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 Table of Contents  
Year : 2014  |  Volume : 107  |  Issue : 3  |  Page : 191-199

Nonincisional (threading) levator plication in mild and moderate blepharoptosis: a novel technique

Department of Ophthalmology, Suez Canal University Hospital, Ismailia, Egypt

Date of Submission07-May-2014
Date of Acceptance24-Jul-2014
Date of Web Publication30-Dec-2014

Correspondence Address:
Heba M Khalaf
Department of Ophthalmology, Suez Canal University Hospital, Ismailia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2090-0686.148171

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The aim of this study was to evaluate our technique of nonincisional (threading) levator plication operation in cases of mild to moderate blepharoptosis.
Ophthalmology Department, Suez Canal University Hospital, Ismailia, Egypt.
This study was interventional in design.
Patients and methods
We perform nylon threading 7/0 through the skin using a guiding syringe needle gauge no. 21 and the superior levator palpebral muscle and Mόller's muscle are tucked in by sutures guided to the tarsus surface; then, threads are tightened till the lid margin is elevated to the correct level, and the thread is knotted and inserted under the skin and orbicularis muscle. A total of 21 eyelids of 18 patients were subjected to this procedure.
A total of 18 patients (12 male and six female, mean age 40 years) were studied. Nineteen eyelids were normally corrected or within 0.5 mm of normal, yielding a success rate of 90.5%. One (4.8%) patient was elevated within 1 mm of normal, and it was accepted. One (4.8%) eyelid was undercorrected and it wasn't accepted. An excellent lid contour was noted in all cases, except one, in whom a slight irregularity of the lid margin was observed, which was corrected spontaneously within 1 month.
The nonincisional (threading) levator plication technique is a safe and effective surgery for the treatment of mild to moderate blepharoptosis. It has a high success rate and good cosmetic outcome.

Keywords: blepharoptosis; correction; eyelid; levator; tarsus

How to cite this article:
Badawy MS, El Nahrawy OM, Abdelghany AA, Khalaf HM. Nonincisional (threading) levator plication in mild and moderate blepharoptosis: a novel technique. J Egypt Ophthalmol Soc 2014;107:191-9

How to cite this URL:
Badawy MS, El Nahrawy OM, Abdelghany AA, Khalaf HM. Nonincisional (threading) levator plication in mild and moderate blepharoptosis: a novel technique. J Egypt Ophthalmol Soc [serial online] 2014 [cited 2022 Dec 8];107:191-9. Available from: http://www.jeos.eg.net/text.asp?2014/107/3/191/148171

  Introduction Top

Blepharoptosis is caused by various factors, such as genetic abnormality [1], vernal keratoconjunctivitis [2], trauma [3,4], neurological disorder [5], constant wearing of contact lenses [6], and aging [7].

Blepharoptosis impairs patients' features and presenting sleepy appearances. Besides these cosmetic. Besides these cosmetic disadvantages, blepharoptosis induces functional disorders such as headache and eyestrain [8]. Correction of blepharoptosis by a surgical intervention is needed to remove these disadvantages and improve patients' quality of life. Many surgical techniques have been described for blepharoptosis correction [9-12].

This brief discussion is a guide for ptosis correction using the most common surgical techniques [13-15].

(1) If levator function is poor (<4 mm) or absent, the use of frontalis slings can yield desirable postoperative results [16-18].

(2) With mild or moderate blepharoptosis, the functioning of the superior levator palpebral and Müller's muscles is not totally impaired. Therefore, the operation is performed to enhance the residual functioning of these muscles. This is carried out by shortening or advancing these muscles [19,20]. The levator can be approached from an anterior or a posterior direction [20,21].

(a) In the anterior approach, an external eyelid incision is made using the natural lid crease (if present) to allow for direct visualization of the aponeurosis. Once the levator aponeurosis is identified, it is disinserted from the tarsus, advanced, resected, and reattached. The amount of advancement depends on the degree of blepharoptosis being treated. The aponeurosis is also attached to the skin to reform the crease [20,21].

(b) Small skin paracentral incision techniques to access the levator aponeurosis have also been used using a single suture as a threading technique to re-establish the connection between the levator and the tarsus [22].

(c) In another threading technique with posterior levator resection, the eyelid is everted and the conjunctiva is separated from the Mόller's muscle and the levator aponeurosis. Double-armed sutures are placed in the conjunctiva. The Mόller's muscle and levator are separated from the septum and clamped. Then, the preplaced sutures in the conjunctiva are passed through the levator and the excess tissue is excised. The sutures are passed through the skin with one arm of the double-armed suture taken slightly through the tarsus and these sutures are tied, reforming the eyelid crease [20,21].

(3) In the Fasanella - Servat ptosis procedure, the conjunctiva, tarsus, and the Mόller's muscle are resected. Two hemostats are placed across the superior tarsal border. The tissue below the hemostats is sutured and then the tissue is resected [20,21].

(4) The internal levator advancement, known more commonly as the Mόller's muscle - conjunctival resection, is performed on the underside of the lid, as in a Fasanella - Servat procedure. This surgery is chosen if the eyelid has shown a good response to phenylephrine. The conjunctiva and the Mόller's muscle are marked off, clamped with a specialized clamp, sutured, and the tissues are resected. The conjunctival layer is then closed. This procedure is believed to advance the levator aponeurosis, thereby elevating the ptotic lid [23].

The present study introduces a completely new correction method for mild and moderate blepharoptosis using the threading plication technique through the skin without skin incisions, and no dissection of the eyelid tissues is required.

Nylon threading 7/0 is performed through the skin using a guiding syringe needle gauge no. 21 and the superior levator palpebral muscle and Mόller's muscle are tucked in by sutures guided to the tarsus surface; then, threads are tightened till the lid margin is elevated to the correct level and the thread is knotted.

Our rationale in this study is to provide a good surgical method for mild and moderate blepharoptosis with a simple technique, minimized recovery time, and no scarring.

  Patients and methods Top

This is an interventional study for evaluation of nonincisional (threading) levator plication in mild and moderate ptosis.

All patients provided informed consent before participating in the study and the study was approved by the Ethics Committee of the Faculty of Medicine, Suez Canal University. This study focused on the first 21 mild and moderate ptotic eyelids of patients with congenital or acquired blepharoptosis attending the outpatient ophthalmic clinic.Inclusion criteria were as follows:

We included 21 eyelids of patients who will were scheduled to undergo surgical ptosis repair.

(1) Both sexes.

(2) Any age.

(3) Congenital or acquired ptosis.

(4) Mild and moderate ptosis.

Exclusion criteria:

(1) Severe ptosis.

The patients enrolled were evaluated according to the preferred practice pattern of the American Academy of Ophthalmology [24] by a complete ophthalmologic evaluation (history, examination, and investigations) using a predesigned checklist in conjunction with a designed database computerized program for data entry and analysis.

The procedures of this study were explained both in English (see below) in terms of the aim of the study and in Arabic for the work team (medical and nonmedical):

(1) History :

(a) Personal data: name, age, sex, residency, telephone number, and occupation.

(b) Data on medical condition and current medications used.

(2) Examination :

(a) Visual acuity assessment: unaided and aided using the Landolt C chart and cycloplegic refraction for children.

(b) Refraction: auto refractometer.

(c) External examination: lids, lashes, lacrimal apparatus, and orbit.

(d) Examination of ocular alignment and motility.

(e) Compensatory manifestations of ptosis such as eye brow elevation and chin elevation.

(f) Assessment of pupillary function.

(g) Slit-lamp biomicroscopic examination (Topcon, Japan): for keratopathy and tear film examination.

(h) Test for Bell's phenomena: by holding the lid open and asking the patient to try and shut the eyes and observe the upward rotation of the globe.

(i) Evaluation of increased innervations to the ptotic lid in case of unilateral ptosis: by manual elevation of the ptotic lid and looking for droop of the opposite lid; in this case, surgical correction of the ptotic lid may induce ptosis in the opposite lid.

(j) Serial external photographs of the eyes and the face may be included in the patient's record for documentation.

(k) Assessment of relevant aspects of the patient's mental and physical status.


(1) The palpebral fissure height is the distance between the upper and the lower eyelid in vertical alignment with the center of the pupil.

(2) The marginal reflex distance (MRD1) is the distance between the upper lid margin and the corneal reflection of the apen torch.

(a) Normal: 4-4.5 mm.

(b) Mild ptosis: from ≥2 to <4 mm.

(c) Moderate ptosis: from ≥1 to <2 mm.

(3) Upper lid crease is the vertical distance between the lid margin and the lid crease in the downward gaze. In females, it measures about 10 mm and in males, it measures about 8 mm.

(4) Levator function is measured by placing a thumb firmly against the patient's brow with the eyes in a downward gaze. The patient then looks up as far as possible and the extent of excursion is measured.

(a) Normal: ≥15 mm.

(b) Good: 12-14 mm.

(c) Fair: 5-11 mm.

(d) Poor: ≤4 mm.


Routine preoperative investigations were performed: complete blood count, bleeding time, clotting time, random blood sugar, serum creatinine, and liver enzymes.

Surgical technique of nonincisional (threading) levator plication ([Figure 1], [Figure 2], [Figure 3], [Figure 4])

(1) The procedure is performed under general or local anesthesia, according to the age, general health, and cooperation of the patient.

(2) The skin crease is marked to the desired height.

(3) Using a needle of a syringe with gauge no. 21 as a guide for nylon thread through the levator muscle to the tarsus, and then passing nylon thread 7/0 through it and pulling the needle.

(4) From a point about 0.5 cm beside the last point and at the same level, the needle is inserted to the last point horizontally and partially in the tarsus and then the thread is inserted and the needle is pulled.

(5) The needle is inserted through the levator to the tarsus to the last point in the tarsus and then the nylon thread is inserted and the needle is pulled.

(6) We perform another suture at the same level as the first one.

(7) We insert the needle from one point to another point to make the two ends of the thread meet at one point for each suture.

(8) We elevate the lid to the desired level and tie the sutures.

(9) We cut two ends about 0.5 cm above the knot and then insert two ends and the knot through the last needle opening using a thin needle holder tip to push them deep into the orbicularis muscle and skin.

(10) We can perform two or three sutures in this technique.

Postoperative follow-up

(1) Regular follow-up visits were scheduled after 1 week, 1, 3, and 6 months.

(2) On each visit, the following assessments were performed:

(a) MRD1.

(b) Palpebral fissure height.

(c) Lid contour and lagophthalmos.

(3) The success rate was assessed on the basis of the following factors:

(a) Cosmetically acceptable appearance.

(b) Normal contour of the eyelid.

(c) Symmetry of the normal lid (whether unilateral).

(d) Amount of elevation of the lid.

(e) Need for reoperation.

Postoperative treatment

(1) Systemic drugs: systemic antibiotics, systemic anti-inflammatory, and analgesics.

(2) Topical drugs: tobramycin and dexamethasone eye drops five times per day.

(3) Ice compresses on the first day.

(4) Hot fomentation from the second day.

Clinical pathway for the teamwork

On the basis of the American Academy of Ophthalmology for preferred practice pattern and clinical practice guidelines [24], a clinical pathway for the patient and teamwork (doctors and nurses) was used to explain and summarize the steps to be adopted for every patient with blepharoptosis from admission to discharge by all members of the healthcare team.

The collected data were organized, tabulated, and statistically analyzed using the statistical package for the social sciences (version 16; SPSS Inc., Chicago, Illinois, USA) on an IBM compatible computer.

  Results Top

A nonincisional (threading) levator plication operation was performed in 21 eyelids (of 18 patients) for correction of mild to moderate blepharoptosis.

The sex distribution among the study group was 12 (67%) male and six (33%) female.

The age of the patients ranged between 9 months and 79 years.

Three (17%) patients had acquired ptosis; one of them had bilateral ptosis and 15 (83%) patients had congenital ptosis, and two of these had bilateral ptosis.

There were 15 (83%) patients with unilateral ptosis and three (17%) patients with bilateral ptosis.

(1) Nine (50%) patients had ptosis in the left side.

(2) Six (33%) patients had ptosis in the right side.

(3) Three (17%) patients had bilateral ptosis:

(a) Ptosis was the same in one patient.

(b) Ptosis was more severe in the right lid in the other patient.

(c) Ptosis more severe in the left lid in the last patient.

According to MRD1, three (14%) eyelids had mild ptosis and 18 (86%) eyelids had moderate ptosis.

Sixteen (76%) eyelids had fair levator muscle function (5-10 mm), three (14%) eyelids had poor levator muscle function (0-4 mm but two eyelids had MRD1 = 0.5 mm, one eyelid had MRD1 = 1 mm), and two (10%) eyelids had good levator function (12 mm).

A successful operation was determined on the basis of postoperative eyelid elevation. Patients were divided into three categories according to MRD1 (Figure 1], [Figure 2], Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]):
Figure 1: Passing of nylon 7/0 through the levator to the tarsus using syringe needle no. 21.

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Figure 2: (a, b) Passing of nylon 7/0 partially in the tarsus.

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Figure 3: Passing of nylon 7/0 from the tarsus to the levator muscle and the first suture.

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Figure 4: Cutting of the suture after tying it and inserting the two ends under orbicularis muscle and skin.

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Figure 5: Success rates among the studied patients.

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Figure 6: Top (preoperative), bottom (postoperative).

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Figure 7: Top (preoperative), bottom (postoperative).

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Figure 8: Top (preoperative), bottom (postoperative).

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(1) Successful (90.5%): 19 eyelids had normal elevation (MRD1 = 4-4.5 mm) or were within 0.5 mm of normal (MRD1 = 3.5 mm) [normal elevation 16 (76.2%) eyelids, three (14.3%) eyelids within 0.5 mm of normal].

(2) Accepted (4.8%): One eyelid was corrected within 1 mm of normal (MRD1 = 3 mm).

(3) Undercorrected (4.8%) more than 1 mm: one eyelid [Figure 5].

The mean preoperative MRD1 was 1.19 ± 0.51 mm; the mean postoperative MRD1 was 3.86 ± 0.65 mm. The paired t-test between them was statistically significant ([Table 1], [Table 2], [Table 3]).
Table 1 Success rate and degree of blepharoptosis (mild or moderate)

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Table 2 Success rate of levator muscle function

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Table 3 Difference between preoperative marginal reflex distance and postoperative marginal reflex distance

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(1) Eighteen patients had no postoperative complications.

(2) All patients had normal eye closure.

(3) None of the patients had skin dimpling.

(4) In one patient, the immediate postoperative lid elevation was normal, but there was a slight irregularity of the lid margin that corrected spontaneously within 1 month.

Case 1

An 11-year-old male patient had right congenital moderate ptosis, (MDR1 + 1 mm) and fair levator function (6 mm). MRD1 was 4.5 mm postoperatively [Figure 6].

Case 2

A 25-year-old patient had right congenital moderate ptosis. MRD1 was +0.5 mm preoperatively and levator function was 8 mm. MRD1 was 4 mm postoperatively ([Figure 7]).

Case 3

A one and half-year-old patient with had congenital moderate ptosis. MRD1 was +1.5 mm and levator function was 5 mm preoperatively. MRD1 was 4 mm postoperatively [Figure 8).

  Discussion Top

Blepharoptosis is defined as an abnormal low-lying upper eyelid margin with the eye in primary gaze. The normal adult upper lid lies 1.5 mm below the superior corneal limbus and is the highest just nasal to the pupil [25]. Blepharoptosis can be classified as congenital or acquired [26]. Blepharoptosisimpaires patients' features and presenting sleepy appearances. Besides these cosmetic. Besides these cosmetic disadvantages, blepharoptosis induces functional disorders such as headache and eyestrain [8].

As blepharoptosis is one of the most frequently reported diseases in the field of plastic surgery, its treatment warrants great attention. Hence, numerous operative methods have been reported for its treatment. The optimal operation method is selected for each case, taking the specific requirements of the case into consideration and the degree of the ptosis and residual functionality of suspension muscles [27]. With mild or moderate blepharoptosis, the functioning of the superior levator palpebral and Mόller's muscles is not completely impaired. Therefore, the operation is performed to enhance the residual functioning of these muscles. This is performed by shortening or advancing these muscles [19,20], by flipping the orbital septum and suturing it to the tarsus [28], or by removing parts of the tarsus and Mόller's muscle from the conjunctiva side [29,30].

In the majority of these existing methods, the operation is performed through incisions made in the skin or the conjunctiva of the upper eyelid. As a result of this surgical invasion, the upper eyelid develops edema, requiring a recuperation period of 1-2 weeks. These prolonged recovery periods are disadvantageous for patients because surgical correction of mild to moderate blepharoptosis is usually performed without hospitalization and patients often wish to resume normal activities soon after the operation. The recuperation time can be shortened by reducing invasion of the eyelid tissues [27].

For this purpose, we believed that avoiding incision of the skin or conjunctiva, and splitting the superior levator palpebral and Mόller's muscles would minimize invasion and recuperation time. Thus, we developed the present method. As the present method requires no incision and dissection, eyelids develop little edema after the operation. Also, there is no postoperative scarring at all as skin incisions could lead to irregular scars that may be disadvantageous. Patients can resume their normal activities immediately.

This study was carried out to assess the use of the nonincisional (threading) levator plication technique for the management of mild to moderate blepharoptosis.

In this study, we attempted to adhere to quality concepts, principles, and methodology for healthcare provision. Evidence-based practice, clinical practice guidelines and preferred practice patterns were considered.

We studied 21 eyelids in 18 patients; three (14%) eyelids had mild ptosis and 18 (86%) eyelids had moderate ptosis, less than that reported by Shimizu et al. [27] [624 eyelids in 390 patients; 416 (67%) eyelids had mild ptosis and 208 (33%) had moderate ptosis], Ben Simon et al. [31] (272 eyelids in 159 patients), Lucarelli and Lemke [22] (28 eyelids in 17 patients), Lake et al. [32] (61 eyelids in 48 patients), Jung and La [33] (52 eyelids in 33 patients), Seung et al. [34] (51 eyelids in 26 patients), and Singh et al. [35] (80 patients).

The mean age of our patients was 40 years, ranging from 9 months to 79 years, which is younger than that reported by Ben Simon et al. [31], mean age 70 years, and Jung and La [33], 67 years.

Positive family history in our patients was present in one (4.8%) case, but there was no positive consanguinity between parents in our patients.

In terms of the bilaterality, in our study, three (17%) cases had bilateral ptosis and 15 (83%) cases had unilateral ptosis. In the study by Shimizu et al. [27], 234 (60%) cases had bilateral ptosis.

The mean preoperative MRD1 (1.19 ± 0.51 mm) ranged between +0.5 and +2.00 mm, which is higher than MRD1 in Ha et al. [36] (−2.00 to 0.50 mm) (average −0.50 ± 1.10 mm), higher than that in Lake et al. [32] (−1.00 to 3.50 mm), higher than that of Lucarelli and Lemke [22] (average 0.8 ± 0.4 mm), less than the average MRD1 in Seung et al. [34] (1.56 ± 0.70 mm), but closer to Jung and La [33] (average 1.1 ± 0.8 mm). However, the mean postoperative MRD1 (3.86 ± 0.65 mm) in our study was higher than that reported by Lucarelli and Lemke [22] (average 3.7 ± 0.3 mm), higher than that of Jung and La [33] (average 2.8 ± 1.1 mm), but closer to Seung et al. [34] (average 3.86 ± 0.94 mm).

Levator function in our study was good in 10%, fair in 76%, and poor in 14% of cases. It was good in Lake et al. [32] (9-14 mm); in Ben Simon et al. [31] (levator function was >10 mm), and in Jung and La [33] (it was ≥8 mm).

In our study, the levator muscle was tucked in using a 7/0 nylon thread and a guided syringe needle gauge no. 21 without any skin incisions. In the traditional approach, a 20-22-mm long lid crease skin incision is made using a no. 15 blade, which results in severing of the attachments of the levator aponeurosis to the overlying orbicularis muscle and these should be recreated at the end of the procedure to ensure an appropriate postoperative lid crease [37].

However, many techniques had been performed before for repair of mild and moderate blepharoptosis through an anterior or a posterior approach using skin or conjuctival incisions and tissue resections as follows:

Anterior approach

Liu in 1993 used a single 6-0 nylon suture for poneurotic ptosis correction [38].

Meltzer et al. [38] and Lucarelli and Lemke [22] performed ptosis repair by a long traditional incision with a 5-6 mm wide-bite single adjustable suture 'hang-back' 5-0 silk suture for plication of the superior portion of the levator aponeurosis.

The dissection technique of Lucarelli and Lemke [22] is similar to the traditional approach using an 8-mm skin incision site marked in the upper eyelid crease at the horizontal position, where lifting produces the desired margin contour using a 5-0 nylon suture passed in partial thickness through the tarsus and in full thickness through the levator.

Jung and La [33] corrected blepharoptosis coexisting with dermatochalasis surgically through a small orbital septum incision and minimal dissection after redundant upper lid skin excision and a single fixation suture between the levator aponeurosis and the tarsus. If the levator function is poor, more advancement and upward dissection of levator aponeurosis is required. Recurrence of ptosis or eyelid contour abnormalities, which can occur because of the use of a single fixation suture, can be prevented by a wide-bite suture into the tarsal plate [33].

The correction in Seung et al. [34] was performed through an external upper blepharoplasty approach. Once the orbital septum was opened, Mόller's muscle - levator aponeurosis was advanced and tucked under the posterior surface of the tarsus by a single lifting suture of 6-0 nylon (just medial to the mid-pupillary line).

Posterior approach

Lake et al. [32] performed a subtotal resection of Mόller's muscle plus underlying conjunctiva under direct visualization. The muscle stump was reattached to the tarsus and the sutures were passed through to the skin crease. In those cases where the phenylephrine test was positive to a level less than the desired lid height, a 1 mm of strip of tarsus is included in the tissue resection.

Singh et al. [35] performed a procedure in which the levator was picked up from the depth of the fornix and attached at three points, to the anterior surface of the tarsal place, without the need for extensive dissection or excision of tissues. They used 80-μm vanadium steel sutures, which have the advantage of no tissue drag during application, no tissue reaction, and no need for removal [35].

Shimizu et al. [27] reported a procedure where the skin at the marked points on the eyelid is penetrated with a scalpel to make minor slits less than 1 mm in length in which the suspension sutures are enfolded at the end of the operation. They turned the upper eyelid inside out, and threads of nylon 7/0 were introduced into it through the conjunctiva close to the superior fornix. Then, the superior palpebral levator muscle and the tarsus were connected using threads. This thread application is performed at two-to-four locations of the upper eyelid. By tightening the threads, the tarsus is elevated and the ptotic eyelid is corrected [27].

In our study, the success rate was 90.5% (4.8% acceptable and 4.8% undercorrected).

According to severity, the success rate for mild ptosis was 100% and that of moderate ptosis was 88.9% normal corrected or within 0.5 mm of normal, 5.6% acceptable. With the technique of Shimizu et al. [27], the success rate was 97.5% for mild and 88.9% for moderate ptosis. This was higher than that reported by Lucarelli and Lemke [22] (89.3%) and Jung and La [33] (84.6%), but lower than that reported by Lake et al. [32] (92%) and Seung et al. [34] (96.1%).

The correlation between severity and success rate in our study was statistically insignificant (P > 0.05).

We achieved a 100% success rate in cases with good levator function, with fair levator function, 93.8% were normal corrected or 0.5 mm within normal, 6.3% was acceptable, and 67% with poor levator function.

The correlation between levator function and success rate in our study was also statistically insignificant (P > 0.05).

There were no complications in 20 (95.2%) eyelids; one (4.8%) eyelid had an early postoperative mild irregular lid contour, which improved spontaneously within 1 month. In the rest of the cases, a smooth lid contour was observed and all the patients had normal lid closure. None of our patients had skin scars, dimpling, any signs or symptoms of dry eye, or postoperative corneal abrasion, but we observed one undercorrected eyelid in one patient who had preoperative MRD1=1 mm and poor levator function = 4 mm.

Lake et al. [32] also reported no patients with any signs or symptoms of dry eye or problems with upper lid entropion. Lid entropion was prevented by passing the suture through the upper border of tarsus to the skin crease, which exerts an everting action on the upper lid, maintaining lid stability and position [32].

In all 46 patients tested by Putterman and Urist [39], no transient dry eye symptoms were observed. Ha et al. [36] reported no complication in their study.

According to the complications reported by Lake et al. [32], only two (3%) patients developed a corneal abrasion, which healed rapidly with adequate lubrication. Abrasion could be attributed to preoperative post anesthesia surface drying rather than problems with the sutures looped through the conjunctival surface; this was confirmed by healing of the cornea before suture removal.

Shimizu et al. [27] reported foreign body sensation and hematoma present in 11 (2.3%) and five (1.0%) eyelids, respectively. However, no cases with these complications required secondary surgery. Foreign body sensation disappeared within 2-3 weeks after the operation; hematoma disappeared within 1-2 weeks of the operation.

Singh et al. [35] reported two cases of corneal abrasion for which bandage lenses were used successfully. In mild, moderate, and severe ptosis, there is no lid lag and the lid moves in harmony with the other side. However, many patients are operated for severe ptosis who show significant lid lag, but no lagophthalmos was observed in the patients.

Jung and La [33] reported peaking or unsatisfactory lid contour in five eyelids. Seung et al. [34] reported minor complications, with one patient (both eyelids) showing undercorrection and three patients showing asymmetry.

Therefore, this study yielded good results in the treatment of mild and moderate blepharoptosis and this operation can be reperformed if there is undercorrection.

  Conclusion Top

(1) Nonincisional (threading) levator plication is a safe and effective method for the treatment of mild to moderate blepharoptosis.

(2) It has the advantages of good cosmetic results because of avoidance of scar and skin dimpling, smooth good contour, and the ability of normal eye closure.

(3) It has a shorter operation time and is easy to teach and learn.

(4) It has a high success rate (90.5%).

(5) In terms of the postoperative complications, we had one patient with a slight irregularity of the lid margin, which corrected spontaneously within 1 month.

  Acknowledgements Top

  References Top

Small KW, Stalvey M, Fisher L, et al. Blepharophimosis syndrome is linked to chromosome 3q. Hum Mol Genet 1995; 4 :443-448.  Back to cited text no. 1
Griffin RY, Sarici A, Unal M. Acquired ptosis secondary to vernal conjunctivitis in young adults. Ophthal Plast Reconstr Surg 2006; 22 :438-440.  Back to cited text no. 2
Paul A, Rahim A, Mikhail M, et al. An unusual case of complete ptosis and failure of elevation due to severe facial trauma. Orbit 2007; 26 :323-325.  Back to cited text no. 3
Hwang K, Kim SG, Lee SI, et al. Blepharoptosis caused from compression of levator muscle by fractured orbital roof fragment. J Craniofac Surg 2004; 15 :942-945.  Back to cited text no. 4
Glatt HJ, Putterman AM, Fett DR. Müller's muscle-conjunctival resection procedure in the treatment of ptosis in Horner's syndrome. Ophthalmic Surg 1990; 21:93-96.  Back to cited text no. 5
Tossounis CM, Saleh GM, McLean CJ. The long and winding road: contact lens-induced ptosis. Ophthal Plast Reconstr Surg 2007; 23:324-325.  Back to cited text no. 6
Elfervig LS. Drooping eyelids due to aging. Plast Surg Nurs 2000; 20 :166-169.  Back to cited text no. 7
Finsterer J. Ptosis: causes, presentation, and management. Aesthetic Plast Surg 2003; 27 :193-204.  Back to cited text no. 8
Dutton JJ. Atlas of clinical and surgical orbital anatomy. Philadelphia: WB Saunders 1994; 120-125.  Back to cited text no. 9
Levine MR. Manual of oculoplastic surgery. Oxford, England: Butterworth-Heinemann 1996; 75-105.  Back to cited text no. 10
Putterman AM. Cosmetic oculoplastic surgery: eyelid, forehead, and facial techniques. London: WB Saunders; 1999. 137-159.  Back to cited text no. 11
Cohen AJ, Weinberg DA, editors. Evaluation and management of blepharoptosis. 1st ed. New York, NY: Springer-Verlag; 2010.  Back to cited text no. 12
Frueh BR, Musch DC, McDonald H. Efficacy and efficiency of a new involutional ptosis correction procedure compared to a traditional aponeurotic approach. Trans Am Ophthalmol Soc 2004; 102 :199-206. discussion 206-207.  Back to cited text no. 13
Frueh BR, Musch DC, McDonald HM. Efficacy and efficiency of a small-incision, minimal dissection procedure versus a traditional approach for correcting aponeurotic ptosis. Ophthalmology 2004; 111 :2158-2163.  Back to cited text no. 14
Tsa CC, Li TM, La CS, et al. Use of orbicularis oculi muscle flap for undercorrected blepharoptosis with previous frontalis suspension. Br J Plast Surg 2000; 53 :473-476.  Back to cited text no. 15
Goldey SH, Baylis HI, Goldberg RA, et al. Frontalis muscle flap advancement for correction of blepharoptosis. Ophthal Plast Reconstr Surg 2000; 16 :83-93.  Back to cited text no. 16
Arslan E, Demirkan F, Unal S, et al. Enhanced frontalis sling with double-fixed, solvent-dehydrated cadaveric fascia lata allograft in the management of eye ptosis. J Craniofac Surg 2004; 15 :960-964. discussion 965-6.  Back to cited text no. 17
Carter SR, Meecham WJ, Seiff SR. Silicone frontalis slings for the correction of blepharoptosis: indications and efficacy. Ophthalmology 1996; 103 :623-630.  Back to cited text no. 18
Ichinose A, Tahara S. Transconjunctival levator aponeurotic repair without resection of Müller's muscle. Aesthetic Plast Surg 2007; 31 :279-284.  Back to cited text no. 19
Emsen IM. A new ptosis correction technique: a modification of levator aponeurosis advancement. J Craniofac Surg 2008; 19 :669-674.  Back to cited text no. 20
Waqar S, McMurray C, Madge SN. Transcutaneous blepharoptosis surgery - advancement of levator aponeurosis. Open Ophthalmol J 2010; 4 :76-80.  Back to cited text no. 21
Lucarelli MJ, Lemke BN. Small incision external levator repair: technique and early results. Am J Ophthalmol 1999; 127.  Back to cited text no. 22
Park DH, Baik BS. Advancement of the Müller muscle-levator aponeurosis composite flap for correction of blepharoptosis. Plast Reconstr Surg 2008; 122 :140-142.  Back to cited text no. 23
American Academy of Ophthalmology. Preferred practice pattern. San Francisco: The Eye M.D. Association; 2008.  Back to cited text no. 24
Collin JRO,MA,MB,DO. Ptosis. In: Manual of systematic eyelid surgery.Oxford, England: Butterworth-Heinemann 1999; 41-72.  Back to cited text no. 25
Sakol PJ, Mannor G, Massaro BM. Congenital and acquired blepharoptosis. Curr Opin Ophthalmol 1999; 10 :335-339.  Back to cited text no. 26
Shimizu Y, Nagasao T, Asou T. A new non-incisional correction method for blepharoptosis. J Plast Reconstr Aesthet Surg 2010; 63 :2006 -2014.  Back to cited text no. 27
Matsuo K. Restoration of involuntary tonic contraction of the levator muscle in patients with aponeurotic blepharoptosis or Horner syndrome by aponeurotic advancement using the orbital septum. Scand J Plast Reconstr Surg Hand Surg 2003; 37 :81-89.  Back to cited text no. 28
Pang NK, Newsom RW, Oestreicher JH, et al. Fasanella - Servat procedure: indications, efficacy, and complications. Can J Ophthalmol 2008; 43 :84-88.  Back to cited text no. 29
Rosenberg C, Lelli Jr GJ, Lisman RD. Early postoperative adjustment of the Fasanellae - Servat procedure: review of 102 consecutive cases. Ophthal Plast Reconstr Surg 2009; 25 :19-22.  Back to cited text no. 30
Ben Simon GJ, Lee S, Schwarcz RM, MacCann JD, Goldberg RA. Müller's muscle conjunctival resection for correction of upper eyelid ptosis: relationship between phenylephrine testing and the amount of tissue resected with final eyelid position. Arch Facial Plast Surg 2007; 9 :413-417.  Back to cited text no. 31
Lake S, Mohammad-Ali FH, Khooshabeh R. Open sky Müller's muscle conjunctival resection for ptosis surgery. Eye 2003; 17 :1008-1012.  Back to cited text no. 32
Jung Y, La TY. Blepharoptosis repair through the small orbital septum incision and minimal dissection technique in patients with coexisting dermatochalasis. Korean J Ophthalmol 2013; 27 :1-6.  Back to cited text no. 33
Seung Il Ch, Byung JA, Ki YK, Yong GC, Jong YH, Won YY, et al. Blepharoptosis correction using retrotarsal tucking of Müller muscle - levator aponeurosis. New York: The Aesthetic Meeting; 2013.  Back to cited text no. 34
Singh D, Kaur A, Singh K, Singh SK, Singh RS. Sutureless levator placation by conjuctival route: a new technique. Ann Ophthalmol 2006; 38 :285-292.  Back to cited text no. 35
Ha SW, Lee JM, Jeung WJ, Ahn HB. Clinical effects of conjunctiva-Müller's muscle resection in anophthalmic ptosis. Korean J Ophthalmol 2007; 21 :65-69.  Back to cited text no. 36
Shovlin JP. The aponeurotic approach for the correction of blepharoptosis. Int Ophthalmol Clin 1997; 37 :1- 3.  Back to cited text no. 37
Meltzer MA, Elahi E, Taupeka P, Feuer WJ. A simplified technique of ptosis repair using a single adjustable suture. Ophthalmology 2001; 108 :1889-1892.  Back to cited text no. 38
Putterman AM, Urist MI. Müller muscle-conjunctival resection. Arch Ophthalmol 1975;93:619-623.  Back to cited text no. 39


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

  [Table 1], [Table 2], [Table 3]


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