The goal of this clinical trial is to compare the efficacy of two surgical techniques-anterior and posterior white line advancement-for the correction of primary aponeurotic ptosis in adult patients. The main questions it aims to answer are:
Does the anterior approach lead to a greater improvement in Marginal Reflex Distance 1 (MRD1) at 6 months compared to the posterior approach?
Are there differences in eyelid symmetry, contour, visual function, and patient satisfaction between the two techniques?
Researchers will compare the anterior approach group to the posterior approach group to see if one offers better functional and aesthetic outcomes, fewer complications, or higher patient satisfaction.
Participants will:
Be randomly assigned to receive either anterior or posterior white line advancement surgery.
Undergo preoperative and postoperative evaluations at 7 days, 2 months, and 6 months, including:
Measurements of eyelid position (MRD1), contour, and symmetry
Vision and tear film tests (e.g., refraction, TBUT, Schirmer's test)
Surveys on dry eye symptoms (OSDI), scar quality (POSAS 2.0), satisfaction, and psychosocial function
Monitoring of surgical time and complications
Age over 18 years.
Diagnosis of primary aponeurotic upper eyelid ptosis.
Levator muscle function of 12 mm or greater.
Provision of written informed consent after receiving adequate information about the study.
Diagnosis of non-aponeurotic eyelid ptosis.
Poor levator muscle function.
History of recurrent eyelid ptosis or previous eyelid ptosis surgery.
Medical or surgical history that, in the investigator's judgment, may interfere with participation.
Parallel
Anterior White Line Advancement Surgery
Procedure/SurgeryThis technique involves a skin incision at the eyelid crease, dissection through the orbicularis muscle to expose the tarsus, and proximal dissection in the pre-Müller-conjunctival plane to visualize the white line. A double-armed 5-0 absorbable suture is used to advance the white line to the anterior tarsal surface. Eyelid height and contour are assessed before final fixation. Skin closure is completed with a non-absorbable suture.
Posterior White Line Advancement Surgery
Procedure/SurgeryThis conjunctival technique uses a traction suture and eyelid eversion to access the posterior surface of the eyelid. A conjunctival incision is made above the superior tarsal border, followed by dissection to expose the white line. A double-armed 5-0 absorbable suture is passed through the anterior tarsus and the white line, and tied after confirming adequate eyelid position. The conjunctiva is not sutured.
Change in Marginal Reflex Distance 1 (MRD1) at 6 Months
MRD1 will be measured preoperatively and at 6 months postoperatively to assess the difference in eyelid position between the anterior and posterior approach groups.
Change in MRD1 at 2 Months
Measured preoperatively and at 2 months postoperatively to compare eyelid position between groups.
Postoperative Interpalpebral Symmetry at 2 and 6 Months
Symmetry between eyelids will be evaluated to assess aesthetic outcomes.
Eyelid Contour Evaluation at 2 and 6 Months
Eyelid contour will be assessed using standardized frontal photographs in primary gaze. Objective analysis will be performed with ImageJ software using the Bézier plugin to calculate the percentage of overlap with an ideal curve (Excellent: \>90%, Good: 85-90%, Poor: \<85%). Subjective assessment will be conducted by three masked investigators based on symmetry, curvature, and slope criteria, rated as Excellent (3/3), Good (2/3), or Poor (0-1/3).
Change in Refractive Error at 2 and 6 Months
Comparison of pre- and postoperative refractive measurements.
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