From January 2024 to January 2025, 102 Chinese patients with suboptimal double eyelids were enrolled in this retrospective study. The inclusion criteria were as follows: (1) age over 18 years; (2) at least six months since the last oculoplastic surgery; (3) no history of botulinum toxin or filler injection in the upper face within the previous 6 months; and (4) absence of neuromuscular disorders, Parkinsonism, or myasthenia gravis.

This study was approved by the Ethics Committee of Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine (approval No. SH9H-2024-T30-1). The requirement for informed consent for participation was waived by the Ethics Committee because of the retrospective nature of this study.

The severity of each patient’s suboptimal double-eyelid deformity was assessed using the height, shape, and function (HSF) scoring criteria. The HSF system was adapted from Chen’s grading framework and was used as a composite difficulty classification system for revisional blepharoplasty. Unlike a simple arithmetic summation of the three dimensions, the final score represents the overall revision difficulty determined by the predominant deformity pattern^[17] [Table 1].

To evaluate the consistency and objectivity of the assessments between two independent plastic surgeons (Jin R and Yu W), inter-rater reliability was calculated using Cohen’s kappa coefficient (κ). In instances where there was a discrepancy in HSF grading, a third senior surgeon (Yang J) reviewed the clinical photographs, and a final grade was determined through consensus.

The patient was placed in the supine position. Routine disinfection and sterile draping were performed according to standard protocols. The double-eyelid incision line was delineated based on the desired height and curvature, with the original scar tissue temporarily preserved. Local anesthesia was achieved via subcutaneous infiltration, typically with 2% lidocaine and 1:100,000 epinephrine. An incision was made along the marked line. Meticulous dissection was performed to identify and isolate the previous surgical scar. Layer-by-layer separation was performed to expose the anterior orbital septum, followed by thorough release of cicatricial adhesions using high-frequency electrocautery under direct visualization. No laser was used during dissection. The orbital septum was then opened to fully mobilize the residual septal fat.

For patients presenting with volume deficiency, particularly those with upper eyelid retraction and a sunken superior sulcus, mobilized central and lateral orbital fat was transposed medially into the pre-aponeurotic space to restore a functional sliding layer. Orbital fat transposition was performed in nearly all eyes with residual orbital fat requiring volume redistribution. Concurrently, the Pendulum Movement of Orbital Fat and Retro-Orbicularis Oculi Fat technique was employed: a superior-medial pedicled flap of the retro-orbicularis oculi fat was dissected and narrowed. This flap was then rotated laterally in a pendulum-like fashion to fill the lateral tissue defect created by medial displacement of the orbital fat^[18]. In cases where local autologous tissue was insufficient, distant-site autologous fat grafting was performed for volume augmentation. The graft material consisted primarily of sheet-like autologous fat or a vascularized periumbilical fat flap, selected according to the degree of soft-tissue deficiency^[13,14].

Restrictive bands and ligaments between the levator aponeurosis and the posterior orbital septum were meticulously released. The orbital septum-levator aponeurosis flap was then dissected superiorly from the superior tarsal border. At this point, a flap containing the orbital septum and underlying levator aponeurosis was formed. This construct acted as a motor transmitter and was termed the “bridge”.

For patients with blepharoptosis, the motor transmitter consisted of the levator aponeurosis and Müller’s muscle. All 37 eyes with blepharoptosis underwent levator aponeurosis advancement to restore eyelid height. In severe ptosis, dissection extended beyond the check ligament to facilitate sufficient anterior advancement and force transmission. For patients with upper eyelid retraction, the levator aponeurosis-Müller’s muscle complex was lengthened using transverse incision-longitudinal suturing. All 11 eyes with upper eyelid retraction underwent this maneuver, and 3 eyes with insufficient soft-tissue volume additionally received vascularized periumbilical fat flaps.

A portion of pretarsal tissue was preserved, and the complex was anchored to the superior one-third of the tarsal plate with four to five horizontal mattress 6-0 silk sutures. At this stage, the bridge was constructed, and the knots on the tarsus were termed piers. Eyelid height, curvature, and symmetry were assessed intraoperatively, and adjustments were made until an optimal shape was achieved without entropion or angular deformity.

A multi-layered closure was performed using 7-0 nylon sutures to approximate the orbicularis oculi muscle, levator aponeurosis, and retro-orbicularis oculi fat/orbital fat layers. This step is referred to as the sandwich suturing technique, as the complex is secured between the superior and inferior segments of the orbicularis oculi muscle. Particular emphasis is placed on re-anchoring orbital fat and retro-orbicularis oculi fat superior to the intended eyelid crease to reconstruct the physiological gliding plane and prevent postoperative superior sulcus deformity.

After confirming sufficient skin redundancy, redundant skin and original scar tissue were excised. If skin laxity was inadequate, the original scar was preserved to avoid lagophthalmos. Finally, the skin incision was integrated with the bridge cable to create the double-eyelid fold. During this step, levator aponeurosis fibers were incorporated between the superior and inferior dermal edges in an interrupted fashion, simulating the physiological anatomy of a natural crease in which terminal levator aponeurosis fibers extend to the dermis. This approach was intended to maximize the long-term stability and natural dynamic appearance of the postoperative fold (Figure 1; see Supplementary Video 1 for a detailed demonstration). A diagram of the entire operation procedure is presented in Figure 2.

Antibiotic ointment was applied to the incision, followed by a light gauze dressing and intermittent cold compresses to minimize postoperative edema. Cold compresses were applied for approximately 30 min per session during the first 24 h postoperative period.

Outcomes were evaluated across three domains: aesthetic refinement, functional restoration, and surgical complications. To avoid ambiguity in data presentation, eye-level denominators were used for HSF severity classification and functional outcomes, whereas patient-level denominators were used for overall aesthetic grading and satisfaction-related outcomes.

Aesthetic outcomes were assessed by two independent plastic surgeons (Jin R and Yu W) at the final follow-up, 11-14 months postoperatively. The assessment included a retrospective review of standardized digital photographs and clinical records. Patients were seated in a neutral position with the head in the Frankfort horizontal plane. High-resolution images were captured in primary gaze, with the eyes open and closed, to evaluate fold dynamics and scar quality. The detailed aesthetic evaluation criteria are presented in Table 2.

Functional efficacy was prioritized for patients presenting with preoperative upper eyelid retraction or blepharoptosis. The primary functional outcome measure was margin reflex distance 1 (MRD1). MRD1 was measured on standardized frontal photographs using ImageJ software (National Institutes of Health, Bethesda, MD, USA). Quantitative changes between preoperative and postoperative values were analyzed using paired t-tests. All statistical analyses were performed using IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY, USA), with P < 0.05 considered statistically significant.

Adverse events and surgical morbidities were documented during follow-up. The assessment focused on recurrence of the initial deformity, undercorrection, incomplete eyelid closure, exposed sutures, and the formation of postoperative upper-eyelid fat nodules or granulomas.

A total of 102 patients (137 eyes) were included in this study. The study population consisted of 5 males (4.9%) and 97 females (95.1%), with a mean age of 31.4 years (range, 18-48 years). Based on the HSF classification, preoperative severity was categorized at the eye level as follows: 17 eyes (12.4%) had an HSF score of 1-3, 39 eyes (28.5%) scored 4-7, and 81 eyes (59.1%) scored 8-10. The mean follow-up period was 12.4 months (range, 11-14 months). Baseline demographic information and the distribution of the 137 treated eyes are summarized in Table 3 and Figure 3.

The Pendulum Movement of Orbital Fat and Retro-Orbicularis Oculi Fat technique was applied in 95 eyes (approximately 70% of treated eyes). Orbital fat transposition was performed in nearly all eyes with residual orbital fat requiring volume redistribution. All 37 eyes with blepharoptosis underwent levator aponeurosis advancement. All 11 eyes with upper eyelid retraction underwent transverse incision-longitudinal suturing, and 3 of these eyes additionally received vascularized periumbilical fat flaps because of insufficient soft-tissue volume.

Inter-rater reliability for preoperative HSF severity grading was almost perfect, with a Cohen’s κ value of 0.85 (P < 0.001).

Among the cohort, 37 eyes presented with blepharoptosis, comprising 29 eyes with mild-to-moderate ptosis and 8 eyes with severe ptosis. The mean MRD1 improved significantly from 1.82 ± 0.65 mm preoperatively to 3.94 ± 0.42 mm postoperatively (P < 0.001). Additionally, 11 eyes exhibited upper eyelid retraction before surgery. After intervention, the mean MRD1 decreased from 6.15 ± 0.58 mm to 4.08 ± 0.35 mm (P < 0.001), indicating significant improvement in eyelid position [Figures 4 and 5].

Postoperative aesthetic outcomes were independently evaluated by two raters. After minor discrepancies were resolved by consensus, 81 of 102 patients (79.4%) were graded as excellent [Figure 6]. Outcomes were graded as good in 9 patients (8.8%), primarily because of mild asymmetry. Seven patients (6.9%) received a fair grading; among these, 2 had significant asymmetry, 3 showed mild residual upper eyelid hollowing, and 2 presented with noticeable scarring. Five patients (4.9%) were graded as poor, including 4 cases of severe asymmetry and 1 case of recurrent multiple folds.

The overall complication rate was low, and no severe adverse events such as retrobulbar hemorrhage, infection, or corneal injury occurred. The primary postoperative issue was partial recurrence of functional deformities in severe cases. Among the 37 eyes with preoperative ptosis, mild recurrence was observed in 2 eyes (5.4%), and 1 eye (2.7%) regressed to the preoperative level. Among the 11 eyes with retraction, 1 eye (9.1%) exhibited mild recurrence. These cases were managed conservatively or scheduled for secondary adjustment after 6 months. No cases of lagophthalmos, exposed sutures, or granuloma formation were noted during follow-up.

A detailed review of recurrent cases suggested that recurrence was associated with severe preoperative scarring, insufficient residual skin or soft tissue reserve, and reduced elasticity of the levator aponeurosis-Müller’s muscle complex after multiple prior operations. In the ptosis cases that recurred, intraoperative adjustment initially achieved acceptable eyelid height, but postoperative scar contraction and weakening of force transmission likely contributed to partial loss of correction. In the retraction case, marked preoperative fibrosis and shortage of anterior lamellar tissue may have limited stable downward repositioning despite levator complex lengthening. These observations emphasize the importance of careful preoperative grading, conservative patient counseling, and staged secondary adjustment when tissue conditions are unfavorable.

Indiscriminate manipulation of the levator complex during primary surgery may lead to iatrogenic functional disorders. In this study, 37 eyes developed iatrogenic ptosis and 11 eyes had upper eyelid retraction. The Bridge Technique restored MRD1 to the normal range in most patients by adjusting levator force transmission. Nevertheless, the recurrence observed in severe cases underscores that neuromuscular recovery in heavily scarred tissues remains variable.

The timing of intervention for iatrogenic ptosis is also critical. Patients are often anxious and request immediate correction, but premature surgery may exacerbate inflammation and increase the risk of secondary complications. We advocate a waiting period of 3 to 6 months to allow edema to subside and tissues to soften; some ptosis-like symptoms may spontaneously improve during this period. Preoperative assessment should also consider Hering’s law of equal innervation, and surgeons should anticipate the contralateral eyelid response to unilateral correction to improve postoperative symmetry^[19].

Soft-tissue deficiency is a major hurdle in revisional surgery. Rather than relying heavily on free fat grafts, which have unpredictable resorption, we prioritize vascularized local tissue. The Pendulum Movement of Orbital Fat and Retro-Orbicularis Oculi Fat technique and orbital fat transposition are used to correct upper eyelid hollowing. Crucially, these autologous tissues are fixed above the newly formed supratarsal crease. This placement reconstructs the physiological gliding plane between the levator aponeurosis and the overlying skin-muscle flap, creating a physical barrier against recurrent adhesion. This step is essential for preventing postoperative incisional depression and recurrence of multiple folds.

Aesthetic refinement focuses on eliminating the artificial appearance. To resolve pretarsal fullness and step-like depression, the incision line is redesigned to lower excessively high fixation points to an optimal height. Pretarsal skin of the lower flap is tightened superiorly, while continuity of the orbicularis oculi muscle is restored to reduce incisional depression. Skin excision requires extreme caution. We adopt a preservation-first strategy in which the original scar is initially retained, and excision is performed only after internal fixation is complete and skin redundancy can be accurately assessed.

For severe cases with HSF scores of 8-10, particularly high-fold patients with significant skin shortage, a preoperative tissue expansion strategy may be considered. Patients are instructed to perform manual traction exercises on the upper eyelid for 3 to 6 months before surgery. This regimen may increase skin laxity and recruit a degree of tissue surplus, providing a safer margin for the revision procedure.

Revision surgery demands a high level of anatomical expertise because normal landmarks are often destroyed or obscured by fibrosis. To navigate this, we employ a touch-bottom, or retrograde dissection, strategy. The surgeon first identifies the deep, healthy, unscarred anatomical planes and then dissects layer by layer toward the scarred superficial tissues. This reverse-engineering approach maximizes preservation of remaining normal tissue and minimizes collateral damage. Given the uncertainty and great difficulty of these procedures, thorough preoperative communication regarding realistic expectations is as important as the surgery itself.

The Bridge Technique offers a biomimetic solution to revisional blepharoplasty. The bridge pier provides a stable anchor to the tarsus and allows precise adjustment of crease height, depth, and levator force. The sandwich technique incorporates the orbicularis oculi muscle, retro-orbicularis oculi fat, and orbital fat into internal fixation to prevent adhesion, depression, and rigidity. The bridge cable mimics the natural terminal fibers of the levator aponeurosis extending to the skin. By modulating suture depth between the bridge cable and the muscle, the technique fine-tunes eyelid contour and creates a floating pretarsal segment rather than a stiff static scar.

This study has several limitations. First, it was a retrospective case series without a control group, which limits the ability to draw definitive comparative conclusions between the Bridge Technique and other revisional methods. Second, although the total number of treated eyes was relatively large for complex revision blepharoplasty, several important subgroups, particularly upper eyelid retraction and severe recurrent ptosis, contained limited numbers of eyes. This restricts subgroup analysis and may underestimate recurrence in the most severe categories. Third, aesthetic evaluation was based on standardized photographs and independent surgeon assessment; however, validated patient-reported outcome instruments, such as the Facial Assessment and Cosmetic Enhancement Quality of Life Questionnaire (FACE-Q) scale for double-eyelid blepharoplasty, were not prospectively collected^[20]. Fourth, because the study population consisted of Asian patients seeking revision after double-eyelid surgery, the findings may not be directly generalizable to non-Asian eyelid anatomy or to revision strategies commonly used in Western patients. Finally, the technique requires familiarity with scarred eyelid anatomy, levator complex manipulation, and local tissue transposition; therefore, outcomes may vary according to surgeon experience. Future prospective studies with longer follow-up, larger subgroup samples, standardized patient-reported measures, and comparative control groups are needed to further validate the clinical advantages and boundaries of this technique.

The Bridge Technique represents a composite physiological reconstruction strategy for revisional Asian blepharoplasty, moving beyond simple static fixation. By addressing the triad of levator function, volume restoration, and skin tension, this method addresses multifactorial revision challenges, including iatrogenic ptosis, pretarsal fullness, upper eyelid hollowing, multiple folds, and extensive scarring. The technique appears feasible, safe, and reproducible in experienced hands, with favorable functional and aesthetic outcomes in this retrospective cohort. Nevertheless, prospective controlled studies with larger sample sizes, validated patient-reported outcomes, and longer follow-up are needed to further validate its comparative efficacy.