Oculoplastic Surgery

Aesthetic Surgery Journal

2015, Vol 35(7) 774–781
The Effect of Hering’s Law on Different Ptosis © 2015 The American Society for
Aesthetic Plastic Surgery, Inc.
Repair Methods Reprints and permission:
journals.permissions@oup.com
DOI: 10.1093/asj/sjv052
www.aestheticsurgeryjournal.com

Arie Y. Nemet, MD

Abstract
Background: The Hering’s law effect has significant importance in surgical planning and outcomes of eyelid surgery.
Objectives: The current study examined the preoperative and intraoperative effect of Hering’s law in Mullerectomy and levator aponeurosis
advancement.
Methods: A retrospective analysis was conducted of 52 patients with unilateral ptosis who underwent surgical repair from January 2011 through June
2013. Patients underwent levator aponeurosis advancement or Mullerectomy with or without tarsectomy. Preoperative and postoperative clinical documen-
tation and photographs were evaluated. Preoperative Hering’s dependency and postoperative changes in positioning of the non-operated eyelid were mea-
sured. The decision to operate on the ptotic eye alone or on both eyelids was based on preoperative Hering’s dependence and intraoperative changes in
the contralateral eyelid.
Results: Fifty-two patients with unilateral ptosis were included. Average age was 63.3 ± 20.1 years (range, 22–88 years; median, 61 years); 34 (65.4%)
were female. The 14 cases that were not aponeurotic (either congenital, secondary to trauma, or due to postoperative ptosis) did not need contralateral
repair ( p = .000). In 4 (19%) cases of Mullerectomy and in 9 (52.9%) cases of levator advancement, both eyelids required surgery ( p = .029). Hering’s
law effect was significantly more apparent in the levator advancement approach than in Mullerectomy.
Conclusions: Levator surgery resulted in a higher incidence of combined intraoperative and postoperative Hering’s law effect than did Mullerectomy.
Cases with poor levator function or congenital ptosis can be repaired unilaterally with no need for contralateral surgery. The fibrotic levator palpebrae
muscle and its special innervations probably explain this phenomenon. This should be considered in surgical planning.

Level of Evidence: 3

Accepted for publication March 5, 2015; online publish-ahead-of-print April 24, 2015. Therapeutic

Outcomes of ptosis surgery are less predictable than those
of blepharoplasty and other types of eyelid surgery. In most
cases of asymmetric eyelid ptosis, the level of the contralat-
eral eyelid is at least partially dependent on both the preop-
erative and postoperative positions of the ptotic eyelid.1
Hering originally described the phenomenon of equal in-
nervations for dependent extraocular eye muscles.2 Walsh3
was the first to describe Hering’s law for eyelids, which is
the compensatory retraction of the contralateral upper
eyelid in cases of unilateral ptosis. The Hering’s law phe-
nomenon is explained by the special innervations of the
levator palpebralis (LP). Phylogenetically, it evolves by sep-
arating from the superior rectus muscle and differentiates
from it only late in embryogenesis.4 Therefore, the LP
would be expected to obey neurophysiologic rules that
apply to the superior rectus. The motor neuronal pool for
the levators lies in a single, unpaired central caudal nucleus
of the oculomotor complex. Single motor neurons innervate
the LP bilaterally.5,6 Clinically, according to Hering’s law, a
patient’s attempt to overcome ptosis in one eye will induce
Dr Nemet is the Director of Oculoplastic Service in the Department of
Ophthalmology at the Meir Medical Center, Kfar Sava, Israel, a Senior
Lecturer in the Sackler Medical School Tel Aviv University, Tel Aviv,
Israel, and Chair of the Israeli Society of Ophthalmic Plastic and
Reconstructive Surgery.
Corresponding Author:
Dr Arie Y. Nemet, Department of Ophthalmology, Meir Medical
Center, Tchernichovsky 59, Kfar Sava 44281, Israel.
E-mail: nemet.arik@gmail.com

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an increase in innervation in both levators, resulting in
contralateral lid retraction.7,8 The development of ptosis
in the contralateral upper eyelid after successful repair of
unilateral ptosis was demonstrated in 9.6% to 17% of
patients.7,9 The postoperative effect might be suppressed at
different levels by mechanisms including, but not limited
to, frontalis muscle action.7
Hence, it is important to consider Hering’s law when
planning blepharoptosis repair, bearing in mind every spe-
cific condition. In cases of bilateral ptosis, even with differ-
ent levels in each eye, both eyelids are repaired. However,
in unilateral cases, the repair of one eyelid may result
in contralateral eyelid drooping due to Hering’s law phe-
nomena. Likewise, Hering’s law effect may be influenced
either by the etiology of the ptosis or by the method of
surgical repair. It does not manifest in some circumstances,
for example with congenital ptosis.1,10,11 Thus, the Hering’s
law effect for different ptosis etiologies has not yet been
investigated.
Another unanswered question is whether Hering’s law
presents similarly when different surgical approaches are
used. Anterior repair by levator advancement and posterior
repair by Mullerectomy are two entirely different tech-
niques. In Mullerectomy, Muller’s muscle still regulates
the position of the upper eyelid. However, when the
levator aponeurosis is sutured directly to the tarsal plate, it
bypasses this mechanism. Muller’s muscle no longer
affects the eyelid level; rather, the levator aponeurosis per-
forms this function.1
The current study examined the effect of Hering’s law
on Mullerectomy and levator aponeurosis advancement
repair methods for cases of unilateral ptosis. Based on our
clinical impression, each surgical repair creates a different
Hering’s dependence.
METHODS
Study Population
This study reports a retrospective analysis of patients who
had surgical repair for unilateral ptosis performed by a
single surgeon (A.Y.N.), from January 2011 through June
2013. In this study, patients with bilateral ptosis were
excluded. When performing the surgery, the decision to
operate only on the ptotic eye or also on the contralateral
eyelid was based on the preoperative Hering’s dependence
and on the intraoperative result of the contralateral eyelid,
in all cases.
Patient Evaluation
The preoperative evaluation included a full-slit lamp exami-
nation, visual acuity test, and ptosis workup. Medical and
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general histories were taken. Patients were photographed
preoperatively and 1 and 6 months postoperatively.
The ptosis workup includes measurements of the mar-
ginal reflex distance (MRD), levator function (LF), the pal-
pebral fissure, and the presence of Bells’ phenomena. We
traditionally classify ptosis as mild (2 mm), moderate (3
mm), or severe (4 mm). Here, only cases with a MRD dif-
ference of more than 1 mm between eyes were operated.
Hering’s dependence was tested by manually elevating the
ptotic eyelid with a single finger to the desired position
during the patient’s initial assessment, and the contralateral
MRD was remeasured.12 The 2.5% phenylephrine test was
also performed for patients on whom a Mueller muscle re-
section procedure was considered, which also helps deter-
mine the effect of Hering’s law. The test is performed by
instilling 2 drops of 2.5% phenylephrine into the eye. The
phenylephrine test is more physiologic than the manual
lift; however, it influences the lower eyelid position and
dilates the pupil diameter, so both tests were performed.
After 5 minutes, the MRD1 was reassessed. An increase of
2 mm or more in the MRD1 is considered a positive test.
Based on these results, Mullerectomy was performed when
the test was positive and when no significant dermato-
chalasis was present. In the presence of significant der-
matochalasis, the anterior approach was chosen (although
some surgeons use a posterior approach with skin ex-
cision). When it was negative, levator advancement
was performed. Intraoperatively, if the contralateral eyelid
drooped, it was also corrected using the same surgical tech-
nique performed on the first side.
Surgical Procedures
All surgeries were performed under local anesthesia with
2% lidocaine and 1/100,000 epinephrine, administered by
local infiltration. No sedation was used, in order to prevent
eyelid drooping from the sedation effect.
For Mullerectomy, the surgical procedure was based on
the Hering’s dependence (if positive, the contralateral
eyelid was operated simultaneously). The amount of resec-
tion was adjusted slightly as needed to achieve small differ-
ences in the degree of elevation. Usually, a 2 mm ptosis
requires an 8 mm resection of Muller’s muscle and con-
junctiva. In cases needing more than 2 mm of elevation,
additional tarsectomy of 1 to 2 mm was performed, de-
pending on the amount of ptosis (Figure 1).13
The anterior levator aponeurosis advancement approach
was performed in cases with a negative phenylephrine test
or when significant dermatochalasis was present. The lid
crease was cut and the levator aponeurosis and the anterior
margin of the tarsal plate was exposed. The levator was ad-
vanced to the tarsus using 3 Vicryl 5-0 stitches. The eyelid
contours and heights were compared and evaluated with
the patient in a sitting position (Figure 2). Excess muscle
 776
Figure 1. Mullerectomy (the posterior approach). (A) The eyelid of a 42-year-old woman is elevated and two forceps are used to
catch the edge of the Muller’s muscle and the palpebral conjunctiva 4.5 mm below the tarsus. (B) The eyelid is elevated and the
Putterman’s clamp catches the Muller’s muscle and the palpebral conjunctiva. Additional tarsectomy can be included, based on
the amount of ptosis.
Figure 2. Levator aponeurosis advancement (the anterior ap-
proach). The lid crease of a 65-year-old man is cut and the
levator aponeurosis (upper arrow) and the anterior margin of
the tarsal plate (middle arrow) are exposed. The levator is ad-
vanced to the tarsus using 3 Vicryl 5-0 stitches. The lower
arrow points to the edge of the orbicularis oculi muscle.
and skin were excised and the skin sutured with single,
deep Vicryl 6-0 stitches. Supratarsal fixation to aponeurosis
was used to recreate the lid crease. Following repair of one
eyelid, the patient was again examined in a sitting position
and the lid height of both eyes measured. If the contralater-
al eye was ptotic, it was also repaired surgically.
Postoperatively, an eyelid position of less than 1 mm dif-
ference from the contralateral eyelid position, with a sym-
metrical contour was considered a good result. Otherwise, a
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Aesthetic Surgery Journal 35(7)
contralateral repair was performed on a second occasion.
The medical documentation was evaluated 6 months postop-
eratively, along with clinical examination of the preoperative
and postoperative photographs. The study was approved by
the Meir Medical Center Institutional Review Board.
Statistical Analysis
Categorical variables were analyzed using Fisher’s exact
test. Results were considered statistically significant when
p < .05. Data were analyzed using SPSS-12 Statistical
Software SPSS (SPSS Inc. Chicago, IL).
RESULTS
A total of 52 adult patients (range, 22–88 years; median, 61
years) with unilateral ptosis were included in the study.
There were 34 females (65.4%). Mullerectomy was per-
formed on 27 patients (52%), with an average follow-up of
15 months (range, 9–22 months), and levator advancement
was performaed on 25 (48%), with an average follow-up of
16 months (range, 11–24 months). Patient demographics
and preoperative measurements are presented in Table 1. A
summary of the surgical procedures is presented in Table 2.
The results of cases with aponeurosis ptosis were evaluated
separately.
Unilateral ptosis in those with Hering’s is actually bilat-
eral ptosis (latent) that is masked by the Hering’s in the re-
tracted eyelid. Hering’s law effect was encountered less
frequently with the posterior surgical approach. Both
 Nemet 777

Table 1. The Result of Ptosis Repair of the Contralateral Eye in Patients Table 2. Summary of Cases With Unilateral and Bilateral Ptosis Repair
With Unilateral Ptosis
Variable Mullerectomy Levator advancement
Variable Mullerectomy Levator Advancement (n = 27) (n = 25)
(n = 27) (n = 25)
Etiology
Gender, female 20 (74.5%) 14 (56.0%)
Aponeurotic 21 17
Mean age (years) 63.5 ± 18.9 62.9 ± 21.2
Other 6 8
Side (right) 10 (37.0%) 10 (40%)
Primary surgery
Bilateral 8 15
Unilateral 19 10
Secondary contralateral 2 2
surgery Bilateral 8 15

Average follow-up, 15 (9-22) 16 (11-24) Secondary contralateral surgery 2 2

months (range)
Total contralateral surgeries 10 (37%) 17 (68%)
Ptotic eye MRD
Aponeurosis ptosis contralateral 4/21 (19%) 9/17 (52.9%)
Preoperative 0.64 ± 0.59 0.813 ± 1.05 repaira

a
Postoperative 3.18 ± 0.76 3.33 ± 0.76 Excluding cases with congenital, poor levator function, or post-traumatic/surgical ptosis.

Difference 2.54 2.52

We further evaluated the ptosis repair for aponeurotic
Contralateral eye MRD ptosis only. In 19% of Mullerectomy cases and in 53%
Preoperative 3.03 ± 0.92 3.18 ± 1.13 cases of levator advancement, both eyelids needed surgery
(Pearson chi-square = 4.795, DF = 1, p = .029). Hering’s
Postoperative 3.24 ± 0.77 3.28 ± 0.2
law was significantly more common with the levator ad-
Difference −0.21 −0.1 vancement approach than with posterior surgical approach
(Mullerectomy).
Preoperative to postoperative −0.15 ± 0.8 −0.12 ± 0.65
MRD change

MRD, marginal reflex distance. DISCUSSION

eyelids required surgery in 10 (37%) cases of Mullerectomy
and in 17 (68.0%) cases of levator advancement. For both
surgical methods, the 14 cases that were not aponeurotic
(congenital, post-trauma, or post-ocular operative ptosis)
did not need contralateral ptosis repair ( p = .000, Pearson
Chi-Square = 26.580).
Among the cases of Mullerectomy, eight (29.6%) had a
Hering’s effect on the contralateral eyelid that was lifted
during the first operation, while two cases (7.4%) with re-
sidual ptosis of more than 1 mm had ptosis repair on a
second occasion. The same surgical procedure was per-
formed with good results. The etiology of ptosis was apo-
neurotic in 21 cases (77.8%). The etiologies of the
remaining six cases were congenital ptosis in four (16.7%)
and post-intraocular surgery in two (8.3%).
Among patients who underwent levator advancement,
15 (60%) needed lifting of the contralateral eyelid during
the first operation (Figure 3) and two (8%) needed ptosis
repair on a second occasion (Figure 4). The etiology of
ptosis was aponeurotic in 17 cases (68%), congenital in
three (12%), mechanical ( post-trauma or postoperative) in
four (16%), and neurological (third cranial nerve paresis)
in one (4%).
This series shows that levator surgery results in a higher in-
cidence of combined intraoperative and postoperative
Hering’s law than the Mullerectomy procedure. Hering’s
law effect was not present in patients with post-traumatic,
post-intraocular surgery, or in congenital ptosis (even with
good LF). Retraction of the contralateral eyelid depends on
multiple factors that affect eyelid height, including the fron-
talis muscle, the orbicularis oculi, sympathetic reaction by
Muller’s muscle, and coexisting mild ptosis in the opposite
eye. In addition, a compensatory retraction may not be
visible if the patient uses the fellow eye for fixation.14
Ocular dominance probably has a strong influence on the
surgical results, as well.7
In order to predict contralateral ptosis, preoperative eval-
uation of Hering’s dependency is based on various studies,
including digital lift, closure, and pharmacologic stimula-
tion tests.12,15,16 Corrective surgery for Hering’s depend-
ency is reported to give predictable results and excellent
symmetry.17
Cetinkaya et al7 recently showed that bilateral ptosis
cases with documented Hering’s dependency yield better
results when both eyes are operated in the same session,
rather than delaying surgery for the second eyelid.
However, Hering’s dependency is not documented in all

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Figure 3. (A) A 34-year-old man with left ptosis (marginal reflex distance 1.5 mm in his right eye and 0.5 mm in the left). He had
levator advancement on his left eye in April 2011. Intraoperatively, there was right eyelid drooping and the right eyelid was correct-
ed. (B) Twelve months postoperatively, there is a symmetric result of 3.5 mm, bilaterally.

Figure 4. A 71-year-old man with left Horner’s syndrome (marginal reflex distance 2 mm in right and 0 in left eye). He had levator
advancement on his left eye in June 2011. (A) Postoperatively, he had symmetric results. (B) Two years later he presented with
right ptosis with 0 mm marginal reflex distance. He underwent Mullerectomy with tarsectomy. (C) Twelve months after the right
ptosis repair.

cases of unilateral ptosis. Lepore et al18 initially suggested
that Hering’s law applies only to patients with ptosis result-
ing from neuromuscular junction or more distal dysfunc-
tion. However, Averbuch-Heller et al10 showed that some
cases were due to third nerve palsy proximal to the neuro-
muscular junction, so the effect was not restricted to neuro-
muscular junction dysfunction.1 Mehta19 reported that
Hering’s law also occurs in mechanical ptosis.
While McCulley et al9 reported that reoperation was
more than twice as likely in patients undergoing bilateral
versus unilateral procedures (13% and 5.2%, respectively),
the success rates for unilateral ptosis repair reported by
other studies have varied from 27% to 72%.20-22
The postoperative effect on the contralateral eyelid ap-
parently continues to evolve a long time after surgery
(Figure 4). Erb et al23 noted that 17% of patients undergo-
ing unilateral ptosis repair developed a decrease in contra-
lateral eyelid height of at least 1 mm over the course of a
year, resulting in a 5% rate of contralateral surgery.
Interestingly, this effect was not correlated with preopera-
tive Hering’s law interdependence. In one study, a week
after unilateral blepharoptosis repair, 64% of patients had
decreased MRD on the contralateral eyelid, whereas it was
present in only 36% after 6 months.24
It has recently been shown that Hering’s law does not
occur in congenital ptosis when addressed with either
levator resection or frontalis sling procedures.11 In the
current study, Hering’s law did not manifest in cases of
poor levator function, post-trauma, or in congenital ptosis
(even with good LF). A possible explanation for these

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 Nemet
findings is that the LP muscle is fibrotic and not elastic in
cases of traumatic or congenital ptosis.25,26 Thus, in con-
trast to the normal elastic eyelid (also in aponeurotic ptosis
cases), if one pulls up the ptotic eyelid in cases of fibrotic
muscle, sensory input is diminished and the unpaired
motor central caudal nucleus of the oculomotor complex
does not respond.5,26 The contralateral eyelid will not
retract preoperatively.
This study compared the results of two surgical methods
for unilateral ptosis repair (Figures 1–7). The preferred
method for ptosis repair is controversial. Some physicians
prefer Mullerectomy with or without tarsectomy over
levator advancement, even when performed in conjunction
with blepharoplasty. Many consider this method more pre-
dictable, shorter, and easier for the patient.27,28 In addition,
it eliminates the need for patient cooperation. The orbicula-
ris plane can be preserved29 and it reduces the chance of
postoperative lagophthalmos, as well.29 Others advocate
aponeurotic approaches as more predictable, simple to
reverse, and more logical and anatomical.30
The anterior and posterior approaches involve signifi-
cantly different mechanisms. Hence, it is reasonable that
the Hering’s law effects vary between these approaches.
The actual eyelid level is regulated from moment to
moment by Muller’s muscle, which attaches directly from
the levator muscle to the upper edge of the tarsal plate. A
delicate mechanism and power balance are present in
every normal eyelid and account for some of the unusual
manifestations of various presentations of ptosis. For
example, the aponeurosis acts as a “check” ligament only,
preventing too much eyelid descent.1 If a ptotic eyelid is
corrected with the usual technique of aponeurosis to tarsus
reinsertion, the contralateral lid is still dependent on
Muller’s muscle and the elastic aponeurosis. There will, in
fact, be a difference between the lifting mechanisms of the
previously ptotic (operated) eyelid and the contralateral
(unoperated) eyelid, which might drop.1 However, after
Mullerectomy, the length of the muscle does not affect LP
Figure 5. (A) A 61-year-old woman with left aponeurotic ptosis (marginal reflex distance 4 mm in right and 1 mm in the left eye).
She had Mullerectomy with tarsectomy on the left eye, in December 2011. (B) 12 months postoperatively, she had symmetric
results of 4 mm, bilaterally.
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779
activity, as the length is decreased, but not the muscle
tension. Hence, Hering’s law effect is less significant than
in levator advancement, where the muscle tension is more
significant. Another possible difference of Hering’s law on
various ptosis approaches is that the eyelid lift in
Mullerectomy stems from the conjunctival shortening and
plication or scarring of the posterior lamella and not the
amount of resected Muller muscle.31 As such, there is no
influence on the LP nucleous (which innervates the LP bi-
laterally) and the LP of other eye does not stretch.
More Hering’s effect was found in levator repair of com-
bined intraoperative and postoperative cases, but not with
pure postoperative cases. A staged, second surgery on the
contralateral lid was required in only 20% and 12% of
Mullerectomy and levator surgery patients, respectively. So
while Hering’s effect was seen more often with levator
surgery, most manifested on the table with less need for
a second surgery. Intraoperative Hering’s testing is not accu-
rate and might lead to an inaccurate MRD1 assessment.
Injection and surgery usually cause swelling and bruising,
making such intraoperative evaluations inaccurate for assess-
ing Hering’s law on the un-operated side. The author uses
about 1 cc of local anesthesia for the posterior approach and
about 2 cc for the anterior approach for each eyelid, so the
swelling and bruising is different between these methods.
The findings presented here are limited by possible con-
founding factors. It is possible that a second surgery was re-
quired less often with Mullerectomy because these patients
responded to a physiologic phenylephrine test to lift the lid
with a similar physiologic lowering of the other lid (an ac-
curate evaluation of Hering’s). In patients who had levator
advancement, the lid was lifted manually, which may be a
less accurate assessment of Hering’s effect. In addition, for
these cases a posterior approach was chosen when the
phenylephrine test was positive. It is possible that it is not
necessarily the surgical approach that causes the difference
detected, but rather the physiology of the eyelid as to
whether or not it respond to pheynylephrine.
 780 Aesthetic Surgery Journal 35(7)

Figure 6. (A) A 21-year-old woman with left congenital ptosis (marginal reflex distance 4 mm in right and 1 mm in the left eye).
She had good levator function (12 mm). She underwent left levator advancement on April 2009. (B) Two years postoperatively,
she had symmetric results of 4 mm, bilaterally.

Figure 7. (A) A 50-year-old woman with right congenital Horner’s syndrome. Note the characteristic iris heterochromia (the iris of
the affected eye is lighter in color than that of the unaffected eye). Since there was a positive Hering’s dependency, she had under-
gone bilateral levator advancement on July 2010. (B) Three years postoperatively, she had symmetric results of 3 mm, bilaterally.

Despite the fact that there was no significant difference
preoperatively in MRD1 between both methods in the
current study, it is possible that the likelihood of a Hering’s
dependence and contralateral ptosis following surgery
would be higher with levator surgery since it is often per-
formed in cases with more severe initial ptosis. In addition,
the results may be related to the parameters dictated (ie, at
least 2 mm ptosis). For patients with smaller degree of
ptosis, as is often the case with aesthetic patients, the situa-
tion may differ.
The study includes a relatively small number of patients.
Moreover, they have a heterogeneous ptosis etiology, which
we attempted to differentiate. Hence, each parameter might
change the statistical interpretation. Likewise, many factors
can influence ptosis repair, including etiology, preoperative
values (LF, MRD, etc.), and measurement errors by the ex-
aminer, among others.32 Palpebral fissure height and
diurnal variation can also change the surgical outcome.33
CONCLUSION
In the current study, the Hering’s law effect was not found in
cases with poor levator function, post-trauma, or congenital
ptosis (even with good LF). These cases can be performed
unilaterally, with no need to repair the contralateral side. We
also found that the Hering’s law effect was more common
with the levator advancement approach than Mullerectomy.
This information has broad clinical applicability. In
some cases of unilateral ptosis, as in congenital ptosis,
there is no need to examine for Hering’s law phenomena
preoperatively or to operate on the contralateral eyelid. A
thorough patient history and preoperative assessment, in-
cluding specific inquiry regarding poor levator function
and trauma, are needed, as well as early childhood photo-
graphs and a clinical examination. If indeed Hering’s law
effects occur less often with a posterior surgical approach,
this should be considered in the surgical plan for cases
where a second surgery is less desired (such as with elderly
patients). Despite the mentioned limitations, we believe
that the current results can assist surgical planning and
intraoperative management of ptosis repair. To investigate
this phenomenon more thoroughly, a prospective study
should be conducted with preoperative videos, additional
photographs, and long-term follow-ups.
Acknowledgments
The author would like to thank Faye Schreiber, MS, for editing
the manuscript.

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Disclosures 17. Wladis EJ, Gausas RE. Transient descent of the contralat-
The author declares no potential conflicts of interest with respect eral eyelid in unilateral ptosis surgery. Ophthal Plast
to the research, authorship, and publication of this article. Reconstr Surg. 2008;24(5):348-351.
18. Lepore FE. Unilateral ptosis and Hering’s law. Neurology.
1988;38(2):319-322.
Funding 19. Mehta HK. The contralateral upper eyelid in ptosis: some
observations pertinent to ptosis corrective surgery. Br J
The author received no financial support for the research,
Ophthalmol. 1979;63(2):120-124.
authorship, and publication of this article.
20. Bartley GB, Lowry JC, Hodge DO. Results of levator-
advancement blepharoptosis repair using a standard
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