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Page 2 of 6 Campbell et al. Plast Aesthet Res 2020;7:12 I http://dx.doi.org/10.20517/2347-9264.2019.59

eyelids (1.31%) required reoperation due to residual ptosis or overcorrection. No patients had postoperative
lagophthalmos. Ninety-one percent of patients who underwent bilateral surgery had satisfactory symmetry defined
as less than or equal to 1-mm difference between right and left MRD . Eighty-two of the 85 patients were satisfied
1
with their postoperative appearance.

Conclusion: This simple and standardized technique for suture placement gives reliable and effective results for
external elevator advancement for ptosis repair by eliminating contour as an adjustable variable. Addressing the
central 6 mm of tarsus is not only paramount but also in and of itself satisfactory in achieving optimal contour during
external levator resection, without regard to more medial or lateral lid anatomy.

Keywords: Ptosis, levator advancement, central 6

INTRODUCTION
[1,2]
Acquired eyelid ptosis is most commonly due to involutional changes of the levator aponeurosis . There
are various surgical techniques to correct ptosis, and the majority of them focus on tightening or advancing
[5]
[3,4]
the levator aponeurosis onto tarsus . External levator advancement was first described in the 1880s ,
and since then it has been repeatedly modified and improved. The traditional surgical technique is to place
one or more sutures to reattach the levator aponeurosis to the anterior surface of tarsus once it has been
carefully dissected and partially resected. The first suture is placed centrally to achieve appropriate eyelid
height, and more sutures are then placed medially and laterally to achieve proper contour. This approach
can be cumbersome and require multiple adjustments intraoperatively to achieve proper contour. There
have been several studies suggesting modifications of the procedure in order to standardize and simplify
the process [6-9] . It remains a challenging surgery in order to achieve adequate lift of the eyelid while
retaining proper eyelid contour.

[10]
A recent study describing a single stitch müeller muscle conjunctival resection for ptosis repair has suggested
that only the central portion of the eyelid needs to be addressed surgically. Excellent results were demonstrated
with this technique, and it is similar to the concept we propose for the external levator advancement surgery.
We propose a technique for external levator resection that standardizes suture placement on only the
central 6 mm of tarsus, thereby eliminating contour as an adjustable variable and simplifying the surgery.

METHODS
A retrospective chart review was performed at the practice of the main author. The institutional review
board from Ascension St Vincent Hospital in Indianapolis granted exception status for the study. The
research was Health Insurance Portability and Accountability Act compliant and adhered to the principles
of the Declaration of Helsinki. All patients who underwent ptosis surgery by the main author from 2012 to
2019 using the central six technique were identified. The medical records were analyzed to record pertinent
clinical examination measurements and outcomes, including measurements of margin-to-reflex distance
(MRD ) and reoperation rates.
1
Patients with aponeurotic ptosis with levator function greater than 12 mm were included. Exclusion criteria
included those who underwent concomitant brow lifting procedures, those with prior ptosis surgery, and
those with inadequate follow up.

Surgical technique
Cases were performed under monitored anesthesia care with approximately 4-5 mL of local anesthetic
injected in each upper eyelid. Corneal protectors were placed to ensure no damage to the globe. A lid