Many surgical techniques have been developed to address eyelid retraction with varying results. Identifying and evaluating the anatomical and pathophysiological factors involved will assist in its surgical treatment. This prospective study evaluated the graded levator hinge procedure, in combination with a Müllerectomy and/or lateral canthoplasty when indicated, in an attempt to precisely and selectively target the pathophysiology responsible for the various causes of eyelid retraction in only one surgical session.

This is a clinical, prospective study of patients with moderate to severe eyelid retraction due to various causes who underwent the graded levator hinge procedure, in combination with a Müllerectomy and/or lateral canthoplasty when indicated. The exact amount of hinging of the levator aponeurosis, and combination with a Müllerectomy and/or lateral canthoplasty, was determined by the clinical operative findings with active cooperation from the conscious patient.

Thirty-two consecutive patients (48 eyelids) with varying degrees of upper eyelid retraction underwent the graded levator hinge procedure in combination with a Müllerectomy and or lateral canthoplasty when indicated. The mean (± standard deviation) preoperative palpebral vertical fissure height was 12.4 mm (± 0.45 mm), and the mean postoperative palpebral fissure height was 9.0 mm (±0.20 mm). The mean preoperative asymmetry in the palpebral fissure height was 2.41 (± 0.29) mm, and the mean postoperative asymmetry was 0.59 mm (± 0.09), and this difference was statistically significant (P <.001). The mean reduction in the palpebral fissure height was 4.6 mm (± 0.29 mm) (range, 1–10 mm). The graded levator hinge procedure in combination with a Müllerectomy and or lateral canthoplasty when indicated, led to a statistically significant (P <.001) reduction in mean palpebral fissure height for all patients, the bilateral subset of patients, the unilateral subset of patients, and the thyroid-related orbitopathy subgroup. The graded levator hinge procedure in combination with a Müllerectomy and/or lateral canthoplasty when indicated led to a statistically significant reduction in palpebral fissure height, asymmetry between the eyes in the total set of patients, the unilateral set of patients, and the thyroid-related orbitopathy subset, but not in the bilaterally operated subset of patients, which were already relatively symmetric preoperatively. Postoperatively 90.6 % of all eyelids were within 1 mm of the desired postoperative level (25% were equal, 68.8% were within 0.5 mm, and 6.2% greater than 1 mm from the desired level).

The graded levator hinge procedure, alone or in combination with a Müllerectomy and/or lateral canthoplasty, is a safe and highly effective surgical approach for the treatment of various causes of upper eyelid retraction. Through consideration of the various anatomical and pathophysiological causes of eyelid retraction, excellent functional and cosmetic results are achieved with a graded procedure tapered to the needs of each individual.