CHAPTER 11 Müller’s Muscle–Conjunctival Resection–Ptosis Procedure Combined with Upper Blepharoplasty

Patients often present for cosmetic rejuvenation of the upper periorbita and the examination reveals both dermatochalasis and upper eyelid ptosis. In these situations it is both possible and preferable, to combine an upper blepharoplasty with ptosis surgery. Although this technique is commonly performed through an external approach with levator aponeurosis advancement or resection, many cosmetic surgeons do not appreciate the possibility of combining an internal Müller’s muscle–conjunctival resection with an external upper blepharoplasty, especially when the skin and orbicularis oculi muscle are excised and an eyelid crease is reconstructed.

This chapter demonstrates how to combine a Müller’s muscle resection with an upper blepharoplasty, a procedure we have performed for many years. We have found that this combined procedure gives us both superior results compared with the levator aponeurosis procedure with upper blepharoplasty, especially in those patients that desire a lower positioned upper eyelid crease and/or whose upper eyelids elevate to normal levels after administration of phenylephrine. The phenylephrine test also can be helpful in identifying candidates for this combined procedure.

Allen M. Putterman and Steven Fagien

The Müller’s muscle–conjunctival resection–ptosis procedure, described in 1975 by Putterman and Urist, is a technique in which Müller’s muscle in the upper eyelid is partially resected and advanced.¹ The exact mechanism by which the correction of ptosis is achieved is probably due to a number of effects that include resection and advancement of Müller’s muscle as well as the secondary effects of advancing the levator aponeurosis to the superior tarsal border. The classic approach to the treatment of a variety of lid ptosis presentations has been mostly through variations of an external (skin-muscle incision) approach through the upper eyelid crease whereby the anatomic ‘defect’ is visualized and presumably repaired (see Chapter 10). This approach, however, more often requires the cooperation of the patient during the surgical procedure and heralds a host of potential variabilities that include, but are not limited to, sedative effects, local anesthetic effects, edema, and performance anxiety on both the patient’s and surgeon’s part. To the contrary, the Müller’s muscle conjunctival resection can be performed with continuous IV sedation or even general anesthesia as it does not require intraoperative patient cooperation. The procedure is used to treat a variety of upper eyelid ptosis and can be combined with an upper blepharoplasty with or without crease reconstruction via a skin flap or a skin-muscle flap approach. The procedure has the many advantages over other ‘posterior approach’ lid ptosis procedures and the external approaches that includes the preservation of upper eyelid tarsus (which creates less risk of suture-induced keratopathy and theoretically preserves structural and functional aspects of the upper eyelid), repositions the elevated (involutional) eyelid crease to a lower positioned and more youthful level, and can more predictably improve upper eyelid position (MRD) and contour. In addition, the usual skin-muscle and fat excision that is performed for a host of reasons, including adequate exposure to the levator aponeurosis (that can be volume depleting to the upper eyelid), can be avoided if desired. There also is rarely a need for additional surgery to treat residual ptosis or overcorrections. This procedure that was originally felt to be effective mostly in individuals with only mild to moderate upper eyelid ptosis and/or had a positive response to neosynephrine eye drops, can in fact be applied in most all types of ptosis presentations.

Diagnosis and preoperative evaluation

Two tests are done preoperatively to determine optimal candidates for the Müller’s muscle–conjunctival resection procedure:

• Margin reflex distance-1 (MRD₁) measurement.

• Phenylephrine test.

MRD₁ test

The MRD₁ measurement is used to assess the upper eyelid levels (see Chapter 3, Fig. 3-8). It should be performed both before and during the phenylephrine test.

The difference in MRD₁ between the normal and ptotic sides indicates the degree of ptosis. The normal MRD₁ ranges from approximately 3.0 mm to 4.5 mm, and this value is used as a reference in bilateral cases. The MRD₁ measurement has the advantage of being able to quantify the ptosis alone without the palpebral fissure width. This is preferred because there is a Müller’s muscle in the lower eyelid that can also respond to phenylephrine. Measuring the palpebral fissure width would lead to an erroneous interpretation of the upper eyelid level after instillation of phenylephrine.

Phenylephrine test

The MRD₁ is again measured, this time after instillation of 2.5 percent or 10 percent phenylephrine drops. The patient can be partially reclined and their head is tilted backward, the upper eyelid is lifted, and the patient is instructed to gaze downward. Several drops of phenylephrine are dripped between the upper eyelid and the globe. To minimize the entry of phenylephrine into the nasal cavity and the potential side effects of systemic absorption in those potentially at cardiovascular (rare) risk, the examiner or patient may use the finger to digitally compress the canaliculi for 10 seconds. Topical anesthetic is often useful to reduce or avoid the stinging that can occur with application of neosynephrine. This step may be repeated immediately two more times. One minute later, two additional drops may be applied. Three to five minutes after instillation of the phenylephrine, the MRD₁ is measured.

Side effects, such as myocardial infarction and hypertension, have been reported after instillation of phenylephrine drops,² but are exceedingly rare. Therefore, it is important to determine that the patient does not have a significant cardiac risk before the phenylephrine test is performed. In our collective experience this has, however, rarely posed a problem but if there is ever a significant concern then the patient’s primary care physician or cardiologist should be consulted.

Glatt and Putterman ³ have compared test results using 2.5 percent and 10 percent phenylephrine. It appears that both solutions are effective in determining candidates for the Müller’s muscle–conjunctival resection procedure, but that the 2.5 percent solution may theoretically result in fewer vasoactive side effects. Our experience has been primarily with the 10 percent solution. Patients should be warned regarding the likely pupillary dilation after this test which may yield transient photophobia and visual blurring. If there is a history of glaucoma, it may be prudent to contact their ophthalmologist regarding any concerns of pupillary dilation. Finally, regarding other symptomatology after these tests, it is not uncommon for patients to experience transient ocular irritation that might relate to dryness or exposure symptoms and indicate to the surgeon the possibility of dry eye symptoms after surgery.