Optimizing esthetic outcomes in graded full-thickness anterior blepharotomy for Graves’ ophthalmopathy

  • Jason Kian Seng Lee
  • Mei-Xue Loi
  • Yi-Hsuan Wei
  • Shu-Lang LiaoEmail author
Oculoplastics and Orbit



Current outcome measures do not adequately address the esthetic aspect of the surgical outcome of anterior blepharotomy for Graves’ ophthalmopathy. This study aims to highlight the role of tarsal platform show (TPS) in optimizing the esthetic outcome of graded full-thickness anterior blepharotomy for dysthyroid upper eyelid retraction in an ethnic Chinese population.


The records of patients with Graves’ ophthalmopathy who underwent anterior blepharotomy for upper eyelid retraction over a period of 30 months were retrospectively reviewed.


Fifty-five patients (77 eyelids) with upper eyelid retraction underwent anterior blepharotomy. A statistically significant decrease in marginal reflex distance (MRD1) and lagophthalmos and significant increase in TPS following anterior blepharotomy was observed. A significantly higher proportion of patients who underwent unilateral anterior blepharotomy had TPS asymmetry post-operatively as compared to the bilateral group (p < 0.001). Using logistic regression, the study found that for every 1-mm change in MRD1, there was approximately a 1.045-mm change in TPS. The mean percentage increase in TPS observed in our study was 303.1 ± 191% due to the low pre-operative TPS seen in Asian patients.


To achieve the most ideal surgical outcome in graded full-thickness anterior blepharotomy, the surgeon will need to consider not only eyelid height but also the subsequent TPS change. The surgeon needs to be mindful of the relationship between MRD1 change and TPS change to optimize esthetic outcome as well as symmetry. Special considerations need to be taken in unilateral cases as well as patients with low pre-operative TPS.


Esthetic outcome Anterior blepharotomy Upper eyelid retraction Tarsal platform show Graves’ ophthalmopathy 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Financial disclosure

The authors have no financial or proprietary interest in any materials or methods mentioned in this article.


  1. 1.
    Bartley GB, Fatourechi V, Kadrmas EF, Jacobsen SJ, Ilstrup DM, Garrity JA, Gorman CA (1996) Clinical features of Graves’ ophthalmopathy in an incidence cohort. Am J Ophthalmol 121(3):284–290CrossRefGoogle Scholar
  2. 2.
    Bartley GB (1996) The differential diagnosis and classification of eyelid retraction. Ophthalmology 103(1):168–176CrossRefGoogle Scholar
  3. 3.
    Grove AS Jr (1981) Upper eyelid retraction and Graves’ disease. Ophthalmology 88(6):499–506CrossRefGoogle Scholar
  4. 4.
    Shih MJ, Liao SL, Kuo KT, Smith TJ, Chuang LM (2006) Molecular pathology of Muller’s muscle in Graves' ophthalmopathy. J Clin Endocrinol Metab 91(3):1159–1167. CrossRefGoogle Scholar
  5. 5.
    Ohnishi T, Noguchi S, Murakami N, Nakahara H, Hoshi H, Jinnouchi S, Futami S, Nagamachi S, Watanabe K (1993) Levator palpebrae superioris muscle: MR evaluation of enlargement as a cause of upper eyelid retraction in Graves disease. Radiology 188(1):115–118. CrossRefGoogle Scholar
  6. 6.
    Feldon SE, Levin L (1990) Graves’ ophthalmopathy: V. Aetiology of upper eyelid retraction in Graves’ ophthalmopathy. Br J Ophthalmol 74(8):484–485CrossRefGoogle Scholar
  7. 7.
    Shih MJ, Liao SL, Lu HY (2004) A single transcutaneous injection with Botox for dysthyroid lid retraction. Eye 18(5):466–469. CrossRefGoogle Scholar
  8. 8.
    Mancini R, Khadavi NM, Goldberg RA (2011) Nonsurgical management of upper eyelid margin asymmetry using hyaluronic acid gel filler. Ophthal Plast Reconstr Surg 27(1):1–3. CrossRefGoogle Scholar
  9. 9.
    Putterman AM (1981) Surgical treatment of thyroid-related upper eyelid retraction. Graded Muller’s muscle excision and levator recession. Ophthalmology 88(6):507–512CrossRefGoogle Scholar
  10. 10.
    Tucker SM, Collin R (1995) Repair of upper eyelid retraction: a comparison between adjustable and non-adjustable sutures. Br J Ophthalmol 79(7):658–660CrossRefGoogle Scholar
  11. 11.
    Liu D (1993) Surgical correction of upper eyelid retraction. Ophthalmic Surg 24(5):323–327Google Scholar
  12. 12.
    Harvey JT, Corin S, Nixon D, Veloudios A (1991) Modified levator aponeurosis recession for upper eyelid retraction in Graves’ disease. Ophthalmic Surg 22(6):313–317Google Scholar
  13. 13.
    Mourits MP, Koornneef L (1991) Lid lengthening by sclera interposition for eyelid retraction in Graves’ ophthalmopathy. Br J Ophthalmol 75(6):344–347CrossRefGoogle Scholar
  14. 14.
    Elner VM, Hassan AS, Frueh BR (2004) Graded full-thickness anterior blepharotomy for upper eyelid retraction. Arch Ophthalmol 122(1):55–60. CrossRefGoogle Scholar
  15. 15.
    Hintschich C, Haritoglou C (2005) Full thickness eyelid transection (blepharotomy) for upper eyelid lengthening in lid retraction associated with Graves’ disease. Br J Ophthalmol 89(4):413–416. CrossRefGoogle Scholar
  16. 16.
    Nimitwongsakul A, Zoumalan CI, Kazim M (2013) Modified full-thickness blepharotomy for treatment of thyroid eye disease. Ophthal Plast Reconstr Surg 29(1):44–47. CrossRefGoogle Scholar
  17. 17.
    Lee J, Lee H, Park M, Baek S (2016) Modified full thickness graded blepharotomy for upper eyelid retraction associated with thyroid eye disease in East Asians. Ann Plast Surg 77(6):592–596. CrossRefGoogle Scholar
  18. 18.
    Goldberg RA, Lew H (2011) Cosmetic outcome of posterior approach ptosis surgery (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc 109:157–167Google Scholar
  19. 19.
    Lew H, Goldberg RA (2016) Maximizing symmetry in upper blepharoplasty: the role of microptosis surgery. Plast Reconstr Surg 137(2):296e–304e. CrossRefGoogle Scholar
  20. 20.
    Papageorgiou KI, Ang M, Chang SH, Kohn J, Martinez S, Goldberg RA (2012) Aesthetic considerations in upper eyelid retraction surgery. Ophthal Plast Reconstr Surg 28(6):419–423. CrossRefGoogle Scholar
  21. 21.
    Li TG, Shorr N, Goldberg RA (2005) Comparison of the efficacy of hard palate grafts with acellular human dermis grafts in lower eyelid surgery. Plast Reconstr Surg 116(3):873–878 discussion 879-880CrossRefGoogle Scholar
  22. 22.
    Evans JA, Clark TJE, Zimmerman MB, Allen RC, Nerad JA, Carter KD, Shriver EM (2018) Rethinking our definition of postoperative success: a comparative analysis of three upper eyelid retraction repair techniques using novel metrics to capture functional and aesthetic outcomes. Ophthal Plast Reconstr Surg 34(1):55–63. Google Scholar
  23. 23.
    Hassan AS, Frueh BR, Elner VM (2005) Mullerectomy for upper eyelid retraction and lagophthalmos due to facial nerve palsy. Arch Ophthalmol 123(9):1221–1225. CrossRefGoogle Scholar
  24. 24.
    Golan S, Rootman DB, Goldberg RA (2016) The success rate of TED upper eyelid retraction reoperations. Orbit 35(6):335–338. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Jason Kian Seng Lee
    • 1
  • Mei-Xue Loi
    • 2
  • Yi-Hsuan Wei
    • 3
  • Shu-Lang Liao
    • 3
    • 4
    Email author
  1. 1.Ophthalmology and Visual Sciences DepartmentKhoo Teck Puat HospitalSingaporeSingapore
  2. 2.Department of OphthalmologyTaipei Medical University Wan Fang HospitalTaipeiTaiwan
  3. 3.Department of OphthalmologyNational Taiwan University HospitalTaipeiTaiwan
  4. 4.School of MedicineNational Taiwan UniversityTaipeiTaiwan

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