Comparison of eyelid contour symmetry after ptosis repair via centralized versus temporally biased levator suturing techniques

Eyelid contour symmetry is an essential parameter in ptosis repair, yet temporal asymmetry often persists after traditional levator advancement. This study compared postoperative eyelid symmetry following centralized versus temporally biased levator suturing techniques in severe involutional ptosis patients. A retrospective comparative study was conducted on 60 patients (30 per group) with severe involutional ptosis [Margin Reflect Distance 1 (MRD1) ≤ 0 mm] who underwent external levator advancement by a single surgeon. Group 1 received conventional three-suture fixation with central-first placement; Group 2 underwent a two-suture technique starting slightly temporally to the mid-pupillary line. The eyelid contour was analyzed via Bézier curve modeling, and the symmetry indices were analyzed via MATLAB and ImageJ. Pre- and postoperative metrics included MRD1, Peak Height of Upper Lid (PHUL) location, and nasal/temporal symmetry scores. Both groups demonstrated significant improvements in MRD1 (p < 0.001). Although not statistically significant, Group 2 exhibited numerically superior postoperative symmetry (overall: 75.5% vs. 72.0%, p = 0.08) and more centralized PHUL positioning. Temporal symmetry improved to 71.0% in Group 2 and 68.0% in Group 1 (p = 0.09). Postoperative complication rates were comparable. Temporally biased suture placement tends to improve temporal eyelid symmetry without compromising overall outcomes. Although the differences were not statistically significant, the numerical trends suggest potential clinical benefits. Larger prospective studies are warranted.