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Page 4 of 6 Campbell et al. Plast Aesthet Res 2020;7:12 I http://dx.doi.org/10.20517/2347-9264.2019.59

Table 1. Results
Number of patients 85
Total eyelids 153
Bilateral surgery 68
Average age 72
1.05 mm
Average preoperative MRD 1
3.18 mm
Average postoperative MRD 1
2.13 mm
Average improvement in MRD 1
Reoperation required 2
Post op symmetry (MRD 1 difference < 1 mm) 91.2%
Patients satisfaction 96.5%
MRD 1 : margin-to-reflex distance

1.32 mm). Only two patients (1.31%) required reoperation: one for overcorrection and the second for
residual ptosis. Both of these patients had undergone unilateral surgery. The patient with residual ptosis
who underwent reoperation had to be converted to general anesthesia intraoperatively due to patient
pain and discomfort, thus not allowing for intraoperative adjustment of eyelid height. Of those who
underwent bilateral surgery, 62 patients (91.2%) had satisfactory postoperative symmetry of eyelid height
defined as an MRD difference less than 1 mm between the two eyes. Postoperatively, 82 of 85 patients
1
(96.5%) were satisfied with the outcomes of surgery. The three patients who were not satisfied included
the two who required reoperation, while the third patient elected not to have a reoperation performed
for residual ptosis. The two who underwent a secondary surgery using the same technique had good
results. No patients developed postoperative lagophthalmos. There were no immediate postoperative
complications. Figure 2 shows typical patients who underwent surgery with the central six technique.

DISCUSSION
The two main goals of ptosis surgery are to restore eyelid height and contour, which can often be a
challenging process requiring multiple intraoperative adjustments. The traditional approach is to place
a central stitch to achieve the correct height, but this then leaves a peak centrally. Additional sutures are
placed medially and laterally to restore a natural eyelid shape. Multiple techniques to simplify the procedure
[4]
have been proposed since modern ptosis surgery was described in the 1970s by Jones et al. . In the 1990s,
there were several modifications. Liu et al. proposed the concept of a single-suture ptosis repair, while
[6]
[7]
Lucarelli and Lemke later introduced small incision ptosis repair without concurrent blepharoplasty.
Meltzer et al. presented their experience using an adjustable suture. Later, Ahuero et al. proposed a
[9]
[8]
refinement to small-incision surgery with a standardized suture placement at the medial pupillary border
and lateral limbus.
In a similar fashion, our proposed technique standardizes suture placement and thus eliminates contour as
an adjustable variable. In our practice, those patients who have external ptosis surgery performed generally
require concomitant blepharoplasty for dermatochalasis and are not good candidates for small-incision
ptosis surgery. We have had excellent results with high patient satisfaction by only focusing on the central
6 mm of tarsus for suture placement. Operative time is reduced, thus leading to improved patient comfort
and safety. Intraoperative adjustments for height can be made by tightening or loosening sutures, or on
occasion a suture must be replaced to achieve more lift. Eyelid contour is typically excellent, without need
to adjust suture placement horizontally.

Eyelid contour is a key component to satisfactory lid position and appearance following ptosis repair, the
components of which have been highly debated and remain difficult to objectively measure [11-13] . External
[11]
photos can be analyzed with geometrical models to quantify contour . Another technique involves