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Minimally Invasive Conjoint Fascial Sheath Suspension for Blepharoptosis Correction

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  • Oculoplastic
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Blepharoptosis can not only affect facial appearance but physical and mental health as well. Traditional treatments require long recovery time and leave unpleasant scars. In this study, we explored a simple and effective way to correct mild, moderate blepharoptosis and analyzed the causes and precautions for postoperative complications.


From March 2014 to May 2017, patients presenting with mild or moderate bilateral or unilateral blepharoptosis underwent minimally invasive blepharoptosis correction using suspension of the conjoint fascial sheath of the levator and superior rectus. Mild blepharoptosis was corrected by 1 or 2 of loops suspension sutures, whereas moderate blepharoptosis was corrected by 3 or 5 loops. The postoperative evaluation, including the degree of correction or residual ptosis, asymmetry and presence of lagophthalmos, was performed after a minimum follow-up period of 9 months.


Forty patients (55 eyelids) were included. The mean followed up period was 13.40 ± 4.60 months. Good results were seen in 48 ptosis eyes (87.27%). Double eyelid crease was formed simultaneously without an obvious wound. Two mild ptosis eyelids received a fair result, and 4 moderate ptosis eyelids improved to “mild ptosis.” The mean marginal reflex distance 1 significantly increased postoperatively.


Long-term follow-up indicates that minimally invasive conjoint fascial sheath suspension works well for mild and moderate ptosis. With its short recovery time, simultaneous double eyelid crease formation and long-lasting effect, the surgery is worth popularizing.

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  1. Finsterer J (2003) Ptosis: causes, presentation, and management. Aesthetic Plast Surg 27:193–204

    Article  Google Scholar 

  2. Richards HS, Jenkinson E, Rumsey N, Harrad RA (2017) Pre-operative experiences and post-operative benefits of ptosis surgery: a qualitative study. Orbit 36:147–153

    Article  Google Scholar 

  3. Khooshabeh R, Baldwin HC (2008) Isolated Muller’s muscle resection for the correction of blepharoptosis. Eye (Lond) 22:267–272

    Article  CAS  Google Scholar 

  4. Bautista SA, Wladis EJ, Schultze RL (2018) Quantitative assessment of dry eye parameters after Muller’s muscle-conjunctival resection. Ophthalmic Plast Reconstr Surg 34:562–564

    Article  Google Scholar 

  5. Ben Simon GJ, Lee S, Schwarcz RM, McCann JD, Goldberg RA (2007) Muller’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 9:413–417

    Article  Google Scholar 

  6. Pang NK, Newsom RW, Oestreicher JH, Chung HT, Harvey JT (2008) Fasanella–Servat procedure: indications, efficacy, and complications. Can J Ophthalmol 43:84–88

    Article  Google Scholar 

  7. Saonanon P, Sithanon S (2018) External levator advancement versus Muller muscle-conjunctival resection for aponeurotic blepharoptosis: a randomized clinical trial. Plast Reconstr Surg 141:213e–219e

    Article  CAS  Google Scholar 

  8. Parsa FD, Wolff DR, Parsa NN, Elahi EE (2001) Upper eyelid ptosis repair after cataract extraction and the importance of Hering’s test. Plast Reconstr Surg 108:1527–1536 discussion 37–8

    Article  CAS  Google Scholar 

  9. Kokubo K, Katori N, Hayashi K et al (2016) Frontalis suspension with an expanded polytetrafluoroethylene sheet for congenital ptosis repair. J Plast Reconstr Aesthet Surg 69:673–678

    Article  Google Scholar 

  10. Holmstrom H, Santanelli F (2002) Suspension of the eyelid to the check ligament of the superior fornix for congenital blepharoptosis. Scand J Plast Reconstr Surg Hand Surg 36:149–156

    Article  Google Scholar 

  11. Hwang K, Shin YH, Kim DJ (2008) Conjoint fascial sheath of the levator and superior rectus attached to the conjunctival fornix. J Craniofac Surg 19:241–245

    Article  Google Scholar 

  12. Ahn TJ, Kim JH, Lee EI et al (2017) Nonincisional conjoint fascial sheath suspension: a novel technique for minimally invasive blepharoptosis correction. Ann Plast Surg 79:334–340

    Article  CAS  Google Scholar 

  13. Santanelli F, Paolini G, Renzi LF, Longo B, Pagnoni M, Holmstrom H (2011) Correction of myopathic blepharoptosis by check ligament suspension: clinical evaluation of 89 eyelids. J Plast Surg Hand Surg 45:194–199

    Article  Google Scholar 

  14. Putterman AM (2012) Margin reflex distance (MRD) 1, 2, and 3. Ophthalmic Plast Reconstr Surg 28:308–311

    Article  Google Scholar 

  15. Hickson-Curran S, Brennan NA, Igarashi Y, Young G (2014) Comparative evaluation of Asian and white ocular topography. Optom Vis Sci 91:1396–1405

    Article  Google Scholar 

  16. Chen AD, Lai YW, Lai HT et al (2016) The impact of Hering’s law in blepharoptosis: literature review. Ann Plast Surg 76(Suppl 1):S96–S100

    Article  CAS  Google Scholar 

  17. Ettl A, Priglinger S, Kramer J, Koornneef L (1996) Functional anatomy of the levator palpebrae superioris muscle and its connective tissue system. Br J Ophthalmol 80:702–707

    Article  CAS  Google Scholar 

  18. Lee EI, Ahn TJ (2014) Mild ptosis correction with the stitch method during incisional double fold formation. Arch Plast Surg 41:71–76

    Article  Google Scholar 

  19. Shimizu Y, Nagasao T, Asou T (2010) A new non-incisional correction method for blepharoptosis. J Plast Reconstr Aesthet Surg 63:2004–2012

    Article  Google Scholar 

  20. Scuderi N, Chiummariello S, De Gado F, Alfano C, Scuderi G, Recupero SM (2008) Surgical correction of blepharoptosis using the levator aponeurosis-Muller’s muscle complex readaptation technique: a 15-year experience. Plast Reconstr Surg 121:71–78

    Article  CAS  Google Scholar 

  21. Cetinkaya A, Brannan PA (2008) Ptosis repair options and algorithm. Curr Opin Ophthalmol 19:428–434

    Article  Google Scholar 

  22. Byun JS, Hwang K, Lee SY, Kim HT, Kim K (2017) Levator aponeurosis and Muller muscle plication reinforced with levator sheath advancement for blepharoptosis correction. J Craniofac Surg 28:1849–1851

    Article  Google Scholar 

  23. Park JW, Kang MS, Nam SM, Kim YB (2015) Blepharoptosis correction with buried suture method. Ann Plast Surg 74:152–156

    Article  CAS  Google Scholar 

  24. Lee JH, Nam SM, Kim YB (2015) Blepharoptosis correction: levator aponeurosis-Muller muscle complex advancement with three partial incisions. Plast Reconstr Surg 135:388–395

    Article  CAS  Google Scholar 

  25. Ma CJ, Lu F, Liu L (2018) A modified double eyelid plastic surgery method: continuous buried suture method accompanied by simultaneous correction of mild blepharoptosis. Aesthetic Plast Surg 42(6):1565–1570.

    Article  PubMed  Google Scholar 

  26. Park DH, Baik BS (2008) Advancement of the Muller muscle-levator aponeurosis composite flap for correction of blepharoptosis. Plast Reconstr Surg 122:140–142

    Article  CAS  Google Scholar 

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Correspondence to Xiaolei Jin.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the clinical research committee of plastic surgery hospital (12100000400266049B) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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Zhou, J., Chen, W., Qi, Z. et al. Minimally Invasive Conjoint Fascial Sheath Suspension for Blepharoptosis Correction. Aesth Plast Surg 43, 956–963 (2019).

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