharoplasty incision. For the superior border of the excision, 1 mm more than limbal diameter is marked from the upper orbital rim. For example, with a limbal width of 9 mm, the lower incision was placed 9 mm above the ciliary margin and the upper incision 10 mm below the superior orbital rim. The lateral extent of the incision was planned with the patient seated and fixating in primary gaze, ensuring complete excision of excess lateral canthal skin; medially, the incision did not cross the medial canthus. In cases where there is no excess skin, an incision of approximately 2.5\u0026ndash;3.0 cm was made at the level of the supratarsal fold. If the supratarsal crease was shifted upwards, the target crease level was determined by, again, adding the limbal diameter to the ciliary margin. Following the skin incision, the levator aponeurosis and the superior edge of the tarsal plate were exposed either by excising a strip of orbicularis oculi muscle at the level of the supratarsal crease when muscle excess was present, or by direct incision of the muscle \u003cem\u003e(\u003c/em\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e. Dissection of the anterior surface of the levator aponeurosis was continued until the LPS muscle belly was reached \u003cem\u003e(\u003c/em\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e. Reattachment was performed at the mid-pupillary line using horizontal mattress sutures with 7/0 polypropylene, securing the muscle-aponeurosis junction to the upper border of the tarsal plate. During this step, the conjunctival surface was carefully examined to ensure that the sutures did not penetrate the conjunctiva.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003ePatients were seated for evaluation (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Unilateral blepharoptosis was assessed for symmetry, while bilateral blepharoptosis was evaluated to ensure an optimal MRD. Slight overcorrection was intended in all patients. If the postoperative outcome was satisfactory, reattachment was completed by placing two additional mattress sutures immediately medial and lateral to the initial suture \u003cem\u003e(\u003c/em\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cem\u003e)\u003c/em\u003e. If excessive correction occurred, the suture level was lowered to a more distal position on the levator aponeurosis. When the desired palpebral fissure height was not achieved, adequate palpebral fissure height was attempted by plicating the levator, once firm adherence of the levator to the tarsus had been confirmed. In refractory cases, the posterior surface of the levator aponeurosis was dissected from the conjunctiva to facilitate reattachment. After confirming hemostasis, the orbicularis oculi muscle and skin were approximated and sutured. Skin sutures were removed on the seventh postoperative day.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe preoperative ptosis types and degrees are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePreoperative Degree and Etiology of Ptosis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePtosis Type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMild (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eModerate (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSevere (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTotal (n)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCongenital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcquired\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e138\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e196\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFor the 264 operated eyelids, the preoperative mean MRD1 was 2.3 mm and the mean palpebral fissure height was 6.7 mm. Measurements at 12 months postoperatively demonstrated a mean MRD1 of 4.1 mm and a mean palpebral fissure height of 8.9 mm. Analysis with the paired sample t-test revealed a statistically significant difference between preoperative and postoperative measurements (p\u0026thinsp;\u0026lt;\u0026thinsp;0,05).\u003c/p\u003e\u003cp\u003eOn the first postoperative day, complete eyelid closure was achieved in 161 eyelids (61%), while lagophthalmos ranging from 1 to 3 mm was observed in 103 eyelids (39%). During follow-up visits in the first week, mild massage was advised for patients with persistent lagophthalmos, and no cases persisted at the one-month follow-up. No major complications requiring surgical intervention were encountered. Some of our results are shown in Figs.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e and \u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e. The comparison of preoperative and postoperative data is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStatistical Analysis of Preoperative and Postoperative MRD1 and Palpebral Fissure Height Measurements\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePreoperative (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePostoperative (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean Difference (mm)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMRD1 (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e+\u0026thinsp;1.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePalpebral fissure height (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e6.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e+\u0026thinsp;2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOut of the 264 eyelids, 193 (73%) achieved a MRD1 of 4\u0026ndash;5 mm, which is considered within the normal range [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In 53 patients (20%), MRD1 ranged from 3\u0026ndash;4 mm, resulting in mild-residual ptosis. Eighteen patients (7%) whose MRD1 remained below 3 mm at 6 months postoperatively despite levator reattachment were admitted to have insufficient levator function and were scheduled for reoperation using frontalis suspension techniques.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBlepharoptosis is a frequently encountered condition in daily practice. Studies in the literature report a prevalence of blepharoptosis ranging from 4.7% to 13.5% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. According to a study conducted by Tan MC et al. at an oculoplastic clinic in Singapore, blepharoptosis was the most common condition among patients presenting to the clinic, with a prevalence of 11.7% [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAdditionally, with the increasing use of botulinum toxin injections in the frontal region, there has been a rise in the incidence of eyelid ptosis caused by the elimination of compensatory mechanisms provided by the frontalis muscle in patients who were not adequately evaluated preprocedurally. When a detailed medical history was taken from the patients, it was learned that 7 patients (4% of all patients) had a history of recurrent eyelid ptosis after botulinum toxin injection. Examination of pre-injection photographs showed that their ptosis had been compensated by the frontalis muscle, recognizable by eyebrow asymmetry at rest. Patients who consented underwent ptosis repair using the above-described technique; postoperative follow-up demonstrated restoration of eyebrow symmetry, and these patients did not experience recurrent blepharoptosis with subsequent botulinum toxin injections (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe earliest studies on the correction of ptosis date back to 1897. In a study by Oliver CA., levator resection and advancement were performed on a patient with traumatic ptosis [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Since then, although numerous surgical techniques utilizing anterior or posterior approaches have been described for ptosis correction, a gold standard method has not been established.\u003c/p\u003e\u003cp\u003eIn a meta-analysis conducted by Karam M., M\u0026uuml;ller muscle resection performed via the posterior approach was compared with levator advancement techniques using the anterior approach. The analysis revealed no statistically significant differences between the two groups regarding patients' MRD and the surgeons' learning curves [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn a study by Scuderi et al., the levator aponeurosis-M\u0026uuml;ller's muscle complex was re-adapted onto the anterior surface of the tarsus as a single flap via an anterior approach [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In our technique, although a repair very similar to the one described in this article is accomplished, it should be noted that the levator aponeurosis or the levator aponeurosis-M\u0026uuml;ller's muscle complex is reattached to the superior edge of the tarsus to achieve a more anatomical reconstruction.\u003c/p\u003e\u003cp\u003eLimitations of our study include the narrow ethnic diversity of the patient cohort. A larger series of patients with blepharoptosis masked by frontalis compensation that becomes apparent after botulinum toxin injection would allow a more detailed investigation in this area.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates that our surgical technique, which emphasizes the anatomical reattachment of the levator palpebrae superioris to the upper edge of the tarsus, achieves significant improvements in eyelid position and function, with complete correction or mild-residual ptosis observed in 93% of patients, and provides satisfactory aesthetic outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eE.A. conceived and designed the study.T.B.B. and D.Y. wrote the manuscript.E.A. supervised the project.T.B.B. and D.Y. collected and analyzed the data.E.A., T.B.B. and D.Y. prepared the figures.All authors reviewed and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data supporting the findings of this study are available within the paper.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBron AJ, Tripathi RC, Tripathi BJ: Wolff\u0026rsquo;s anatomy of the eye and orbit. 2. 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Curr Opin Ophthalmol 16(6):351\u0026ndash;355. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/01.icu.0000186647.00413.21\u003c/span\u003e\u003cspan address=\"10.1097/01.icu.0000186647.00413.21\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKoka K, Patel BC. Ptosis Correction. [Updated 2023 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK539828/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK539828/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTan MC, Young S, Amrith S, Sundar G. Epidemiology of oculoplastic conditions: the Singapore experience. Orbit. 2012;31:107\u0026ndash;13. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3109/01676830.2011.638095\u003c/span\u003e\u003cspan address=\"10.3109/01676830.2011.638095\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOliver CA. Resection and advancement of the levator palpebrae muscle in traumatic ptosis. Trans Am Ophthalmol Soc. 1897;8:103\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaram M, Alsaif A, Abul A, Alkhabbaz A, Alotaibi A, Shareef E, Behbehani R. Muller's muscle conjunctival resection versus external levator advancement for ptosis repair: systematic review and meta-analysis. Int Ophthalmol. 2023;43(7):2563\u0026ndash;2573. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10792-023-02633-1\u003c/span\u003e\u003cspan address=\"10.1007/s10792-023-02633-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eScuderi N, Chiummariello S, De Gado F, Alfano C, Scuderi G, Recupero SM, Surgical correction of blepharoptosis using the levator aponeurosis-M\u0026uuml;ller's muscle complex readaptation technique: a 15-year experience Plast Reconstr Surg. 2008;121(1):71\u0026ndash;78. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/01.prs.0000293878.26535.de\u003c/span\u003e\u003cspan address=\"10.1097/01.prs.0000293878.26535.de\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"inte","sideBox":"Learn more about [International Ophthalmology](https://www.springer.com/journal/10792)","snPcode":"10792","submissionUrl":"https://submission.nature.com/new-submission/10792/3","title":"International Ophthalmology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Blepharoptosis, Levator palpebrae superioris, MRD 1, Re-attachment, Re-insertion","lastPublishedDoi":"10.21203/rs.3.rs-8049911/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8049911/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eUpper eyelid ptosis is defined as an abnormally low-lying margin of the eyelid in the primary gaze position, resulting in the narrowing of the palpebral aperture. We aimed to execute an anatomical repair that secures the adherence of the levator palpebrae superioris (LPS) to the superior border of the tarsus, with the goal of achieving optimal aesthetic and functional results.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e\u003cp\u003eA total of 196 patients and 264 eyelids were treated using this technique. At 12 months postoperatively, the marginal reflex distance (MRD) and palpebral fissure height were assessed and compared with preoperative measurements.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOut of the 264 eyelids, 193 (73%) achieved a MRD1 of 4\u0026ndash;5 mm, which is considered within the normal range, and in 53 patients (20%) MRD1 ranged from 3\u0026ndash;4 mm, resulting in mild residual ptosis. Analysis revealed a statistically significant difference between preoperative and postoperative measurements (p\u0026thinsp;\u0026lt;\u0026thinsp;0,05).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThis study demonstrates that our surgical technique, which emphasizes the anatomical reattachment of the levator palpebrae superioris to the upper edge of the tarsus, achieves significant improvements in eyelid position and function.\u003c/p\u003e","manuscriptTitle":"Surgical Approach to Blepharoptosis: Anatomical Reattachment of the Levator Palpebrae Superioris to Tarsus","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-04 15:21:28","doi":"10.21203/rs.3.rs-8049911/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-07T08:27:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"171803989587009138130279103231923430337","date":"2025-11-26T21:30:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-25T05:48:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-08T02:34:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-08T02:33:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Ophthalmology","date":"2025-11-06T16:04:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"inte","sideBox":"Learn more about [International Ophthalmology](https://www.springer.com/journal/10792)","snPcode":"10792","submissionUrl":"https://submission.nature.com/new-submission/10792/3","title":"International Ophthalmology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2d52f659-4a3e-4d2a-8e0c-4b90e627128d","owner":[],"postedDate":"December 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-04T15:21:29+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-04 15:21:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8049911","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8049911","identity":"rs-8049911","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}