Transcutaneous Levator Aponeurosis Recession Without Spacer Grafts for Upper Eyelid Retraction: A Five-Case Series

This case series describes the surgical technique and early postoperative outcomes of transcutaneous levator aponeurosis recession without spacer grafts or newly created flaps for upper eyelid retraction. We report five consecutive Japanese patients (five eyelids) who underwent this procedure at Kanemori Eye Plastic Surgery Clinic between July 2017 and February 2026. Preoperative and three-month postoperative images were analyzed using ImageJ (National Institutes of Health; Bethesda, Maryland, United States). Palpebral fissure height ratio (PFHR) and upper eyelid margin height ratio (UEMHR) were calculated by normalizing palpebral fissure height and upper eyelid margin height to the white-to-white distance (WTW). Each image was measured three times, and the mean value was used for descriptive analysis. The median PFHR of the operated eyelid decreased from 111.18% (range, 63.57-132.16%) preoperatively to 89.93% (range, 59.50-99.71%) postoperatively. The median UEMHR decreased from 57.59% (range, 28.20-77.38%) to 37.72% (range, 25.17-50.09%). PFHR and UEMHR decreased in all five operated eyelids, and intereye asymmetry in both indices decreased. Exposure-related superficial punctate keratopathy in Cases 2, 3, and 5 and lagophthalmos in Case 4 resolved postoperatively. During the three-month follow-up, no infection, hematoma, diplopia, new severe lagophthalmos, or overcorrection/undercorrection requiring reoperation was observed. These early findings suggest that this spacer-free technique is feasible in selected cases and may provide consistent eyelid lowering when assessed with WTW-normalized eyelid height indices; however, these non-standard photographic indices are not substitutes for prospectively measured margin reflex distance 1 (MRD1). Larger prospective studies with longer follow-up, standardized MRD1 and ocular surface assessment, masked independent graders, and formal measurement reproducibility analysis are needed to assess durability, recurrence, late eyelid contour changes, measurement reliability, and etiology-specific suitability.