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Fig. 20.1 (continued) (e) Adouble-ended 5/0 silk suture is placed through the conjunctiva at the level of the initial incision, through the stump of Müller’s muscle, (f) through the upper border of the tarsal plate and finally out
through the marked skin crease. (g) This suture is tied on a loop, and eyelid height and contour are checked before placing the other two sutures. (h) The eyelid at the end of the operation
phenylephrine has also been used to calculate the amount of tissue to be resected [7, 8, 10]. If the lid has no response or an extremely poor response to the instillation of phenylephrine, an alternative technique, such as a direct levator tuck, resection, or advancement, is traditionally performed.
However, the most likely explanation for the efficacy of the open-sky Müller’s muscle– conjunctival resection technique is that the surgery results in advancement of the levator muscle. This explains how the technique, therefore, works in patients without a positive response to topical phenylephrine.
Discussion
There are two possible explanations for the success of Müller’s muscle–conjunctival resection in raising the lid margin. First, resection of
Müller’s muscle might enhance the stretch reflex transmitted to the levator muscle, and thereby increase the tone in that muscle. However, the clinical results suggest that it is more likely that this technique works by simple advancement of the levator muscle itself, along with the aponeurosis. Suturing muscular and vascular tissue such as Müller’s muscle to the tarsal plate may provide a more stable and durable adhesion than suturing the levator aponeurosis when it has been affected by fibro-fatty degeneration. The mechanism by which Müller’s muscle resection alleviates ptosis would, therefore, be by transmitting the contraction force of levator muscle directly to the tarsal plate instead of transmitting through its aponeurotic attachment. This would occur irrespective of the level of the aponeurotic defect.
The technique presented here is significantly different from other techniques that aim to correct ptosis by excising conjunctiva, tarsal plate,
20 Open-Sky (Anterior Approach) Müller’s Muscle Resection for the Correction of Blepharoptosis |
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and/or Müller’s muscle. The Fasanella–Servat procedure probably does not depend on a Müllerectomy, but is effective due to posterior lamellar shortening, or advancement of the levator aponeurosis complex on the tarsus. It has been shown that the technique was effective in a series of ptosis patients despite histological evidence that absent or minimal smooth muscle resection was performed [22]. The traditional Müller’s muscle–conjunctival resection also relies on a closed-clamp technique, in which the actual amount of smooth muscle resected is not visibly measurable, and may be effective by the same mechanisms as the Fasanella–Servat procedure [23]. The open-sky technique may provide specific advantage for ptosis repair in phenylephrine test-negative patients, as the technique allows for maximal resection of Müller’s muscle under direct visualization to provide for more powerful levator advancement [17].
The open-sky technique for Müller’s mus- cle–conjunctival resection without the use of the clamp has several advantages over the closed technique originally described by
Putterman. First, the technique is performed under direct visualization of the relevant eyelid structures. Second, there is opportunity for intraoperative adjustment by placement of sutures higher up in the residual stump of Müller’s muscle or by resection of a strip of tarsal plate, if necessary. In the event of adequate height still not being achieved, the procedure may easily be converted to a posterior approach levator resection as described by Collin [2]. The timing of removal of “pull-out” silk sutures, also described by Collin in the same paper, allows some postoperative manipulation of lid height. Third, attachment of Müller’s muscle directly to the skin augments the skin crease, which is not the case in other types of posterior approach ptosis surgery. Fourth, the technique is easily modified to allow preservation of the conjunctiva [18]. Finally, the technique has been shown to be effective in phenylephrine test-negative as well as phenylephrine test-positive patients [17], making it a safe and effective method for correction of ptosis in many patients with mild to moderate ptosis (Figs. 20.2–20.4).
Fig. 20.2 Bilateral ptosis corrected with isolated Müller’s muscle resection
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Fig. 20.3 Unilateral ptosis corrected with isolated Müller’s muscle resection
Fig. 20.4 Congenital ptosis (right eye) corrected with isolated Müller’s muscle resection
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