Two-Point Fixation Levator Aponeurosis Tucking Versus
Standard Levator Resection for Congenital Blepharoptosis
Sameh H. Abdelbaky, MD, Rania A. Elessawy, MD; Dina H. Hassanein, MD;
Kareem B. Abdelrahman, MD; Heba H. Mohamed
Pediatric Ophthalmology Department, Cairo University, Cairo, EGYPT
Purpose: to compare the results of two-point fixation levator aponeurosis tucking versus standard levator
resection for congenital blepharoptosis.
Methods: This is a prospective, randomized, comparative, interventional study that included 42 eyelids of 40
children with isolated congenital ptosis with fair to good levator function. Cases were randomized into either
standard levator resection or levator tucking. Outcome was compared regarding margin reflex distance (MRD)
and eyelid contour.
Results: At the end of the follow up period (3 months), successful outcomes of the two techniques regarding
MRD within 3-5 mm were the same in both groups as met by 18 of 21 eyelids (85.7%). Good eyelid contour was
met in the resection group by 17 eyelids (80.95%) and in the tucking group by 16 eyelids (76.2%).
Complications were few and included undercorrection and overcorrection. Using two-point fixation helped to
reduce the operative time while maintaining good contour. Post-operative edema was less in the tucking group
which was attributed to less dissection.
Conclusion: Levator tucking is a good alternative to resection. It respects the normal physiology of the levator
aponeurosis complex, avoids lacrimal gland injury or conjunctival prolapse, and is a reversible procedure.
Keywords: Tucking; Congenital Ptosis; Resection
Ptosis is drooping of the upper eyelid to a lower
level than the normal. Normally upper eyelid cover
the upper 1-2 mm of the cornea in the primary
position. Congenital ptosis is generally unilateral
(70%). Ptosis may be present at birth or it may
develop later in life .If a droopy eyelid is present at
birth or within the first year of life, the condition is
called congenital ptosis. In most cases of congenital
ptosis, the problem is isolated. In severe cases of
ptosis, the drooping eyelid can cover part or the
entire pupil and interfere with vision, resulting in
amblyopia. (Guercio and Martyn, 2007; Berry-
Simple congenital ptosis is the most frequent
type of ptosis in children resulting from partial or
complete loss of levator muscle function mainly
caused by mal development of levator muscle.
(Zhang et al., 2011)
The method of repair depends on treatment
goals, the underlying diagnosis, and the degree of
levator function, Although the primary reason for the
repair is functional, the surgeon has an opportunity
through this procedure to produce symmetry in lid
height, contour, and eyelid crease for better cosmetic
appearance (Bagheri et al., 2007)
There are different techniques for correction and
the most used technique is resection of the levator
muscle through a skin incision in ptosis with fair to
good levator function. This is an effective procedure
for establishing good eyelid position, with reported
success rates from 70% to 95%. In this procedure,
the levator aponeurosis or muscle is usually sutured
to the tarsus with three sutures. However, adjusting
and fixing the levator aponeurosis on the tarsus at
three different points is relatively time and labor
consuming, And as the superior tarsus is narrow
medially and laterally, much more dissection is
needed to insert one additional suture. (Liu, 1993;
Wang and Wang, 2015)
Recently, some clinicians have attempted to
reduce the number of sutures used to fix the levator
aponeurosis on the tarsus. Also, there is a similar
technique, Levator Aponeurosis Tucking that was
first applied in treatment of blepharoptosis by
Mccord. (Mccord, 1981)
Tucking shortens the levator muscle with high
efficacy and safety with preservation of the normal
anatomy as much as possible with minimal
dissection and minimal edema. (Harris and
A successful ptosis surgery should provide good
contour and height of lid. In unilateral cases, the
repaired ptotic lid should be symmetrical as much as
possible with the contralateral lid. Moreover, it
2 Abdelbaky et al. / Two-Point Fixation Levator Aponeurosis Tucking Versus Standard Levator Resection….
should move freely with the globe this result can be
achieved only in cases with mild to moderate ptosis
with good eyelid excursion where shortening or
reinsertion of the levator muscle can be attempted
successfully (Jones et al., 1975).
Patients and Methods
A prospective, randomized, comparative and
interventional study that includes 40 children who
presented to the ophthalmology clinic at Cairo
University specialized pediatric hospital with
The study included cases with unilateral or
bilateral simple isolated congenital ptosis having a
levator function greater than 4mm, and younger than
Cases having congenital ptosis associated with
other ocular syndromes, Traumatic or acquired
ptosis or previous ptosis surgery were excluded.
Patients were randomly divided into two groups;
Group A included 20 patients who underwent levator
aponeurosis resection. Group B included 20 patients
who underwent two-point fixation levator tucking.
Preoperative assessment included history taking;
Age of onset, if it appeared since birth or first years
of life or later, Side (unilateral or bilateral), history
of change, is the condition improving, worsening, or
stationary, history of fatigability would warrant a
workup for myasthenia gravis history of change in
ptosis upon eating and swallowing, eye deviation,
family history, past history if ptosis was associated
with other ocular or systemic disorder.
Full ophthalmological examination including
unaided and aided visual acuity assessment,
cycloplegic refraction, pupil size and reaction ,tear
film and lacrimal system assessment ,anterior and
posterior segment assessment, Cover test to exclude
strabismus and pseudo ptosis in case of vertical
deviation and ocular motility assessment.
Assessment of ptosis was done to measure
amount and severity of ptosis by measuring the
marginal reflex distance (MRD 1) ; the distance
between the inferior margins of the upper eyelid and
the pupillary light reflex in the primary position of
gaze, palpebral fissure height was assessed by
measuring the widest distance between lower and
upper lid margin in the primary gaze and is
measured in millimeters with a transparent rule held
directly in front of the lids, levator function was
assessed by measuring the total upper eyelid
excursion from extreme down gaze to up gaze, while
pressing over the patient’s eyebrow to prevent action
of the frontalis and Bell’s phenomenon was also
Group A underwent standard levator resection,
the surgery was performed under general anesthesia.
The skin crease was marked so that it was symmetric
with that on the opposite side of the eyelid and 1–
2ml of 2% lidocaine with 1:100000 epinephrine was
injected subcutaneously into the eyelid. The eyes
were cleaned and draped taking all needed
precautions. The skin incision was made by scalpel
and deepened with scissors. Skin hooks is used to
gently spread and elevate the skin edges, and the
orbicularis muscle is divided using fine, sharp
scissors. The dissection was directed upward
posterior to the orbicularis muscle in preseptal space
to expose the orbital septum until orbital fat can be
identified through the intact orbital septum. Slight
pressure on the globe; this causes the orbital fat to
prolapse, making the identification easier. The
orbital septum is then divided by scissors for the
length of the skin incision. The orbital fat, orbital
septum and skin are retracted superiorly with a
retractor. Levator attachment at tarsal plate was then
cut and anterior and posterior dissection was done
after cutting the horns. The aponeurosis was
measured for the desired amount of resection, actual
resection of the tendon is reserved until the sutures
have been permanently tied and the position and
contour of the lid accomplished and ﬁxed to the
exposed tarsal border with three mattress sutures
with 6-0 prolene. One of the sutures was placed at
mid-pupil, while the medial and lateral sutures were
placed at the midpoint between the ﬁrst suture and
each canthus. Ellipse of skin was then excised in
cases with redundant skin. Then skin crease is then
closed and reformed by continuous suture (6-0
prolene) which passed from edge of lower skin flap
into levator muscle and out from edge of upper skin
flap. Dressing was applied at the end of the
Group B underwent levator aponeurosis tucking,
surgery was performed under general anesthesia
following the same initial steps of levator resection
till the exposure of the levator aponeurosis. The
aponeurosis was measured for the desired amount of
tucking, actual tucking is done by ﬁxation to the
exposed tarsal border with Two mattress sutures
.The central suture was passed at the level of medial
part of pupil and was first tightened to keep the lid
height and another lateral suture was taken about
6mm lateral to the first one. Ellipse of skin was then
excised in cases with redundant skin. Then skin
crease is then closed and reformed by continuous
suture (6-0prolene) which passed from edge of lower
skin flap into levator muscle and out from edge of
upper skin flap . Dressing was applied at the end of
Postoperatively, patients received combined
steroid and antibiotic eye drops four times daily for
one week and combined steroid and antibiotic eye
ointment once daily at night for one month. Margin-
reflex distance was assessed a at 1st week, 3rd week
and 3rd month.
3 Abdelbaky et al. / Two-Point Fixation Levator Aponeurosis Tucking Versus Standard Levator Resection….
Skin sutures were removed after 1 week. Any
complication was noticed and treated accordingly.
Data management and analysis were performed
using SigmaStat program; version 4 (Systat
Software, Inc., USA). The graphs were done using
Microsoft Excel. The numerical data were
statistically presented in terms of range, mean and
standard deviation. Categorical data were
summarized as percentages. Comparisons between
numerical variables of two groups were done by
Student’s unpaired t-test for parametric data.
Comparing categorical variables were done by Chi-
square test. Correlations between various variables
were done using P-value was considered significant
when P-values less than 0.05.
Pre-operatively, no significant statistical
difference between the age of the study group,
preoperative MRD 1, preoperative Palpebral Fissure
Height PFH, levator function between the two
groups (p=0.191, 0.444, 0.161, 0.806) respectively.
Demographic characteristic Group A Group B P value
Number of patients 20 20
Age (years) 5.310± 2.783 4.158 ±2.018 0.191
Sex( male/female) 12/8 15/5
Preoperative MRD1 (mm) 1.33+/-0.856 1.12+/-1.01 0.442
Preoperative PFH(mm) 5.833+/-0.913 6.38+/-1.499 0.161
Preoperative LF(mm) 6.857+/-1.905 6.714+/-1.875 0.806
Preoperative measurements of the two groups
Postoperative assessment to MRD 1 at each follow up (1st week, 3rd week, 3rd month).
Group A Group B P value
pre MRD 1 1.333±0.856 1.119±1.011 (P = 0.442)
post MRD 1 1week 4.262±1.056 3.833±1.155 (P = 0.294)
post MRD 1 3rd week 4.381±0.850 3.900±0.968 (P = 0.186)
post MRD 1 3rd month 4.143±1.236 3.905±0.983 (P = 0.254)
Difference between MRD 1 between two groups
Three criteria were chosen to identify successful surgical outcome, postoperative MRD 1 within 3-5mm,
difference in eyelid heights less than one millimeter, and satisfactory eyelid contour.
There was no significant statistical difference between the two groups regarding successful surgical
Success criterion Group A Group B P VALUE
( MRD 1: 3–5 mm) 18 /21eyelids
(P = 0.397)
≤1.0 mm difference in eyelid height 14/21 eyelids
(P = 0.563)
Satisfactory eyelid contour 17/21eyelids
(P = 0.683)
This study compares the surgical outcome of the
standard three point fixation levator resection and
two point fixation levator tucking for congenital
ptosis repair with good to fair levator function.
Different authors prefer a postoperative MRD 1 of
2–4 mm (Frueh et al ., 2004; Goncu et al .,2015)
or 2–4.5mm (McCulley et al ., 2003; Al-Abbadi et
al ., 2014) and an acceptable difference in lid height
above the center of the pupil of 0.5 mm (Meltzer et
al ., 2001; Frueh et al ., 2004 ) or 1.0 mm (Jones et
al ., 1975; Harris and Dortzbach ,1975; Fox ,1979)
to assess the surgical outcome. Three criteria for
success were chosen in our study, which included
4 Abdelbaky et al. / Two-Point Fixation Levator Aponeurosis Tucking Versus Standard Levator Resection….
postoperative MRD 1 within 3-5mm, lids within
1mm of each other and a satisfactory eyelid contour.
The results showed no significant statistical
difference in the surgical outcomes between the two
Advantages of levator tucking technique were
reported in many studies as it is simple both in
approach and execution and does not require
extensive dissection. It respects the normal
physiology of levator aponeurosis complex with
preservation of muscle innervation, medial and
lateral horns and avoids lacrimal gland injury (Liu,
1993). The lack of raw surface allows the better
smooth gliding of tissues and prevents postoperative
fibrosis. Maintenance of tissue planes and
preservation of anatomy makes reoperation easy, if
required. Also levator tucking is considered less time
consuming (Burman et al., 2002). Suture does not
penetrate deep into Muller’s muscle, there by
precluding hematoma formation (Liu, 1993).
Kumar and his colleagues in 2010 compared
levator tucking and levator resection in cases with
congenital ptosis, the result was 70% successful
outcome (regarding 1mm difference in eyelid
height )in levator resection group and only 10% in
levator tucking group. They explained that in their
study due to the use of absorbable sutures (5-
0vicryl) while in our study we used non absorbable
sutures (6-0 prolene) for fixation of levator
aponeurosis on the tarsus and we obtained better
results than their study in tucking group (76.2%)
regarding 1mm difference of eyelid heights.
As noted by Fox (1979), Harris and Dortzback
(1975) and Berlin and Vestal (1989) levator tucking
results were disappointing this was attributed to the
use of absorbable sutures. Liu (1993) and Older
(1983) used nylon and prolene sutures respectively
for tucking and both noted 95% results in achieving
good correction. The majority of the patients in Liu
study group were acquired (about 90%) with levator
action ranging from 11–17 mm. He concluded that
levator function of at least 8mm should be present if
more than 1mm of ptosis needs to be corrected.
Burman et al. (2002) and Bajaj et al. (2004)
studied levator tucking in congenital ptosis. Burman
(2002) obtained good results in all cases with levator
function >8mm, and in 85.7% of cases with levator
function 5–7mm which are similar to our results.
Ibrar Hussain (2006) used 3 double armed 6-0
vicryl sutures for plicating the levator aponeurosis
tendon through the skin approach. He obtained good
cosmetic outcome in 92% of the patients. Although
the minimum post-operative follow-up was 8 weeks,
the degree of ptosis after surgery was measured on
multiple occasions and mean of last follow-up was
calculated, thus the follow-up period was not
comparable between different patients.
Anderson and his colleagues (Anderson and
Beard, 1977; Anderson and Dixon, 1979), who
described the anatomy of the levator aponeurosis
and the aponeurosis surgery approach, prefer the
levator resection technique. They also stated that
tucking of the aponeurosis may not yield a
permanent result because it does not have a raw
surface. By this, we suppose they mean that a strong
and permanent adhesion is not formed between the
advanced aponeurosis edge and the superior border
of the tarsal plate. They also believe that, with the
tucking technique, the frequently encountered
postoperative drop of the eyelid may be due to the
suture having been placed in rarefied aponeurosis.
But in our technique, sutures were placed at the firm
attachment of aponeurosis to the superior tarsal
plate. The lack of raw surface allows the better
smooth gliding of tissues, prevents postoperative
fibrosis and facilitates re surgery.
Indeed, much effort has been made to simplify
this procedure. Liu in 1993 reported a technique that
uses a single-suture aponeurotic tuck. Meltzer and
his colleagues in 2001 presented excellent results
with an adjustable single suture. Lucarelli and
Lemke in 1999 published the first small-incision
ptosis procedure and used a single suture
predominantly, adding additional sutures as needed.
Since that time, many surgeons have reported that
this technique is simple and effective. So in our
study we attempted to reduce the number of sutures
for fixation levator muscle on the anterior tarsal
surface believing that will reduce time of operation,
it will decrease the need for more dissection and to
simplify the traditional advancement of the levator
aponeurosis which will improve postoperative
edema, but we were concerned that decreasing the
number of levator fixation sutures might increase the
risk of recurrent ptosis and were concerned about
eyelid contour problems.
Permanence should be considered when judging
the surgical outcome of ptosis repair. Concern that
decreasing the levator fixation suture count might
increase the risk of recurrence of ptosis is legitimate.
Therefore, long-term follow-up is important. In this
study, all patients were followed for at least 3
months. Frueh et al (2004) did not report the
follow-up time in their study comparing the efficacy
of a new small-incision, single-suture ptosis
procedure with that of a traditional ptosis surgery
because all patients were discharged from care if lid
position was adequate at 2 months. Doxanas (1992)
followed 150 patients for 3–5 years and reported no
case of late recurrence, which means that if patients
were over or under corrected, this was evident 1
week after surgery.
Regarding complications, in group A two eyes
were overcorrected as MRD 1 was 5.5mm, one eye
was under corrected as MRD 1 was 0 mm, there was
a difference in eyelid height more than 1mm in 7
patients. One patient with bilateral ptosis and both
eyelids operated at the same time, in the first follow
5 Abdelbaky et al. / Two-Point Fixation Levator Aponeurosis Tucking Versus Standard Levator Resection….
up MRD 1 was 4 mm then in the next follow up
MRD 1 started to decrease in right eye until it
became 0 mm, this was explained mostly by slipped
levator stitch and decision for reoperation taken.
Four patients had lid difference of 1.5 mm ,two
patients had lid difference of 2mm. Medial
notching was noticed in four patients and it slightly
improved by the end of the follow up period.
Infected sutures (figure 1) occurred in one patient in
the first week complicated by excessive fibrosis
resulting in inverted upper eyelid and lash ptosis.
Decision for reoperation was taken to release
adhesion and fibrosis. In group B, two eyes were
under corrected as one postoperative MRD 1 was
2mm ,other eye had postoperative MRD 1 2.5 mm
and only one eye was overcorrected as
postoperative MRD 1 was 5.5mm. There was a
difference more than 1mm in eyelid height in 5
patients as three patients had lid difference of 1.5
mm, one patient had lid difference of 2mm and one
patient had lid difference of 2.5 mm .other reported
complication bad contour happened in five patients,
three of them had medial notching and two had
lateral sagging (figure 2) until the end of follow up.
Lid edema was reported in all patients of
the study but it was more severe in group A and it
completely resolved by the end of follow up.
Lagophthalamos was reported in all patients of the
study and it improved in all patients by the end of
follow up. Exposure keratopathy was reported in one
patient in group B at third week postoperatively,
managed by lubricants and completely resolved in
the next week .Granuloma formation at lid crease in
one patient in group B at third week postoperatively,
managed by combined steroid antibiotic eye
ointment and completely resolved in the next week .
High lid crease (Figure 3) reported only in one
patient in group B and it wasn't significant.
Redundant skin reported only in one case in group A
and it wasn't significant.
Levator tucking is a good alternative to resection.
It respects the normal physiology of the levator
aponeurosis complex, avoids lacrimal gland injury
or conjunctival prolapse, and is a reversible
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