Closed Posterior Levator Advancement in Severe Ptosis

Background: Repair of blepharoptosis from the posterior eyelid approach has usually been done utilizing a Muller's muscle-conjuctival resection (MMCR) or an "open sky" technique. We present a new technique to advance the levator muscle from the posterior-approach in a closed fashion that can be used in patients with severe involutional ptosis. Methods: A retrospective chart review was performed for consecutive patients with severe involutional blepharoptosis during a 6-year period treated by a single surgeon with a Closed Posterior Levator Advancement. The inclusion criteria were good levator function (>= 10mm), graded response to phenylephrine (change in lid height, 0-5mm), and no concomitant procedures. Severe involutional blepharoptosis was defined as a margin-to-reflex-distance-1 (MRD1) of <= 1.5mm. Follow-up for all patients was a minimum of 9 months. The main outcome variables were MRD1, upper eyelid contour, intereye symmetry, and reoperation rates. Results: Three hundred three eyes from 192 patients, with severe ptosis were identified. The average age was 65 years, and the mean preoperative MRD1 was 0.3mm. Postoperatively, mean MRD1 was 3.5mm with a median improvement of 3.2mm. The upper eyelid contour was deemed to be satisfactory by patient and surgeon in 98.3% of eyes. Intereye symmetry was excellent in 96% of our cohort. An overall revision rate of 1.8% was found. Conclusions: We present a new technique that involves an advancement of the levator muscle in a closed posterior eyelid approach. The technique has produced satisfactory outcomes in our cohort of patients with severe ptosis with a low revision rate.