Anterior Versus Posterior White Line Advancement Technique in the Correction of Aponeurotic Ptosis

MRD1 will be measured preoperatively and at 6 months postoperatively to assess the difference in eyelid position between the anterior and posterior approach groups.

Measured preoperatively and at 2 months postoperatively to compare eyelid position between groups.

Symmetry between eyelids will be evaluated to assess aesthetic outcomes.

Eyelid contour will be assessed using standardized frontal photographs in primary gaze.

Objective analysis will be performed with ImageJ software using the Bézier plugin to calculate the percentage of overlap with an ideal curve (Excellent: >90%, Good: 85-90%, Poor: <85%).

Subjective assessment will be conducted by three masked investigators based on symmetry, curvature, and slope criteria, rated as Excellent (3/3), Good (2/3), or Poor (0-1/3).

Comparison of pre- and postoperative refractive measurements.

Assessed using corneal topography to evaluate changes related to surgery.

Measured to assess the impact on tear film stability. TBUT will be measured by instilling fluorescein dye and recording the time (in seconds) from the last blink to the first appearance of a dry spot on the cornea. Each eye will be assessed three times, and the mean value will be used. Lower values indicate greater tear film instability. A TBUT <10 seconds is considered abnormal.

Evaluates tear production before and after surgery. The Schirmer I test (without anesthesia) measures basal and reflex tear production. Standardized strips will be placed in the lower fornix for 5 minutes. The length of wetting (in mm) will be recorded. Values <10 mm indicate decreased tear production.

Patient-reported outcomes on dry eye symptoms. The OSDI questionnaire includes 12 items assessing symptoms, visual function, and environmental triggers. Raw scores are converted to a 0-100 scale using the formula: (sum of scores × 25) ÷ number of questions answered. Higher scores indicate greater symptom severity. Classification: 0-12 (normal), 13-22 (mild), 23-32 (moderate), ≥33 (severe).

Assessed with the FACE-Q Aesthetics "Satisfaction with Eyes" scale. Raw scores are summed and converted to a 0-100 scale using the official Conversion Table. If ≥50% of items are answered, missing values are imputed using the within-person mean. Higher scores indicate greater satisfaction.

Patient-reported impact of surgery on self-image and social interaction. Measured using FACE-Q Aesthetics scales: Psychological Function, Social Function, and Appearance-Related Distress. Raw scores are summed and converted (0-100). Imputation is applied when ≥50% of items are answered. Higher scores reflect better outcomes, except for Distress, where higher scores indicate worse distress.

Evaluates discomfort, swelling, and return to normal activities. Assessed with FACE-Q Aesthetics scales for "Recovery Early Symptoms" and "Eyelids-upper." Scoring follows standard FACE-Q procedure with 0-100 conversion. Missing values are imputed if ≥50% of items are answered. Higher scores reflect better recovery and appraisal.

Includes willingness to undergo the procedure again. Evaluated using FACE-Q Aesthetics scales: "Satisfaction with Outcome" and "Satisfaction with Decision." Scores range from 0 (worst) to 100 (best). Missing data is managed per FACE-Q guidelines: impute mean values if ≥50% of items are completed.

Surgical complications recorded intraoperatively, and at 7 days, 2 and 6 months.

Total duration of the surgical procedure, defined as the time elapsed from the patient's entry into the operating room until their exit after completion of surgery, will be recorded and compared between each surgery group.