Preoperative and postoperative eyelid symmetry (as shown in the numbers) in patients operated on to correct unilateral ptosis by Müller’s muscle–conjunctival resection. Eyelid symmetry was defined as a difference of 1 mm or less in margin reflex distance-1 between operated on and not operated on eyelids.
A, Clinical image of a patient with right upper eyelid involutional ptosis. B, Some improvement in eyelid position is shown 10 minutes after instillation phenylephrine eyedrops, 10%, in the right eye. C, One year after Müller's muscle–conjunctival resection in the right eye, there is good eyelid position and symmetry of the eyelids. The phenylephrine test underestimated the ptosis correction achieved with surgery.
Correlation of change in eyelid height after instillation of phenylephrine (PE) eyedrops vs ptosis correction (delta margin reflex distance-1) postoperatively.
Box plot describes the extent of Müller's muscle conjunctival resection, change in eyelid position after instillation of phenylephrine (PE) drops (ΔMRD1), and change in eyelid position postoperatively (ΔMRD1). MRD1 indicates margin reflex distance-1.
Scatter plot shows ptosis correction vs the extent of Müller's muscle–conjunctival resection. Linear trend lines plus or minus 95% confidence interval of the mean are shown.
Ben Simon GJ, Lee S, Schwarcz RM, McCann JD, Goldberg RA. Müller's Muscle–Conjunctival Resection for Correction of Upper Eyelid PtosisRelationship Between Phenylephrine Testing and the Amount of Tissue Resected With Final Eyelid Position. Arch Facial Plast Surg. 2007;9(6):413-417. doi:10.1001/archfaci.9.6.413
Author Affiliations: Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel (Dr Ben Simon); and Jules Stein Eye Institute and Department of Ophthalmology, David Geffen School of Medicine at the University of California–Los Angeles (Drs Lee, Schwarcz, McCann, and Goldberg).
Correspondence: Guy J. Ben Simon, MD, Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer 52621, Israel (email@example.com).
Objectives To evaluate the outcome of Müller's muscle–conjunctival resection (MMCR) for correction of upper eyelid ptosis and to explore the relationship between phenylephrine testing, muscle resection, and surgical outcome.
Methods Medical records were reviewed for all patients who underwent MMCR at the Jules Stein Eye Institute, Los Angeles, California, from January 1, 1999, through June 30, 2005. Outcome measures were margin reflex distance-1, ptosis correction after instillation of phenylephrine drops, extent of MMCR, ptosis correction, and eyelid symmetry.
Results In 80 patients who underwent 131 MMCR procedures for correction of upper eyelid ptosis, margin reflex distance-1 increased on average by 1.6 mm (P < .001). In 106 patients (81%), eyelid symmetry equal to or less than 1 mm was achieved (P = .02). Phenylephrine testing underestimated the extent of ptosis correction achieved with MMCR. A weak correlation was found between the extent of MMCR and ptosis correction (r = 0.2; P = .04).
Conclusions Müller's muscle–conjunctival resection is effective for ptosis correction in patients with good levator muscle function; good eyelid symmetry is achieved in most patients. Phenylephrine testing underestimated the ptosis correction achieved with MMCR by 40%. The relationship between MMCR and ptosis correction is complex.
Müuller's muscle–conjunctival resection (MMCR), originally described by Fasanella and Servat1 with later modification by Putterman and Urist,2 has been traditionally performed for correction of mild to moderate upper eyelid ptosis with good levator muscle function. It is thought that eyelid elevation is achieved by vertical shortening of the posterior lamella, plication or advancement of Müller's muscle, and levator aponeurosis and cicatricial changes. The procedure requires careful preoperative planning insofar as the desired tissue to be excised, whereas anterior approach levator muscle resection surgery enables intraoperative adjustment of the eyelid height.3-8
Preoperatively, the use of phenylephrine eyedrops, 10% or 2.5%, that stimulate the sympathetically innervated Müller's muscle has been thought to accurately predict final eyelid position achieved with MMCR. Most surgeons do not perform MMCR in patients with no response to phenylephrine eyedrops. Traditionally, eyelid height attained with the phenylephrine (PE) test can be achieved with an 8.25-mm MMCR.9 Similarly, it is believed that for each 1 mm of desired eyelid elevation, 4 mm of Müller's muscle and conjunctiva should be resected. In recent years, several modifications of the original formula have been described; however, each specifies a different extent of resection for a similar degree of preoperative ptosis.3, 7, 10-11
The objective of the present study was to investigate the relationship between change in eyelid height after PE testing, the extent of MMCR, and final eyelid position postoperatively. We questioned the existence of a linear relationship between the amount of tissue resected and improvement in eyelid height.
The study included all consecutive patients with upper eyelid ptosis and good levator muscle function (>10 mm) who underwent MMCR during the 6½ years from January 1, 1999, through June 30, 2005. A retrospective review of the medical records for all patients was performed. Data retrieved included age, sex, preoperative and postoperative digital photographs, visual acuity, margin reflex distance-1 (MRD1) (the distance between the inferior margin of the upper eyelid to the pupillary light reflex in primary position of gaze, measured in millimeters), lagophthalmos, and surgical complications. Patients were examined at 1 day, 1 week, and 1, 3, 6, and 12 months postoperatively and every year thereafter. Postoperative measurements at the last follow-up visit were used for comparison. The study complied with the policies of the local institutional review board.
Before surgery, all patients underwent pharmacologic elevation of the ptotic eyelid using 10% phenylephrine eyedrops instilled in the inferior cul-de-sac. The MRD1 was assessed before and 10 minutes after instillation of the phenylephrine eyedrops. Resection was planned according to the desired eyelid position, keeping in mind that the height attained with the PE test can be achieved with 8.25 mm of MMCR.9 A 4-mm MMCR was performed for each 1 mm of desired elevation; tarsus was not removed during the procedure. The phenylephrine test is also used to unmask contralateral ptosis so that bilateral surgery or less resection on one side can be performed. Patients who did not respond to the PE test underwent an anterior approach levator muscle advancement and were excluded from the study. Similarly, patients with ocular surface disease or with superior functioning filtering blebs were excluded. Phenylephrine eyedrops were instilled in both eyes in patients with bilateral ptosis.
Ptosis correction concomitant with blepharoplasty was performed after the skin-muscle flap was excised. Patients who required bilateral correction underwent simultaneous upper eyelid surgery.
Statistical analysis was performed using the paired samples t test to evaluate preoperative and postoperative visual acuity, intraocular pressure, and MRD1. The independent samples t test was used to calculate the difference in ΔMRD1 in patients undergoing MMCR with concurrent blepharoplasty and patients undergoing MMCR only. The one-sample t test was used to evaluate the change in these variables by calculating delta values. Pearson bivariate correlation was used to examine the change in eyelid position after the PE test and postoperatively and to evaluate the relation between the extent of MMCR and change in eyelid position after surgery. Linear and polynomial trend lines were calculated for change in eyelid position after PE testing, extent of MMCR, and final eyelid position after surgery. Statistical analysis was performed with commercially available software (Excel; Microsoft Corp, Redmond, Washington; and SPSS version 13.0; SPSS Inc, Chicago, Illinois). Conversion of Snellen acuity to logarithm of the minimum angle of resolution values was performed. Values throughout are given as mean ± SD.
Eighty patients (54 women and 26 men; mean age, 67 years) underwent 131 MMCR procedures for correction of upper eyelid ptosis. Fifty-one patients underwent bilateral surgery; concurrent blepharoplasty was performed in 74 patients. Follow-up was 18 ± 14 months.
Postoperatively, patients achieved a better eyelid position, with change in MRD1 of 1.6 mm. The MRD1 increased from 1.5 mm preoperatively to 3.1 mm postoperatively (P < .001, paired samples t test). Similar improvement in MRD1 was calculated in patients undergoing concurrent blepharoplasty and patients undergoing MMCR only (P = .80, independent samples t test).
Eyelid asymmetry, defined as the difference in MRD1 in the operated-on eye compared with the contralateral eye or as the difference in MRD1 in the right and left eyes in cases of bilateral surgery, improved after MMCR (Table 1). Good eyelid symmetry, defined as an eyelid height difference (right and left) of 1 mm or less, was achieved in 106 cases (81%) (P = .02, χ2 test).
Subgroup analysis of patients who underwent unilateral surgery showed a greater improvement in eyelid asymmetry, from 1.6 ± 1.4 mm preoperatively to 0.16 ± 0.9 mm postoperatively, with a delta change of 1.4 ± 1.5 mm (P < .001, paired samples t test). Surgery improved eyelid symmetry from 28% (8 patients) to 69% (20 patients) (P = .001, χ2 test) (Figure 1).
Eyelid crease height did not change with MMCR surgery (delta change of 0.4 mm; P = .20, paired samples t test). Visual acuity and intraocular pressure remained stable (Table 2).
Patients achieved an increase in MRD1 of 0.7 ± 1.0 mm after instillation of phenylephrine eyedrops, 10%, to the ptotic eyelid or bilaterally in cases of planned bilateral surgery. Postoperatively, the change in MRD1 in the operated-on eye was 1.6 ± 1.4 mm (P = .007, paired samples t test); that is, a greater improvement in eyelid height was achieved after surgery than what originally was predicted by the PE test (Figure 2). The PE test underestimated final eyelid position by 0.56 ± 1.2 mm. Change in MRD1 with phenylephrine eyedrops was correlated with a change in eyelid position after surgery (r = 0.47; P = .02, Pearson bivariate correlation) (Figure 3).
These differences were less apparent when calculating the effect of PE eyedrops on eyelid position on patients with unilateral ptosis. On average, these patients achieved a 0.83-mm improvement in eyelid height (MRD1) after PE testing vs 1.34 mm postoperatively (P = .30, paired samples t test); that is, the PE test underestimated surgical correction on average by 0.35 ± 1.3 mm. No significant correlation, however, was found between these variables, most likely owing to the relatively small number of patients (P = .26).
Trend line calculations (linear, polynomial, or both) for change in eyelid position after PE testing vs change in eyelid position postoperatively suggested that with each 1-mm increase in eyelid position after instillation of phenylephrine eyedrops, eyelid height increased by 1.4 mm after surgery. That is, the PE test underestimated the final eyelid position that can be achieved with MMCR (Table 2 and Figure 4).
Only a weak correlation was found between the extent of MMCR and the change in eyelid height postoperatively (ΔMRD1; r2 = 0.2; P = .04, Pearson bivariate correlation) (Figure 4 and Figure 5). Trend lines (linear, logarithmic, or both) between the extent of MMCR and the change in eyelid position postoperatively showed that with each 1 mm of MMCR, final eyelid position will change by 0.6 or 0.8 mm, respectively (Table 2). Polynomial trend line results do not comply with clinical outcome.
One patient with overcorrection and consecutive eyelid retraction underwent eyelid recession. One patient with recurrence of ptosis 1 year after primary MMCR underwent successful reoperation.
Müller's muscle–conjunctival resection resulted in improved eyelid position in patients with upper eyelid ptosis and good levator muscle function. Eyelid symmetry (within 1 mm) was achieved in 81% of the patients; this was more apparent in patients undergoing unilateral surgery. The PE test underestimated, by 40%, ptosis correction achieved with MMCR. The eyelid crease did not change with MMCR, implying that the attachments of levator aponeurosis and skin orbicularis complex were not severed during surgery. Trend line calculations for the extent of MMCR and ptosis correction do not seem to correlate with clinical outcome. Rates of overcorrection and undercorrection were very low (<1%).
Various algorithms have been described for calculation of MMCR.2-3,6-7,10-12 Although each method calls for a different extent of Müller's muscle resection for a similar desired degree of ptosis correction, most authors describe good results with eyelid symmetry of more than 80% and low rates of overcorrection.
Putterman and Fett6 reported that an 8.25-mm resection should be performed if the ptotic eyelid is elevated to the desired level with preoperative 10% phenylephrine eyedrops; a 6.5- to 9.5-mm resection is performed if the ptotic eyelid is elevated higher or lower than the contralateral eyelid. Weinstein and Buerger7 used a standard 8-mm resection to correct 2-mm eyelid ptosis and added or subtracted 1 mm for every 0.25-mm change in final eyelid position. Dresner10 described a modified MMCR procedure for correction of blepharoptosis. In that study, 4-mm resection was performed to correct 1 mm of eyelid ptosis, 6-mm resection to correct 1.5 mm of ptosis, and 8-mm resection to correct 2 mm of ptosis. To correct 3 mm of eyelid ptosis, a 10-mm resection was performed to avert placing the levator aponeurosis in the resection clamp. Dresner found a linear relationship between the extent of MMCR and postoperative eyelid correction, with r = 0.6. We used a similar algorithm but did not find a strong linear relationship between the extent of MMCR and ptosis correction, with r = 0.2.
Dresner10 used a larger resection of 1 to 2 mm if the PE test response was less than 2 mm. It has been theorized that patients with poor response to PE testing have fatty infiltration of the levator and Müller's muscles.10, 13
Perry et al11 described a new algorithm for determining the extent of tissue excision in patients undergoing MMCR with or without tarsectomy to correct upper eyelid ptosis. The suggested formula was as follows: 9 mm of conjunctiva and Müller's muscle + x mm of tarsus, where x represents the distance of undercorrection after PE testing. Their algorithm was formulated on the basis that 9-mm resection of Müller's muscle yields similar eyelid elevation achieved with 10% phenylephrine eyedrops. Excision of a given amount of tarsus should result in a 1:1 ratio of eyelid elevation; therefore, any undercorrection seen after instillation of phenylephrine eyedrops can be addressed by similar tarsal resection. Tarsal resection in the study by Perry and associates was limited to 2.5 mm to avert tarsal instability. They found that their new algorithm yielded predictable results, with eyelid symmetry achieved in 87% of 68 patients and 95% of patients satisfied with the surgical outcome.
On analyzing our results, it seems that the PE test does not accurately predict postoperative eyelid elevation. The average response to phenylephrine eyedrops in this study was 0.7 ± 1 mm, significantly lower than the 2 mm considered an optimal response. It is not unusual for a certain percentage of patients to respond poorly to phenylephrine eyedrops, but a 0.7-mm average is certainly low enough to be included in the resection algorithm.
The mechanism by which MMCR alleviates ptosis is independent of Müller's muscle function; it has been performed successfully in patients with Horner syndrome14 in whom the Müller's muscle is denervated and in patients with no response to the PE test.12 Patients with no response to phenylephrine eyedrops were excluded from our study because we intended to explore the relationship between eyelid height change after instillation of phenylephrine eyedrops and after MMCR. Shortening of the posterior lamella and advancement of the levator muscle–Müller's muscle–conjunctiva may, at least in part, be responsible for eyelid elevation achieved with surgery. Additional mechanisms other than muscle plication or advancement should exist because a 4-mm MMCR yields only 1 mm of eyelid elevation. Further support is given by histopathologic analysis of 40 consecutive surgical specimens from patients undergoing the Fasanella-Servat procedure.15 Eighty-eight percent of the patients had minimal or absent smooth muscle at histopathologic analysis despite having successful results in comparison with patients with moderate or large amounts of smooth muscle.15
Müller's muscle–conjunctival resection has been recently described as an effective procedure in 15 patients who exhibited no improvement in eyelid position after administration of topical phenylephrine.12 A 3.3-mm increase in MRD1 was achieved with surgery, and no patients required reoperations.
Müller's muscle–conjunctival resection is considered more reproducible and accurate than aponeurotic surgery in treating upper eyelid ptosis (<3 mm) with good levator muscle function and when a positive response to topical phenylephrine has been documented.3, 6, 8, 10, 16 Excellent results can be expected in properly selected patients. Putterman and Fett6 summarized their 10-year experience with MMCR and reported that 90% of the eyelids with acquired ptosis and 100% of those with congenital ptosis were within 1.5 mm of the level of the contralateral eyelid. Only 2 of 232 patients (0.8%) required additional surgery.
Blepharoplasty when performed with MMCR may reduce the anticipated postoperative eyelid elevation by 1 mm.17 Brown and Putterman17 found that for any extent of MMCR, a lesser degree of eyelid elevation was achieved postoperatively in patients who underwent concurrent blepharoplasty. We, however, failed to find such a relationship, and in our study, a similar improvement in eyelid position was achieved in patients who underwent MMCR concurrent with blepharoplasty compared with patients undergoing MMCR alone (ΔMRD1, 1.6 mm; P = .80).
Limitations of our study stem from its retrospective design. We used a specific algorithm for MMCR; however, statistical and mathematical analysis of the data failed to show a simple linear relationship between the extent of MMCR and ptosis correction. Despite that, we achieved acceptable results with good eyelid symmetry in most cases. Given that previous studies in which slightly modified algorithms were used reported similar outcomes, it seems that MMCR is an excellent and predictable surgical procedure for correction of eyelid ptosis with good levator muscle function. A prospective study comparing different algorithms can more accurately demonstrate an advantage of any specific method, if such an advantage exists.
Accepted for Publication: July 29, 2007.
Author Contributions:Study concept and design: Ben Simon, McCann, and Goldberg. Acquisition of data: Lee and Schwarcz. Analysis and interpretation of data: Ben Simon. Drafting of the manuscript: Ben Simon, Lee, and Schwarcz. Critical revision of the manuscript for important intellectual content: Ben Simon, McCann, and Goldberg. Statistical analysis: Ben Simon. Obtained funding: McCann and Goldberg. Administrative, technical, and material support: Ben Simon, Lee, and Schwarcz. Study supervision: Ben Simon.
Financial Disclosure: None reported.