Anterior versus posterior approach ptosis surgery in an NHS tertiary centre: Does technique determine outcome?

Purpose: Anterior (levator aponeurosis advancement) and posterior (Müller muscle–conjunctival resection) approaches to ptosis correction are both well established, but real-world comparative data from UK NHS practice are limited and most published series report a single technique. We evaluated whether surgical approach determines outcome, and which pre-operative factors do.

Methods: Retrospective review of 241 consecutive ptosis corrections performed in 174 patients between November 2024 and December 2025 at a tertiary ophthalmology centre, registered as a clinical audit. Adult and paediatric cases were analysed separately, as paediatric ptosis is pathologically distinct and full correction is deliberately not attempted in children with residual levator function. The primary comparison was anterior versus posterior approach in adult aponeurotic ptosis (n=149; 92 anterior, 57 posterior), using change in margin reflex distance 1 (MRD1) as the primary outcome, analysed by Mann–Whitney U test and by multivariable linear regression adjusted for pre-operative MRD1, levator function and concurrent blepharoplasty. Post-operative MRD1 was modelled directly, to avoid algebraic coupling between change scores and baseline.

Results: Median pre-operative MRD1 was 1.0 mm and median post-operative MRD1 3.0 mm. Both approaches achieved a median MRD1 improvement of +3.0 mm (p=0.722), and adjusted analysis showed no effect of approach (β=+0.64 mm, 95% CI −0.23 to +1.52, p=0.148). Post-operative lid height converged across baseline severity: the coefficient relating pre-operative to post-operative MRD1 was +0.26, significantly below unity (p<0.001), so that eyes with more severe ptosis achieved greater absolute gain but reached a similar endpoint. Fellow-grade and consultant operators achieved comparable outcomes on every measure (MRD1 change p=0.281; success p=0.701). Reoperation occurred in 13.7% of eyes with known status. No posterior-approach case in the series had a levator function of ≤4 mm, indicating that approach selection is driven by levator function rather than being compared across it.

Conclusion: In adult aponeurotic ptosis, approach selection may reasonably reflect surgeon expertise and patient anatomy rather than an expectation of superior lid height. Baseline severity, not technique, determines the magnitude of benefit, with direct implications for pre-operative counselling and consent. Comparable trainee outcomes provide reassurance for oculoplastic surgical training. Limitations include non-randomised, surgeon-led allocation and incomplete post-operative data in 28.9% of adult cases. These are interim findings; data collection is ongoing.