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Aim: Eyelid contour is a key component to satisfactory lid position and appearance following ptosis repair, the components of which have been highly debated and remain difficult to objectively measure. We sought to minimize the number of intraoperative adjustments required and reduce reoperation rates by addressing only the central 6 mm of tarsus when reapproximating levator to the anterior surface of tarsus, thereby eliminating contour as an adjustable variable. Methods: All patients who underwent external levator resection with blepharoplasty for correction of involutional ptosis between 2012 and 2019 by a single surgeon at one center were retrospectively reviewed. Patients who underwent concomitant brow lifting surgery were excluded. The same technique was used for each eyelid with uniform suture placement. One 6-0 silk horizontal mattress suture was placed partial thickness through the superior third of tarsus 3 mm lateral to the center of tarsus; another was passed 3 mm medial to the center of tarsus. No sutures were placed outside of this central 6-mm zone. Patient fixation was used to determine lid height and symmetry. Once satisfactory, the sutures were tied down in a permanent fashion and the eyelid position again verified. In total, 153 eyelids in 85 patients were evaluated. Data obtained included preoperative and postoperative margin-to-reflex distance (MRD 1 ), intraoperative and postoperative complications, reoperation rates, and patient satisfaction with appearance of lid contour and symmetry. Results: The mean follow up time was 3.41 months. The mean preoperative MRD 1 was 1.05 mm. The mean postoperative was 3.18 mm. All patients had recovery of an anatomically normal temporal peak height. Two of 153 eyelids (1.31%) required reoperation due to residual ptosis or overcorrection. No patients had postoperative lagophthalmos. Ninety-one percent of patients who underwent bilateral surgery had satisfactory symmetry defined as less than or equal to 1-mm difference between right and left MRD 1 . Eighty-two of the 85 patients were satisfied with their postoperative appearance. Conclusion: This simple and standardized technique for suture placement gives reliable and effective results for external elevator advancement for ptosis repair by eliminating contour as an adjustable variable. Addressing the central 6 mm of tarsus is not only paramount but also in and of itself satisfactory in achieving optimal contour during external levator resection, without regard to more medial or lateral lid anatomy.

The “central six” of ptosis repair: eliminating contour as a variable in external levator surgery