The anterior layer of the levator aponeurosis in blepharoptosis correction

Background: Conventional aponeurotic surgery for blepharoptosis has many advantages, but there is a potential for recurrence and lagophthalmos. The anatomy of the levator palpebrae muscle is relatively well studied, but the relationship of levator aponeurosis with surrounding layers is still controversial. This study aims to prove the presence of an anterior layer of the levator aponeurosis in clinical cases and to describe a technique involving its use for obtaining predictable outcomes in blepharoptosis correction.Methods: Between January 2014 and October 2018, 173 patients with blepharoptosis underwent correction surgery that involved relocating the anterior layer of the levator aponeurosis. During this procedure, after retracting the preaponeurotic fat pad, we could identify the misinserted anterior layer of the levator aponeurosis on the floor of the fat pad. The anterior layer was divided and advanced with posterior layers to 2 mm below the upper margin of the tarsus. After surgery, patients were followed up for 1 year, and surgical outcomes were evaluated.Results: After 1 year of follow-up, 95.4% of the examined patients showed good long-term outcomes. Moreover, although 4% showed moderate outcomes and lost the double eyelid skin crease, there was no ptosis recurrence in these patients and no lagophthalmos occurred in any of the 173 patients.Conclusions: The authors found the misinserted anterior layer of the levator aponeurosis at the floor of preaponeurotic fat pad in blepharoptosis patients. Relocation of the anterior layer can provide predictable outcomes without lagophthalmos in blepharoptosis correction.