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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 28  |  Issue : 4  |  Page : 954-959

Muller's muscle-conjunctival resection for blepharoptosis repair


Department of Ophthalmology, Faculty of Medicine, Menoufia University, Shibin Elkom, Egypt

Date of Submission10-Nov-2014
Date of Acceptance23-Jan-2015
Date of Web Publication12-Jan-2016

Correspondence Address:
Ahmed E Ramadan
Horeen, Berket Elsabaa, Menoufia, 32651
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.173684

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  Abstract 

Objective
The aim of this study was to evaluate the results of Muller's muscle-conjunctival resection in the treatment of mild-to-moderate ptosis with fair-to-good levator function.
Background
Muller's muscle-conjunctival resection, which was originally described by Fasanella and Servat and later modified by Putterman and Urist, has traditionally been performed for correction of mild-to-moderate upper eyelid ptosis, resulting in improved eyelid height.
Patients and methods
A prospective nonrandomized study was conducted on patients attending the Outpatient Clinic of Ophthalmology Department in Menoufia University Hospital during the period of study from May 2013 to October 2014. This study was conducted on 20 eyes of 20 patients with mild-to-moderate ptosis with fair-to-good levator function. Muller's muscle-conjunctival resection was performed for all cases, and the patients were followed up for 6 months.
Results
Success of the operation was determined by means of postoperative eyelid elevation. Patients were divided into three categories: (a) successful (eyelid elevated to cover 2 mm of the cornea or within 0.5 mm of this level), which included 12 eyelids (60%); (b) accepted (within 1 mm of normal eyelid level, which covers 2 mm of the cornea), which included eight eyelids (40%); and (c) failed (uncorrected 0%).
Conclusion
Muller's muscle-conjunctival resection surgery has high success rate in treating mild-to-moderate ptosis with fair-to-good levator function. It also has few and mild complications, with the advantage of good cosmetic results due to avoidance of cutaneous scar, and results in good eyelid contour.

Keywords: Muller′s muscle-conjunctival resection, open sky technique, ptosis


How to cite this article:
El-Saadani AKI, Mandour SS, Ramadan AE. Muller's muscle-conjunctival resection for blepharoptosis repair. Menoufia Med J 2015;28:954-9

How to cite this URL:
El-Saadani AKI, Mandour SS, Ramadan AE. Muller's muscle-conjunctival resection for blepharoptosis repair. Menoufia Med J [serial online] 2015 [cited 2020 Feb 27];28:954-9. Available from: http://www.mmj.eg.net/text.asp?2015/28/4/954/173684


  Introduction Top


Muller's muscle was first identified in 1869 and was further characterized by Beard in 1985 [1] . Muller's muscle is a small smooth muscle arising from the striated levator muscle, along with the aponeurosis at or slightly above the level of the superior fornix. Most anatomists agree that there is no tendon of origin. It is sympathetically innervated and elevates the upper eyelid by ~2 mm. It is important in the control of lid position, as it acts as a muscle spindle generating stretch reflex for levator muscle [2] .

Muller's muscle-conjunctival resection, which was originally described by Fasanella and Servat [3] , and later modified by Putterman and Urist [4] , has traditionally been performed for correction of mild-to-moderate upper eyelid ptosis, resulting in improved eyelid height. It was thought that eyelid elevation is achieved by vertical shortening of the posterior lamella, plication or advancement of the Muller's muscle and levator aponeurosis and cicatricial changes. The definitive mechanism is still a matter of debate.

The aim of the present work was to evaluate the results of Muller's muscle-conjunctival resection in the treatment of mild-to-moderate ptosis with fair-to-good levator function.


  Patients and methods Top


A prospective nonrandomized study was conducted on patients attending the Outpatient Clinic of Ophthalmology Department in Menoufia University Hospital during the period of study from May 2013 to October 2014. This study was conducted on 20 eyes of patients with mild-to-moderate ptosis with fair-to-good levator function.

All patients were fully informed about the surgical technique and its possible complications. A formal consent was obtained; the protocol was approved by the Ethical Committee of Faculty of Medicine Menoufia University.

Full preoperative assessment of ptosis was carried out, including the following:

  1. Full ocular history, present history, past history and family history.
  2. Ocular examination:
    1. Visual acuity: best corrected; and refraction (manifest and cycloplegic): astigmatism/anisometropia.
    2. Upper lid crease distance from margin
      1. Position: normal - female, 10-11 mm; male, 8-10 mm; children, 7 mm.
      2. Contour: abnormalities - absent, high, duplicated, asymmetry.
    3. Levator function excursion and grading
      1. Good, 8 mm or more; fair, 5-7; poor, 4 mm or less.
    4. Degree/amount of ptosis (margin reflex distance 1).
    5. Vertical palpebral fissure:
      1. Horizontal palpebral fissure.
      2. Contralateral drop.
    6. The margin fold distance (pretarsal show).
      1. Lid lag on down gaze: presents in congenital ptosis.
      2. Frontalis action: overaction/furrow/high arched brow.
    7. Full examination of other ocular structures:
      1. Phenylephrine test.


Surgical technique

All operations were performed under local anaesthesia, apart from those performed on children and on individuals who required general anaesthesia. A millilitre of a 50 : 50 mixture of marcaine 0.5% and lignocaine 2% without adrenaline was injected above the lid margin.

A traction suture was placed at the highest point of the lid margin, and the lid was everted over a Desmarres retractor ([Figure 1]). A further 0.5 ml of the same anaesthetic was injected under the conjunctiva superior to the tarsal plate.
Figure 1 The lid everted over a Desmarres retractor. Conjunctiva and Muller's muscle were incised just above the upper border of the tarsal plate

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Conjunctiva and Muller's muscle were incised just above the upper border of the tarsal plate. The plane between Muller's muscle and the levator aponeurosis was identified and blunt dissection on this plane was extended upwards ([Figure 2]). Muller's muscle was then lifted with the adherent conjunctiva up to the level of the fornix. Careful dissection of Muller's muscle was carried out from the medial side, as well as the lateral side, to avoid peaking of the eyelid ([Figure 3]).
Figure 2 The plane between Muller's muscle and the levator aponeurosis was identified and blunt dissection on this plane was extended upwards.

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Figure 3 Careful dissection of Muller's muscle from the medial side, as well as the lateral side, to avoid peaking of the eyelid

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A 6/0 vicryl suture was placed through the conjunctiva and Muller's muscle at the level of the planned new insertion, and then through the upper border of the tarsal plate ([Figure 4] and [Figure 5]), the conjunctiva and Muller's muscle again ([Figure 6]). Before tying the sutures, Desmarres retractor was removed. Two additional similar sutures were placed through the same structures medially and laterally, and also tied. Thereafter, Muller's muscle with the conjunctiva was resected.
Figure 4 Sutures passed through the conjunctiva and Muller's muscle at the level of the planned new insertion, then through the upper border of the tarsal plate

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Figure 5 Sutures passed through the conjunctiva and Muller's muscle at the level of the planned new insertion, then through the upper border of the tarsal plate.

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Figure 6 Sutures passed again to the planned new insertion

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  Results Top


Muller's muscle-conjunctival resection surgery was performed on 20 eyelids of 20 patients for correction of mild-to-moderate ptosis with fair-to-good levator function. The sex distribution among the study group was as follows: six male (30%) and 14 female patients (70%).

The ages of the patients ranged between 4 and 37 years, with a mean ± SD of 22.3 ± 8.5. There were seven patients between 10 and 20 years of age, eight patients between 20 and 30 years of age, four patients between 30 and 40 years of age and only one patient under 10 years of age ([Table 1]).
Table 1 Characteristics of patients


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Congenital ptosis was present in 17 cases (85%), and Horner syndrome was present in three cases (15%) ([Table 2]).
Table 2 Aetiology of ptosis in operated cases


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Fifteen eyelids had mild ptosis (75%), and five eyelids had moderate ptosis (25%). The mean (margin reflex distance 1) before surgery was 2.05.

Levator function ranged between 9 and 15, with a mean ± SD of 11.6 ± 1.7. Good levator function (11 mm or more) was detected in 17 cases (85%) and fair levator function (5-10 mm) was detected in three cases (15%) ([Table 3]).
Table 3 Preoperative assessment of ptosis


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Follow-up of the patients was carried out at 1 week, 1 month, 3 months and 6 months postoperatively, using margin reflex distance 1, and comparison was made with margin reflex distance 1 before surgery ([Table 4]). A significant improvement was detected.
Table 4 Comparison between margin reflex distance 1 before and after surgery of studied patients


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Success of the operation was determined by means of postoperative eyelid elevation.

Patients were divided into three categories:

  1. successful (eyelid elevated to cover 2 mm of the cornea, or within 0.5 mm of this level), which included 12 eyelids (60%);
  2. accepted (within 1 mm of normal eyelid level, which covers 2 mm of the cornea), which included eight eyelids (40%); and
  3. failed (uncorrected 0%) ([Table 5]).
Table 5 Success of the surgery


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Phenylephrine testing: Eighteen eyelids (90%) were elevated after instillation of 2.5% phenylephrine. The increase in margin reflex distance 1 ranged from 0.5 to 2 mm, with a mean ± SD of 0.97 ± 0.55. Two eyelids showed no response (10%) ([Table 6]).
Table 6 The increase in margin reflex distance 1 after using phenylephrine drops


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  Discussion Top


Open sky Muller's conjunctival resection is a technique, which allows direct visualization of Muller's muscle before its resection. It was first described by Lake et al. [5] . It included 20 eyelids in 15 patients. Forty percent of patients were male and 60% were female. It is almost similar to that reported by Pan et al. [6] .

In our study, sex distribution among the study group was as follows: six male (30%) and 14 female (70%) patients. The large percentage of female patients may be due to their seeking for cosmetic results compared with male patients. The ages of patients in our study ranged between 4 and 37 years, with a mean of 22.3 ± 8, whereas in the study by Lake and colleagues it was 11.80 years, with a range of 4-20 years, and in the study by Pan and colleagues it had a range of 15-48 years. In this study, levator function was good (9-15) and nearly similar to that reported by Lake and colleagues (9-14 mm). In the study by Ben Simon et al. [7] , it was more than 10 mm.

In this study, 60% of cases had postoperative eyelid level within 0.5 mm symmetry with the other normal eyelid, and the remaining cases had within 1 mm symmetry. Putterman and Urist [4] published a study showing 90% of eyelids achieving within 1.5 mm symmetry with the fellow eye. Dresner [8] reported 84% of eyelids being within 0.5 mm symmetry to the fellow eye. In the original study describing the open-sky technique in phenylephrine-positive patients, 92% of 61 eyes were within 0.5 mm symmetry and 98% lids were within 1 mm symmetry with the fellow eye [5] .

In comparison, a large representative study of anterior levator advancement [9] has shown that 77% of eyelids had a symmetry within 1 mm to the fellow eye after one operation, with 8.8% eyelids requiring further surgery to obtain this outcome. A further 14% of eyelids were outside the desirable outcome, but the patients had declined further intervention. Bilateral cases were twice as likely to require reoperation [9] . Thus, all reports on Muller's muscle resection indicate a higher success.

The open-sky technique with isolated Muller's muscle offers several advantages over Muller's muscle-conjunctival resection using the clamp technique [10] and over anterior aponeurosis advancement [11] .

When compared with the clamp technique for Muller's muscle-conjunctival resection, the first advantage is that there is direct visibility of eyelid anatomy. Furthermore, this approach can easily be converted to posterior approach levator resection if adequate lid height is not achieved with Muller's muscle resection alone. This allows the technique to be safely attempted in phenylephrine-negative patients [10] . In the open-sky technique, the sutures transmit the pull of Muller's muscle through orbicularis muscle and skin, resulting in a predictable skin crease, as well as a degree of lash eversion [5] .

In the anterior approach surgery, a persistent medial droop is a problem observed by many, possibly due to thinner and structurally less dynamic medial attachments of the levator [11] . In contrast, a good contour is more consistently achieved with our procedure compared with the anterior approach, as the force of the levator muscle is passed to the upper border of the tarsal plate, rather than the lower border.

Our technique allows as much preservation of healthy conjunctival tissue as possible. Concern has previously been raised that excision of part of the tarsal conjunctiva, and therefore a proportion of goblet cells, might lead to dry eyes following this procedure. There were no subjective or objective symptoms or signs of dry eye in our patients supporting the findings in previous publications [4],[12],[13] . In fact, it appears that none of the elements necessary for a healthy tear film, including mucin secretors (goblet cells), lacrimal secretors (accessory lacrimal glands) and lipid secretors ( Meibomian gland More Detailss), are significantly affected [14] .

The anatomical reasons for the success of Muller's muscle-conjunctival resection have been a matter of debate for some time. Several mechanisms have been suggested for the success of this technique, which include vertical posterior lamellar shortening and secondary contractile cicatrisation of the wound. However, it has been increasingly felt that the success of the procedure is because of advancement of the levator muscle itself, along with the aponeurosis. The mechanism by which Muller's muscle resection alleviates ptosis would therefore be by transmitting the contraction force of the levator muscle directly to the tarsal plate instead of through its aponeurotic attachment. By passing the sutures through the stump of Muller's muscle (which originates at the distal edge of the inferior surface of the levator muscle) and then through the tarsus, one is in effect advancing the levator and attaching it to the tarsal plate and skin, they low. This theory is further supported by the success of the procedure in phenylephrine-negative patients [10] .

In this study, the response to phenylephrine was within 0-2 mm, with a mean elevation of 0.97, which is lower than that reported by Ha et al. [15] , and this difference may be due to the higher concentration of phenylephrine used.

Negative response to phenylephrine in this study was found in 10% of cases. All of them were surgically corrected to within 1 mm of normal. Lake et al. [5] explained the negative phenylephrine test by denervation of the sympathetic chain of Muller's muscle. Baldwin et al. [10] reported that Muller's muscle-conjunctival resection is an effective method in treating ptosis with negative phenylephrine test. Moreover, in our study it was performed successfully in patients with Horner syndrome in whom Muller's muscle was denervated.

In this study, on comparing margin reflex distance 1 after using phenylephrine drops with margin reflex distance 1 after surgery of studied patients (n = 20), we found that a greater improvement in eyelid height was achieved after surgery than what was originally predicted by the phenylephrine test. Thus, we can state that phenylephrine underestimates the final eyelid position ([Figure 7]).
Figure 7 Preoperative and postoperative case

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  Conclusion Top


Open-sky Muller's conjunctival resection surgery has high success rate in treating mild-to-moderate ptosis with fair-to-good levator function. It also has few and mild complications, with the advantage of good cosmetic results due to avoidance of cutaneous scar, and results in good eyelid contour. The procedure has short operation time and is easy to teach and learn.


  Acknowledgements Top


Conflicts of interest

None declared.

 
  References Top

1.
Beard C. Muller superior tarsal muscle anatomy, physiology and clinical significance. Ann Plast Surg 1985; 14 :324-333.  Back to cited text no. 1
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2.
Kiyoshi M. Stretching of the Muller muscle results in involuntary contraction of the levator muscle. Ophthalmic Plast Reconstr Surg 2002; 18 :5-10.  Back to cited text no. 2
    
3.
Fasanella RM, Servat J. Levator resection for minimal ptosis: another simplified operation. Arch Ophthalmol 1961; 65 :493-496.  Back to cited text no. 3
[PUBMED]    
4.
Putterman AM, Urist MJ. Muller muscle-conjunctiva resection. Technique for treatment of blepharoptosis. Arch Ophthalmol 1975; 93 :619-623.  Back to cited text no. 4
[PUBMED]    
5.
Lake S, Mohammad-Ali FH, Khooshabeh R. Open sky Muller's muscle-conjunctiva resection for ptosis surgery. Eye 2003; 17 :1008-1012.  Back to cited text no. 5
    
6.
Pan Y, Zhang H, Yang L, Song B, Xiao B, Yi C, Han Y. Correction of congenital severe ptosis by suspension of a frontal muscle flap overlapped with an inferiorly based orbital septum flap. Aesthetic Plast Surg 2008; 32 :604-612 discussion 613.  Back to cited text no. 6
    
7.
Ben Simon GJ, Lee S, Schwarcz RM, McCann JD, Goldberg RA. External levator advancement vs Muller's muscle-conjunctival resection for correction of upper eyelid involutional ptosis. Am J Ophthalmol 2005; 140 :426-432.  Back to cited text no. 7
    
8.
Dresner SC. Further modifications of the Muller's muscle-conjunctival resection procedure for blepharoptosis. Ophthalmic Plast Reconstr Surg 1991; 7 :114-122.  Back to cited text no. 8
    
9.
McCulley TJ, Kersten RC, Kulwin DR, Feuer WJ. Outcome and influencing factors of external levator palpebrae superioris aponeurosis advancement for blepharoptosis. Ophthal Plast Reconstr Surg 2003; 19 :388-393.  Back to cited text no. 9
    
10.
Baldwin HC, Bhagey J, Khooshabeh R. Open sky Muller muscle-conjunctival resection in phenylephrine test-negative blepharoptosis patients. Ophthal Plast Reconstr Surg 2005; 21 :276-280.  Back to cited text no. 10
    
11.
Kakizaki H, Zako M, Ide A, Mito H, Nakano T, Iwaki M. Causes of undercorrection of medial palpebral fissures in blepharoptosis surgery. Ophthal Plast Reconstr Surg 2004; 20 :198-201.  Back to cited text no. 11
    
12.
Dailey R, Saulny S, Sullivan S. Muller muscle conjunctival resesction effect in tear production. Ophthal Plast Reconstr Surg 2002; 18 :421-425.  Back to cited text no. 12
    
13.
Putterman AM, Urist MJ. Muller muscle-conjunctiva resection ptosis procedure. Ophthalmic Surg 1978; 9 :27-32.  Back to cited text no. 13
[PUBMED]    
14.
Shields M, Putterman A. Blepharoptosis correction. Curr Opin Otolaryngol Head Neck Surg 2003; 11 :261-266.  Back to cited text no. 14
    
15.
Ha S, Lee J, Jeung W, Ahn A. Muller muscle conjunctival resection for correction of blepharoptosis. Korean J Ophthalmol 2007; 21 :65-69.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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