Revision plan and results of anterior and posterior ptosis surgery

Abstract

To assess the outcomes of revision ptosis surgeries performed using a surgical technique different from the initial procedure—either Müller muscle conjunctival resection (MMCR) or external levator surgery (ELS) based on the phenylephrine-induced change in margin reflex distance-1 (MRD-1). This retrospective cohort study reviewed medical records of 780 patients who underwent MMCR or ELS for ptosis between January 2019 and December 2023. Revision surgery was required in 108 patients (15%). Among these, 32 eyes of 28 patients underwent a revision surgery using a technique different from the initial approach. Patient demographics, surgical details, and MRD-1 values at key clinical stages (pre-primary surgery, post-primary surgery, pre-revision surgery, and post-revision surgery) were recorded, along with levator function and postoperative complications. Twenty-eight patients (11 female, 17 male) were included. ELS was performed as the initial procedure in 13 eyes, and MMCR in 19 eyes. Surgical method for revision was determined based on the pre-revision phenylephrine response. Patients who initially underwent MMCR were classified as Group 1; those with initial ELS as Group 2. The mean interval between surgeries was 33.3 ± 38.2 months, and the mean follow-up duration was 42.5 ± 22.9 months. No significant difference in levator function or baseline MRD-1 values was observed between groups. A significant improvement in MRD-1 was noted after both primary and revision surgeries in each group. Eyelid symmetry was achieved in all patients. Satisfactory functional and cosmetic outcomes can be obtained in revision ptosis surgery using an alternative technique to the primary approach. Preoperative phenylephrine testing and comprehensive patient evaluation are critical for surgical planning. Phenylephrine testing is widely used to predict outcomes in primary blepharoptosis surgery, but its utility in revision procedures is not well established. This study demonstrates that selecting revision techniques (MMCR vs. ELS) based on phenylephrine-induced MRD-1 response yields significant functional and cosmetic improvements, ensuring eyelid symmetry even after different primary procedures. Findings support phenylephrine-guided planning as a practical approach to improve revision outcomes, highlighting the potential for broader adoption of individualized strategies in secondary ptosis management.