Adult Ptosis

  • Yoon-Duck KimEmail author
  • Stephanie Ming Young


Ptosis surgery for adults is one of the most commonly performed procedures by Oculoplastic surgeons. A detailed preoperative history and clinical evaluation are crucial for determining the cause of ptosis and the best procedure for the individual patient. Ptosis surgery can be broadly classified according to whether it is targeting the posterior upper lid retractor (Müller’s muscle), anterior upper lid retractor (levator aponeurosis) or the brow (frontalis muscle). Each procedure has its distinct advantages and own set of complications. A thorough knowledge of the steps and nuances of each procedure will enable the surgeon to better use them for the right patients and optimize surgical outcomes.


Ptosis Blepharoptosis Adult ptosis surgery Conjunctivomüllerectomy Levator advancement Levator resection Frontalis suspension Frontalis sling 

Suggested Readings

  1. 1.
    Gausas RE, Goldstein SM. Ptosis in the elderly patient. Int Ophthalmol Clin. 2002;42:61–74.CrossRefGoogle Scholar
  2. 2.
    Bleyen I, Hiemstra CA, Devogelaere T, van den Bosch WA, Wubbels RJ, Paridaens DA. Not only hard contact lens wear but alsosoft contact lens wear may be associated with blepharoptosis. Can J Ophthalmol. 2011;46:333–6.Google Scholar
  3. 3.
    Murchison AP, Sires BA, Amadi AJ. Margin reflex distance in different ethnic groups. Arch Facial Plast Surg. 2009;11:303–5.CrossRefGoogle Scholar
  4. 4.
    Chang S, Lehrman C, Itani K, Rohrich RJ. A systematic review of comparison of upper eyelid involutional ptosis repair techniques: efficacy and complication rates. Plast Reconstr Surg. 2012;129:149–57.CrossRefGoogle Scholar
  5. 5.
    Putterman AM, Urist MJ. Müller’s muscle-conjunctival resection. Arch Ophthalmol. 1975;93:619–23.CrossRefGoogle Scholar
  6. 6.
    Fasanella RM, Servat J. Levator resection for minimal ptosis: another simplified operation. Arch Ophthalmol. 1961;65:493–6.CrossRefGoogle Scholar
  7. 7.
    Patel RM, Aakalu VK, Setabutr P, Putterman AM. Efficacy of Muller’s muscle and conjunctiva resection with or without tarsectomy for the treatment of severe involutional blepharoptosis. Ophthalmic Plast Reconstr Surg. 2017;33:273–8.CrossRefGoogle Scholar
  8. 8.
    Baldwin HC, Bhagey J, Khooshabeh R. Open sky Müller muscle-conjunctival resection in phenylephrine test-negative blepharoptosis patients. Ophthal Plast Reconstr Surg. 2005;21:276–80.CrossRefGoogle Scholar
  9. 9.
    Buckman G, Jakobiec FA, Hyde K, et al. Success of the Fasanella–Servat operation independent of Müller’s smooth muscle excision. Ophthalmology. 1989;96:413–8.CrossRefGoogle Scholar
  10. 10.
    Morris WR, Fleming JC. A Histological analysis of the mullerectomy: redefining its mechanism in ptosis repair. Plast Reconstr Surg. 2011;127:2333–41.CrossRefGoogle Scholar
  11. 11.
    Rootman DB, Sinha KR, Goldberg RA. Change in eyelid position following Muller’s muscle conjunctival resection with a standard versus variable resection length. Ophthalmic Plast Reconstr Surg. 2018;34:355–60.CrossRefGoogle Scholar
  12. 12.
    Guyuron B, Davies B. Experience with the modified Putterman procedure. Plast Reconstr Surg. 1988;82:775–80.CrossRefGoogle Scholar
  13. 13.
    Weinstein GS, Buerger GF Jr. Modification of the Müller’s muscle-conjunctival resection operation for blepharoptosis. Am J Ophthalmol. 1982;93:647–51.CrossRefGoogle Scholar
  14. 14.
    Perry JD, Kadakia A, Foster JA. A new algorithm for ptosis repair using conjunctival Müllerectomy with or without tarsectomy. Ophthal Plast Reconstr Surg. 2002;18:426–9.CrossRefGoogle Scholar
  15. 15.
    Liao SL, Chuang AY. Various modifications of Müller’s muscle-conjunctival resection for ptosis repair. Arch Aesthetic Plast Surg. 2015;21:31–6.CrossRefGoogle Scholar
  16. 16.
    Pang NK, Newsom RW, Oestreicher JH, Chung HT, Harvey JT. Fasanella–Servat procedure: indications, efficacy, and complications. Can J Ophthalmol. 2008;43:84–8.CrossRefGoogle Scholar
  17. 17.
    Anderson RL. Age of aponeurotic awareness. Ophthal Plast Reconstr Surg. 1985;1:77–9.CrossRefGoogle Scholar
  18. 18.
    Jones LT, Quickert MH, Wobig JL. The cure of ptosis by aponeurotic repair. Arch Ophthalmol. 1975;93:629–34.CrossRefGoogle Scholar
  19. 19.
    Anderson RL, Dixon RS. Aponeurotic ptosis surgery. Arch Ophthalmol. 1979;97:1123–8.CrossRefGoogle Scholar
  20. 20.
    Berlin AJ, Vestal KP. Levator aponeurosis surgery: a retrospective review. Ophthalmology. 1989;96:1033–6.CrossRefGoogle Scholar
  21. 21.
    McCulley T, Kersten RC, Kulwin DR, et al. Outcome and influencing factors of external levator palpebrae superioris aponeurosis advancement for blepharoptosis. Ophthal Plast Reconstr Surg. 2003;19:388–93.CrossRefGoogle Scholar
  22. 22.
    Young SM, Lim LH, Seah LL, Choo CT, Chee EW, Shen SY, Lang SS, Looi AL. Prospective audit of ptosis surgery at the Singapore National Eye Centre: two-year results. Ophthalmic Plast Reconstr Surg. 2013;29:446–53.CrossRefGoogle Scholar
  23. 23.
    Shore JW, Bergin DJ, Garrett SN. Results of blepharoptosis surgery with early postoperative adjustment. Ophthalmology. 1990;97:1502–11.CrossRefGoogle Scholar
  24. 24.
    Older JJ. Levator aponeurosis surgery for the correction of acquired ptosis: analysis of 113 procedures. Ophthalmology. 1983;90:1056–9.CrossRefGoogle Scholar
  25. 25.
    Young SM, Kim YD, Kim JH, Lang SS, Woo KI. Lowering of the high eyelid crease in revision upper eyelid surgery. Aesthetic Plast Surg. 2019;43:139–46.CrossRefGoogle Scholar
  26. 26.
    Berke RN. Results of resection of the levator muscle through a skin incision in congenital ptosis. AMA Arch Ophthalmol. 1959;61:177–201.CrossRefGoogle Scholar
  27. 27.
    Wagner R, Mauriello JA Jr, Nelson LB, et al. Treatment of congenital ptosis with frontalis suspension: a comparison of suspensory materials. Ophthalmology. 1984;91:245–8.CrossRefGoogle Scholar
  28. 28.
    Ben Simon GJ, Macedo AA, Schwarcz RM, Wang DY, McCann JD, Goldberg RA. Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material. Am J Ophthalmol. 2005;140:877–85.CrossRefGoogle Scholar
  29. 29.
    Patrinely J, Anderson RL. The septal pulley in frontalis suspension. Arch Ophthalmol. 1986;104:1707–10.CrossRefGoogle Scholar
  30. 30.
    Wagner R, Mauriello JA Jr, Nelson LB, et al. Treatment of congenital ptosis with frontalis suspension: a comparison of suspensory materials. Ophthalmol. 1984;91:245–8.Google Scholar
  31. 31.
    Maycock N, MacGregor C, Saunders DA, Parkin B. Long term patient-reported benefit from ptosis surgery. Eye (Lond). 2015;29:872–4.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of OphthalmologySamsung Medical Center, Sungkyunkwan University School of MedicineSeoulSouth Korea
  2. 2.Department of OphthalmologyNational University Hospital SingaporeSingaporeSingapore

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