aponeurosis incision, and then spreading superiorly, as was done prior to placing the initial suture. An additional suture is similarly placed in that area and tied. When the lid position and contour seem optimal with the patient upright, the patient again assumes the supine position, and each suture is tied permanently. The skin is closed with a running suture of choice.

Why Should This Procedure

Be Adopted When the One You

Are Using Seems Satisfactory?

We live in an age of decreasing reimbursements and increasing examination of outcomes. If a procedure can be done more quickly and yet with greater efficacy, then it is worthy of trial.

The author’s experience with this procedure, evolved by Dr. Hector McDonald of Ottowa, Canada, is that the mean time to perform it in the first 49 lids of 36 patients operated on with the minimal dissection procedure was 26.3 min (SE = 0.1 min) per eyelid, with a range of 13–68 min. The mean operating time for a random sample of 49 recent lids done on 36 patients with a traditional method, which he had been performing for many years, was 56.6 min (SE = 2.5 min), with a range of 35–119 min. Thus the minimal dissection procedure is quicker to perform (p < 0.0001). Dr. McDonald’s quickest time for the minimal dissection procedure is 2.75 min.

The initial 49 lids done by the author required one suture in 34 lids, two sutures in nine lids, with the second suture all placed laterally, and three sutures in six lids, one on either side of the central suture. Of the 49 lids operated on with the traditional procedure, two received one suture, three received two sutures, all placed medially, and 44 received three sutures.

Speed is unimportant if the results are inferior. However, the contour of the 49 lids studied in each group was significantly better with the minimal dissection procedure than the traditional

procedure, 97.6% versus 78.4%, p < 0.01. It is interesting that the one patient with an abnormal contour in the minimal dissection group had had three sutures placed, suggesting that contour was a problem recognized during the operation. The better contour with minimal dissection is presumably due to cutting fewer attachments medial and lateral to the center of the lid, as well as leaving the orbital septum intact. Defining success rigorously as being within 0.5 mm of the opposite side and 2–4 mm above the center of the pupil, the two procedures were not significantly different, with success being 66.7% for the minimal dissection procedure and 61.1% for the traditional procedure.

There is always a learning curve when performing a new procedure. The experience of the author is that it is essential to understand each step of the procedure before doing it, and then the procedure is easy. The author was working with two highly skilled non-eye-plastic ophthalmologists in Guatemala. These surgeons had three patients with involutional ptosis. After observing the procedure, they each operated on one eyelid of each patient. They did it perfectly and have been doing the procedure for the past 8 years successfully.

In summary, this ptosis correction procedure is simple, but the steps must be followed exactly as described. It allows the surgeon to correct ptosis more quickly, with a superior contour, with at least as good an ability to set the lid at the desired position as a traditional procedure.

References

1.Frueh BR, Musch DC, McDonald H. Efficacy and efficiency of a new involutional ptosis correction procedure compared to a traditional aponeurotic approach. Trans Am Ophthalmol Soc. 2004;102:199–207.

2.Lucarelli MJ, Lemke BN. Small incision external levator repair: technique and early results. Am J Ophthalmol. 1999;127(6):637–44.

3.Baroody M, Holds JB, Sakamoto DK, et al. Small incision transcutaneous levator aponeurotic repair for blepharoptosis. Ann Plast Surg. 2004;52(6):558–61.

Abstract  Müller’s muscle-conjunctival resec­ tion is a reliable, time-proven, and relatively easy technique for correction of mild-to-moder- ate blepharoptosis with good levator function.

Putterman and Urist first described Müller’s muscle-conjunctival resection (MMCR) in 1975 [1]. MMCR is traditionally used in selected cases of blepharoptosis with good levator function responding positively to pharmacologic sympathetic stimulation with phenylephrine [1]. Favorable response to MMCR has rarely been found in patients with poor to fair levator function [2, 3].

Müller’s muscle is a sympathetically innervated eyelid elevator. Originating from the undersurface of the levator palpebralis superioris, it is approximately 12 mm in length and inserts on the superior tarsal border. When approached from the posterior surface of the eyelid, Müller’s muscle lies directly beneath the conjunctiva just cephalad to the superior tarsal border. Stimulation of Müller’s muscle results in upper eyelid elevation of approximately 2–3 mm [4]; hence, oculosymphathetic paresis (Horner’s syndrome) seldom produces ptosis of more than 2–3 mm.

The decision to perform MMCR usually rests on elevation of the eyelid in response to

A.J. Cohen (*)

The Art of Eyes, Skokie, IL, USA e-mail: acohen@theartofeyes.com

sympathetic agents. The marginal reflex ­distance (MRD1) should be measured prior to and 5 min following instillation of phenylephrine eye drops [5] or 0.5% apraclonindine solution [6]. Glatt et al. reported a statistically significant but clinical insignificant difference in eyelid position when comparing 2.5 and 10% phenylephrine [7]. Several colleagues have described cardiovascular side effects with the use of 10% phenylephrine [8, 10]. These reports have prompted the use of 2.5% phenylephrine by the authors and many colleagues.

There have been studies of successful outcomes with MMCR in patients with poor response to phenylephrine challenge [9].

The patient is instructed to look down, and one drop of the medicine is placed in the superior fornix. An additional drop is placed 1 min later, and the upper eyelid position is assessed 5 min after that. A positive response is somewhat subjective and is defined as satisfactory eyelid elevation to correct the blepharoptosis from an esthetic and functional standpoint.

One simple approach to quantifying the necessary amount of tissue resection to achieve the desired lid position is as follows. If the ptosis is unilateral, then the affected eyelid is compared to the opposite, “normal” eyelid after instillation of the phenylephrine. The same is true for bilateral asymmetric ptosis when the goal is to bring the height of the more ptotic lid up to the level of the higher lid. An 8-mm resection is performed when the ptotic lid raises to the height of the opposite lid, while the amount of resection is increased (often to 9–10 mm) if the lid is a bit

low or decreased (often to 6–7 mm) if the lid is a bit too high after phenylephrine eyedrops. For bilateral ptosis, there is usually a symmetric response to the phenylephrine drops bilaterally. The amount of resection may be adjusted to address any preoperative asymmetry between the upper lids and to adjust for the degree of response to the phenylephrine.

Several authors have described various algorithms to predict the amount of tissue resection needed to correct various degrees of ptosis. Putterman described an 8.25-mm MMCR when normal eyelid height was achieved in response to 10% phenylephrine [11]. Weinstein [12] described a 4:1 ratio of tissue resection to the amount of eyelid elevation. This linear relationship began with 8 mm of resection to achieve 2 mm of eyelid elevation. Adding or subtracting 1 mm of tissue resection will result in a 0.25-mm difference in eyelid height, according to that formula.

Dresner [13], using a modified technique, also studied the relationship between the amount of resection and postoperative eyelid height. He did not find a linear relationship between the preoperative response to phenylephrine and postsurgical eyelid height. His algorithm supported 4 mm of resection for 1.0 mm of eyelid elevation, 6 mm of resection for 1.5 mm of elevation, 10 mm of resection for 2 mm of elevation, and 11–12 mm of resection to achieve 3 mm or greater of ptosis correction. His algorithm was dependent on a preoperative response to phenylephrine of 2 mm or greater of eyelid elevation.

Mercandetti et al. [14] constructed a linear regression algorithm that found an approximate 3:1 ratio of resection to eyelid elevation. They also suggested tailoring the resection based upon clinical outcomes with the MMCR.

Perry et al. [15] supported a 9-mm MMCR toachievethesameamountofeyelid­elevationafter maximal stimulation with 10% ­phenylephrine. His algorithm advised 9 mm of MMCR + 1 mm of tarsal resection for each ­millimeter of undercorrection with phenylephrine. One should find a 1:1 ratio between the amount of tarsal resection and the amount of eyelid elevation. It has been

recommended that no more than 2.5 mm of tarsus be resected to prevent eyelid instability.

Ben Simon et al. [16] found a 40% underestimation of postoperative eyelid elevation with 10% phenylephrine stimulation. They concluded that a simple linear relationship did not exist based on the analysis of their data.

Ayala et al. [17] described an approximate 5:1 ratio of resection to amount of lift in patients with moderate ptosis, good levator function, and positive response to phenylephrine. Thus, the quantitative relationship between Müller muscle resection and degree of ptosis correction remains somewhat unclear and is probably quite tech- nique-dependent, although there could be patientrelated variables at work. Therefore, surgeons should develop their own regression formula to establish the amount of tissue resection needed to achieve a given amount of ptosis correction in their hands.

Technique [5]

Prior to surgery, the surgeon should review the preoperative plan, and it is recommended to have the planned amount of MMCR resection written down in a visible location and the patient’s preoperative photograph for reference during surgery.

MMCR can be performed with local anesthetic alone or with monitored anesthesia care (MAC). In fact, this procedure may be done under general anesthesia, if so desired, since patient cooperation is unnecessary. A frontal or supraorbital nerve block provides excellent anesthesia without eyelid distortion. The frontal nerve block involves an intraorbital injection, which does carry some risk, although complications are rare when carefully performed. MAC reduces the chance of sudden patient movement during injection that can place the globe and surrounding structures at risk for injury, as well as providing greater patient comfort during the injection.

Frontal nerve block (technique utilized by one of the authors, AJC) – Once the patient has been adequately sedated, a 25-gauge, 1½ in. sharp

needle is passed below the midsuperior orbital rim with the needle lumen facing the orbital roof (bevel up), with the needle orientation parallel to the orbital roof. One should carefully slide along the orbital roof to a depth of 1½ in. One and one half to 2 ml of anesthetic solution is infiltrated followed by gentle digital pressure [17]. Two percent lidocaine with epinephrine and/or 0.5–0.75% bupivicaine is often used, and this varies based upon surgeon preference. If the patient is adequately blocked, complete ptosis will result [18].

Supraorbital Nerve Block- A short 27or 30-gauge needle is used to inject approximately 1 cc of a local anesthetic solution just inside the superior orbital rim adjacent to the supraorbital notch.

To enhance intraoperative comfort, local anesthetic may also be infiltrated just inside the superolateral orbital rim to anesthetize the lacrimal nerve. If additional local anesthesia­ is needed, subconjunctival infiltration above the superior tarsal border can be given. Subconjunctival infiltration is best performed following the placement of the Putterman clamp to avoid tissue distortion and altering the quantitative predictability of the procedure.

The eyelid is everted over a Desmarres lid retractor (Fig. 19.1), and this may be facilitated by an optional 4-0 silk suture passed

through the eyelid margin. A caliper is used to demarcate a point cephalad to the superior tarsal border where traction sutures will be placed (Fig. 19.2). This distance should equal the preoperative-determined amount of resection divided by two. Traction sutures (the authors often employ 4-0, 5-0, or 6-0 silk) are then passed through conjunctiva and Müller’s muscle at the desired height above tarsus using two contiguous sutures medially and laterally, or sometimes three sutures medially, centrally, and laterally (Fig. 19.3). The sutures should be placed with a long and relatively shallow needle pass, deep enough to engage Müller’s muscle but not levator. If one prefers to use a single suture, a double-armed silk suture may be used. After a central bite of tissue is secured, one arm of the suture is passed from central to medial, while the other end is passed from central to lateral. These lateral and medial passes are placed equidistant and parallel to the central pass.

As an alternative to silk traction sutures, the conjunctiva can be marked at the desired height with gentle handheld cautery or methylene blue. If using cautery, the surgeon should be cognizant that the heat can produce a welding effect, ­potentially joining Müller’s muscle to the underlying levator aponeurosis, which could result in

unintentional levator resection that may affect the final eyelid position.

A Putterman Müller’s muscle–conjunctiva resection clamp (Ambler Surgical Corp, Exton, PA, USA) is used to secure the proper amount of conjunctiva and Müller’s muscle (Fig. 19.4). Conjunctiva and Müller’s muscle are pulled anteriorly with either the traction suture or for-

ceps while applying the clamp. Anterior traction on these tissues facilitates clamp placement and aids in separating Müller’s muscle from the levator aponeurosis. There has been some debate over whether the clamp should be centered over the pupil or tarsal plate since lateral shifting of the tarsus may occur with eyelid laxity – the authors usually center the clamp over the tarsal

plate to achieve the optimal eyelid margin contour. The clamp is advanced to the superior edge of tarsus and then locked. The clamp is held while forceps are used to gently tug on the preseptal eyelid skin to be assured that skin and levator aponeurosis are not caught within the clamp. The skin should easily tent upwards, signifying that the proper structures (conjunctiva and Müller’s muscle) are engaged in the clamp.

Fig. 19.4  The traction sutures are placed on upward stretch, and a Putterman clamp is applied and advanced to the superior tarsal border. Care is taken to be certain that levator aponeurosis and skin are not secured within the clamp

There are a variety different ways that have been described to place a suture. One way is to use a 5-0 or 6-0 double-armed, plain gut suture on a G-3 needle (Ethicon, Inc. Skillman, NJ, USA), which is passed approximately 0.5–1 mm below the clamp to avoid cutting the suture when excising tissue within the clamp. The suture is placed lateral to medial in a horizontal mattress, running fashion, resulting in plication of the conjunctiva and Müller’s muscle directly beneath the clamp (Fig. 19.5a, b). Once the medial most aspect of the clamped tissue is reached, the suture may be run in a lateral fashion prior to using a 15 blade to excise the tissue and suture trapped within the clamp (Fig. 19.6). To minimize the risk of cutting the previously placed plain gut suture, the blade is angled with the sharp surface directly abutting the clamp at a 45° angle (Fig. 19.7). If the suture has not been passed laterally prior to tissue excision (Fig. 19.8), the wound is then closed beginning medially by approximating the edges of conjunctiva and Müller’s muscle. Although bleeding can occur, it tends to be self-limited once the conjunctiva is closed. At the lateral most aspect, the suture is cinched, and one of the needles is passed through the conjunctiva in the cephalad portion of the upper eyelid and trimmed at the surface. This completely buries the knot and the end of the suture, avoiding

irritation to the globe. Other surgeons­ use an equally effective technique – externalizing the knot onto the lateral preseptal eyelid skin (Fig. 19.9). If the knot is externalized and concomitant blepharoplasty is performed, one should be cognizant of the knot position to avoid cutting the suture during skin removal. In cases of combined upper blepharoplasty and MMCR, often the skin is resected at the beginning of the

case, but not sutured until the end of the case since eyelid manipulation during MMCR might cause dehiscence of a sutured blepharoplasty incision. Although various modifications of the original technique have been described, one of the authors (AJC) has found the earlier described technique with a slight modification of burying the suture beneath the conjunctiva to provide reliable results.

Typically, an equal amount of tissue is excised medially and laterally. However, one may address an eyelid contour deformity, e.g., ptosis that is greater temporally, by an asymmetric resection, i.e., placing the traction sutures higher and resecting more tissue in the more ptotic region of the eyelid.

Some surgeons prefer placement of a bandage contact lens at the end of the procedure to prevent ocular surface irritation if the suture becomes exposed. In our experience, suture exposure with resultant eye irritation is less of an issue when exteriorizing the suture knot on the skin. A combination antibiotic–steroid drop or ointment may be instilled at the end of the case,

and the patient is asked to use this eye medication four times daily for 1 week, along with artificial tears as needed.

Complications are uncommon and include overor undercorrection of the ptotic eyelid, eyelid asymmetry, corneal epitheliopathy or ulceration, hemorrhage, and rarely intraoperative injury to the globe. Eyelid margin contour deformity is less common with MMCR than with levator resection, and symblepharon formation is rare.

MMCR may be safely performed in patients with glaucoma filtering blebs [19, 20], although one certainly needs to be careful in a patient with an elevated, thin-walled, cystic bleb. Dry eye has

been suggested to be a risk due to resection of accessory lacrimal glands of Wolfring. However, Dailey et al. found no significant effect on tear production resulting from MMCR [21].

Advantages of MMCR include: (1) very quick procedure, (2) very predictable (although it has been suggested that it may be less reliable in congenital ptosis), (3) does not require any intraoperative patient cooperation, (4) the eyelid can be completely anesthetized since it is a prequantified procedure that is not titrated intraoperatively, (5) postoperative eyelid contour problems are rare, and (6) no visible skin incision or resultant scar, unless concurrent upper blepharoplasty is performed. Contraindications to MMCR include: (1) a shallow superior fornix, (2) poor or fair levator function, except

in the rare patient with a positive phenylephrine test. MMCR also may not be the procedure of choice in patients with greater than 3-mm ptosis.

MMCR continues to be a useful technique since its original description and should be included in one’s surgical repertoire for blepharoptosis repair, particularly in patients with mild-to-moderate ptosis and good-to-excellent levator function, whether or not they respond to phenylephrine preoperatively. Despite criticism that MMCR does not directly address the presumed site of pathology in involutional ptosis, i.e., the levator muscle and aponeurosis, MMCR remains a quick, easy and highly effective procedure in appropriate patients with ptosis (Figs. 19.10 and 19.11).