Blepharoptosis: Surgical Outcomes and Complications According to Systematic Reviews

How the evidence was selected: PubMed criteria for the most recent meta-analyses

A targeted PubMed search was conducted, limited to systematic reviews and meta-analyses that directly assessed the outcomes or safety of blepharoptosis surgery. Priority was given to the most recent studies reporting quantitative data on ptosis correction, eyelid position, recurrence, overcorrection, reoperation, and complications.

Recent literature mainly comprises studies on congenital ptosis and the different surgical techniques used to correct it, whereas meta-analyses specifically focused on acquired adult ptosis are more limited. Therefore, the results should be interpreted in relation to the type of ptosis and the surgical technique being evaluated.

What outcomes are assessed after ptosis surgery?

Meta-analyses use several parameters to assess surgical outcomes. The main measures include margin reflex distance 1 (MRD1), palpebral fissure height, the degree of incomplete eyelid closure, symmetry, and the need for additional procedures. In addition to efficacy, complications such as overcorrection, undercorrection, recurrence, lagophthalmos, corneal changes, infection, and problems related to suspension materials are also assessed.

Surgical techniques and outcomes in congenital ptosis

A 2025 meta-analysis compared levator-based procedures with frontalis-based procedures in patients with congenital ptosis and poor levator function. Sixteen studies were included. The analysis found no significant differences in postoperative MRD1 or change in MRD1 between the two categories of procedures. However, levator-based procedures were associated with a lower risk of recurrence and implant- or suture-related complications, while postoperative lagophthalmos was comparable between the groups.

These findings suggest that both strategies can be effective, but the choice of technique should primarily be tailored to residual levator muscle function and the characteristics of the ptosis.

Fascial sheath suspension: efficacy and safety

A 2025 meta-analysis evaluated conjoint fascial sheath suspension for the treatment of blepharoptosis. Ten studies involving a total of 683 patients were included. The analysis demonstrated a significant improvement in MRD1 and greater patient satisfaction compared with the comparator groups. The overall complication rate was also significantly lower in the group treated with this technique, with a favorable pooled risk ratio. However, the authors highlighted substantial heterogeneity in some outcomes and the need for cautious interpretation of the data. These findings indicate a possible advantage of the technique, but they do not support considering it universally superior to all other surgical procedures.

Autogenous fascia lata suspension: outcomes and complications

A 2024 meta-analysis evaluated the use of autogenous fascia lata in ptosis surgery, including 30 studies, 3,690 patients, and 5,059 eyes. The mean improvement in MRD1 was 2.79 mm, while the overall complication rate associated with the technique was 21.3%.

The most frequently reported complications included:

• Lagophthalmos: 19.8%;
• Residual ptosis: 11.5%;
• Corneal injury: 10.4%.

The reoperation rate was 13.4%. The most frequent reasons for reoperation were aesthetic in nature, including asymmetry and changes in the eyelid crease. It is important to note that the high degree of heterogeneity among studies limits direct comparison of complication rates. Nevertheless, the meta-analysis indicated that autogenous fascia lata may represent an effective technique, with fewer reoperations compared with some traditional techniques.

Müller muscle resection or levator advancement?

A 2023 meta-analysis compared conjunctival Müller muscle resection with external levator advancement in ptosis surgery. Seven studies involving a total of 1,038 eyelids were included. No significant differences were observed in postoperative MRD1 or the rate of undercorrection. However, external levator advancement was associated with a higher frequency of overcorrection and reoperation. Müller muscle resection was also associated with better aesthetic appearance, fewer overall complications, and shorter operative time.

These findings suggest that both techniques can effectively correct ptosis, but they may have different profiles in terms of predictability, complications, and the need for revision surgery.

Suspension materials and techniques: what do the meta-analyses show?

A 2023 meta-analysis compared different techniques and materials used in congenital ptosis surgery, including 14 randomized studies, 909 eyes, and 657 patients. The analysis showed that different techniques can produce different outcomes in terms of MRD1, palpebral fissure height, lagophthalmos, and aesthetic results. The material used for suspension may also influence certain outcomes. In particular, autogenous fascia lata demonstrated favorable results for symmetry and the contour of eyelid height. This confirms that there is no single optimal technique for all patients undergoing ptosis surgery: the choice depends on the anatomical and functional characteristics of the eyelid.

Recurrence, undercorrection, and overcorrection

The stability of the result is one of the most important aspects of ptosis surgery. An initially satisfactory correction may be followed by recurrence or residual ptosis, while excessive correction may result in an excessively high eyelid position

Recent meta-analyses show that the risk of these events varies according to the technique. In the comparison between levator-based and frontalis-based procedures, for example, levator-based techniques were associated with a lower frequency of recurrence and implant- or suture-related complications in patients with poor levator function. Surgical selection should therefore consider not only the ability to correct ptosis, but also the stability of the result over time.

Lagophthalmos and ocular surface complications

Lagophthalmos is one of the most relevant complications after ptosis surgery because incomplete eyelid closure can affect the ocular surface. In the meta-analysis on autogenous fascia lata, lagophthalmos was among the most frequent complications, with an incidence of 19.8%. Other analyses have shown that the risk may vary according to the technique and material used.

For this reason, the surgical outcome should not be assessed solely in terms of eyelid height, but should also take eyelid closure and ocular surface safety into consideration.

Factors influencing surgical outcomes

Meta-analyses show that the outcome of ptosis surgery depends on several factors, including:

• Type of ptosis;
• Levator muscle function;
• Surgical technique used;
• Material used for suspension;
• Degree of correction achieved;
• Anatomical characteristics of the eyelid.

These factors contribute to variability in outcomes and explain why a technique that is effective in a specific group of patients cannot automatically be considered the best choice for everyone.

Clinical implications and conclusion

Recent PubMed meta-analyses indicate that blepharoptosis surgery can achieve significant improvement in eyelid position, but outcomes and complication profiles vary according to the technique and patient characteristics.

Key takeaways from the literature include:

• Different surgical techniques can achieve effective correction of ptosis;
• The risk of recurrence, undercorrection, overcorrection, and reoperation varies between procedures;
• Lagophthalmos and ocular surface complications are important aspects of safety;
• The choice of technique should primarily consider levator muscle function and the type of ptosis;
• Surgical outcomes should be assessed not only in terms of eyelid position, but also symmetry, function, and aesthetic appearance.

Overall, the evidence does not support the concept of a universally superior technique. Surgical selection should be individualized according to the type of ptosis, levator function, anatomical characteristics, and the patient’s functional and aesthetic objectives.

Bibliography: the 5 PubMed meta-analyses considered

Abdelsattar NK, Taha AEASA, Fadl ZA, Ibrahim OA, Ali MTS, Farouk HK, Diab MM. Levator-based versus frontalis-based surgeries for poor-function congenital ptosis: Systematic review and meta-analysis. Saudi J Ophthalmol. 2025;39(3):246-255. PMID: 41179375.

Ji D, Liu Y, Han X, Hu S, Zhao Y. Efficacy and Safety of Conjoint Fascial Sheath (CFS) Suspension in the Treatment of Blepharoptosis: A Systematic Review and Meta-analysis. Aesthetic Plast Surg. 2025;49(15):4427-4438. PMID: 39982488.

Ahmad R, Rehman U, Sarwar MS, Ahmed Z, Adebayo O, Brennan PA. Use of autogenous fascia lata slings in the surgical correction of ptosis: a systematic review of the literature and meta-analysis. Br J Oral Maxillofac Surg. 2024;62(2):128-139. PMID: 38290862.

Karam M, Alsaif A, Abul A, Alkhabbaz A, Alotaibi A, Shareef E, Behbehani R. Muller's muscle conjunctival resection versus external levator advancement for ptosis repair: systematic review and meta-analysis. Int Ophthalmol. 2023;43(7):2563-2573. PMID: 36692699.

Chen L, Li J, Zhang C, Li Y, Hou L, Ma J. Surgical Interventions for Congenital Ptosis: a Systematic Review and Meta-analysis of 14 Randomized Controlled Trials. Aesthetic Plast Surg. 2023;47(5):1859-1869. PMID: 37145320.