External Levator Advancement vs Müller’s Muscle–Conjunctival Resection for Correction of Upper Eyelid Involutional Ptosis

doi:10.1016/j.ajo.2005.03.033

American Journal of Ophthalmology

Volume 140, Issue 3, September 2005, Pages 426-432

https://doi.org/10.1016/j.ajo.2005.03.033 Get rights and content

Purpose

To compare external levator advancement and Müller’s muscle–conjunctival resection (conjunctivomullerectomy, or CJM) for correction of upper eyelid involutional ptosis.

Design

Retrospective, nonrandomized, comparative interventional case series.

Methods

Review of medical records of 159 patients (272 surgical procedures) who underwent external levator advancement or CJM was performed. main outcome measures: Functional and cosmetic outcome, marginal reflex distance one (MRD1), and surgical complications.

Results

A total of 159 patients (51 men, 108 women, mean age 70 years) underwent 272 surgical procedures for upper eyelid ptosis; concurrent blepharoplasty was performed in 141 cases. MRD1 increased an average of 1.6 (±1.5) mm, from 0.8 mm (±1.2) preoperatively to 2.3 mm (±1.2) postoperatively (P < .001). Fifteen patients (5.5%) underwent reoperation for residual ptosis, nine (18%) in the external levator advancement group, two (3%) in the CJM group, three (8%) in the external plus blepharoplasty group, and one (1%) in the CJM plus blepharoplasty group (P < .001). Patients who underwent external levator advancement had significantly more severe ptosis preoperatively but attained similar eyelid position postoperatively as compared with CJM patients. Complications included overcorrection in four cases (1.4%), lagophthalmos of 1 mm in 10 (3.6%), and pyogenic granuloma in two (<1%).

Conclusions

External levator advancement and CJM performed alone or with concurrent blepharoplasty are effective treatments for upper eyelid ptosis. Residual ptosis or postoperative eyelid retraction occurs in up to 20% of cases and can be addressed successfully with a second operation.

Section snippets

Methods

A retrospective review of medical records of all patients who underwent surgery for upper eyelid involutional ptosis either with or without blepharoplasty between January 1999 and December 2003 was performed. The data retrieved included age, gender, type of surgery, preoperative and postoperative digital photographs, visual acuity, marginal reflex distance one (MRD1; represents the distant between the inferior margin of the upper eyelid and the pupillary light reflex in primary position of

Results

One hundred and fifty-nine patients (51 men, 108 women, mean age 70 years) underwent 272 surgical procedures for upper eyelid ptosis. One hundred forty-one eyelids underwent concurrent blepharoplasty. Bilateral surgery was performed in 113 patients (71%). External levator advancement was performed in 88 eyelids and CJM in 184 eyelids. Demographics of the study population are summarized in Table 1.

MRD1 increased an average of 1.6 mm (±1.5), from 0.8 mm (±1.2, range 0.5 to 3.0) preoperatively to

Discussion

This study supports previous reports that external levator advancement and Müller’s muscle–conjunctival resection performed alone or with concurrent blepharoplasty are both effective in correction of involutional upper eyelid ptosis.7, 10, 13, 14, 15, 16, 17, 18, 19 Reoperation rate for residual ptosis is low in CJM (<3%) and can be as high as 17% in external ptosis repair. Overcorrection and eyelid retraction is not common (1.4%) but may be more prevalent in CJM. Cosmetic outcome, based on

References (32)

J.W. Shore et al.
Results of blepharoptosis surgery with early postoperative adjustment
Ophthalmology
(1990)
D. Liu
Ptosis repair by single suture aponeurotic tucksurgical technique and long-term results
Ophthalmology
(1993)
J.J. Older
Levator aponeurosis surgery for the correction of acquired ptosisanalysis of 113 procedures
Ophthalmology
(1983)
G. Weinstein et al.
Modifications of the Müller’s muscle-conjunctival resection operation for blepharoptosis
Am J Ophthalmol
(1982)
G. Buckman et al.
Success of the Fassanella-Servat operation independent of Müller’s smooth muscle excision
Ophthalmology
(1989)
R.L. Anderson et al.
The levator aponeurosisattachments and their clinical significance
Arch Ophthalmol
(1977)
R.K. Dortzbach et al.
Involutional blepharoptosisa histopathological study
Arch Ophthalmol
(1980)
L.T. Jones et al.
The cure of ptosis by aponeurotic repair
Arch Ophthalmol
(1975)
J.J. Olson et al.
Loss of vertical palpebral fissure height on downgaze in acquired blepharoptosis
Arch Ophthalmol
(1995)
S.A. Teske et al.
Hering’s law and eyebrow position
Ophthal Plast Reconstr Surg
(1998)

F.E. Lepore

Unilateral ptosis and Hering’s law

Neurology

(1988)

A.M. Putterman et al.

Müller’s muscle in the treatment of upper eyelid ptosisa ten-year study

Ophthalmic Surg

(1986)

A.M. Putterman

A clamp for strengthening Müller’s muscle in the treatment of ptosis. Modification, theory, and clamp for the Fasanella-Servat ptosis operation

Arch Ophthalmol

(1972)

A. Putterman et al.

Müller muscle-conjunctiva resection. Technique for treatment of blepharoptosis

Arch Ophthalmol

(1975)

R.M. Fasanella

Surgery for minimal ptosisthe Fasanella-Servant operation

Trans Ophthalmol Soc U K

(1973)

C.D. McCord

An external minimal ptosis procedureexternal tarsoaponeurectomy

Trans Sect Ophthalmol Am Acad Ophthalmol Otolaryngol

(1975)

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Temporal-fasciae-complex sheet suspension for correction of severe recurrent blepharoptosis
2023, Journal of Plastic, Reconstructive and Aesthetic Surgery
Multiple surgical methods were performed to correct the blepharoptosis. However, the recurrence of blepharoptosis is not uncommon in clinical practice. The Temporal-Fasciae-Complex Sheet (TFC sheet) was an ideal autologous material in correcting the severe blepharoptosis. In the present retrospected study, we introduced our experience in the correction of severe recurrent blepharoptosis with the technique of TFC sheet suspension, and describe the follow-up results to illustrate its effectiveness and practicality.
A total of 16 patients (23 eyes) with severe recurrent blepharoptosis were enrolled in this study. All the patients were performed with temporal-fasciae-complex sheet suspension surgeries for revision> 12 months after the primary surgeries by the same treatment group. The margin-to-reflex distance 1 (MRD1), correction effect, and eyelid symmetry were used to evaluate clinical outcomes.
19 eyelids (82.6%) showed good correction results, and 5 eyelids (21.7%) showed fair correction results. The average value of preoperative-MRD1(pre-MRD1) was − 0.17 ± 0.97, and the average value of postoperative-MRD1(post-MRD1) was 4.01 ± 1.24. There was a statistically significant difference between pre-MRD1 and post-MRD1 (p < 0.0001). Good symmetry was observed in 13 patients (81.3%). All patients enrolled were satisfied with the surgical results.
The Temporal-Fasciae-Complex Sheet Suspension is an effective and safe method for correcting the recurrent blepharoptosis.
Revision ptosis surgery for under-correction after Müller muscle conjunctival resection
2022, Journal of Plastic, Reconstructive and Aesthetic Surgery
Müller muscle conjunctival resection (MMCR) may be more likely to lead to under- rather than over-correction. The choice of revision surgery is not clearly defined.
MMCR patients were included if the post-operated eyelid(s) demonstrated margin reflex distance-1 (MRD1) less than 3.5 mm, or if MRD1 asymmetry was greater than 0.5 mm, and if they underwent subsequent revision surgery. MRD1 was the primary outcome measure and complications were secondary outcome measures. Two groups were defined: patients who underwent MMCR then repeat MMCR (M-M) and those who underwent MMCR followed by external levator resection (ELR) surgery (M-L).
18 eyelids (16 patients) were included, 12 in M-M and 6 in M-L. Mean (SD) preoperative MRD1 was 1.84 mm (0.97), range -0.41 to 3.39 mm. There was no difference (p = 0.70) in preoperative MRD1 between M-M and M-L. In the M-M group, mean (SD) MRD1 was 1.77 mm (1.12) preoperatively, 2.35 mm (0.66) after the first surgery, and 3.44 mm (0.31) after revision. Mean MRD1 was significantly higher after revision, compared to preoperatively (p < 0.05) and after first surgery (p < 0.05). In the M-L group (n = 6), mean (SD) MRD1 was 1.98 mm (0.90) preoperatively, 1.99 mm (0.56) after the first surgery and 3.44 mm (1.24) after revision. The difference between preoperative and post revision surgery MRD1 was significant (p < 0.05).
For patients with insufficient elevation of MRD1 or with asymmetry after MMCR, revision by MMCR or by ELR are both reasonable options.
Challenging the current treatment of residual postoperative ptosis: safety and efficacy of repeat Müller's muscle conjunctival resection
2022, Canadian Journal of Ophthalmology
To determine if repeat Müller's muscle conjunctival resection (MMCR) is a viable approach in the treatment of recurrent or residual eyelid ptosis.
A retrospective review of patients who underwent repeat MMCR was performed using external photos obtained preoperatively, postoperatively, and at last follow-up. The marginal reflex distances (MRD1 and MRD2), brow position (BP), and tarsal platform show (TPS) were evaluated with digital image analysis. The change in upper eyelid height (MRD1) and TPS following repeat ptosis repair were the outcome measures.
Repeat MMCR was performed on 12 eyelids of 11 patients. Mean MRD1 elevation after initial MMCR was 1.6 mm (standard deviation [SD] = 1.0mm, p < 0.00001). Mean decrease in TPS was 1.9 mm (p = 0.04). There was no significant change in MRD2 (p = 0.36) or BP (p = 0.33) with initial MMCR. Mean interval between procedures was 12.8 months (range 2.3–48.0) and follow-up after repeat MMCR was 2.3 months. Total average follow-up after initial MMCR was 15.1 months. Mean elevation in MRD1 after repeat MMCR was 1.0 mm (SD = 0.8 mm, p < 0.002). Mean decrease in TPS was 1.0 mm (p = 0.03). There was no difference in MRD2 (p = 0.90) or BP (p = 0.53). There were no complications of repeat MMCR noted clinically or spontaneously reported, including no entropion, fornix foreshortening, or development of dry eye signs or symptoms.
Repeat MMCR significantly improves recurrent or residual ptosis after initial MMCR without significant adverse consequences. The degree of elevation with repeat MMCR was diminished when compared with initial MMCR.
Déterminer si une reprise de la résection du muscle de Müller (RMM) représente une option viable dans le traitement du ptosis récurrent ou résiduel de la paupère.
Examen rétrospectif de dossiers de patients qui ont subi une reprise de la RMM par le biais de photos externes obtenues avant et après l'intervention de même qu’à la dernière visite de suivi. On a eu recours à une analyse d'images numériques pour mesurer la distance entre le reflet pupillaire et le bord libre (MRD1 et MRD2), la position des sourcils (PS) et l’étendue visible du tarse (TPS). La variation de la hauteur de la paupière supérieure (MRD1) et de la TPS à la suite de la reprise de la RMM a été retenue à titre de paramètre de mesure.
Une deuxième RMM a été réalisée sur 12 paupières de 11 patients. L’élévation moyenne de la MRD1 après la RMM initiale se chiffrait à 1,6 mm (écart-type [é.-t.]  = 1,0 mm; p < 0,00001). La diminution moyenne de la TPS s’élevait à 1,9 mm (p = 0,04). On n'a enregistré aucune variation significative au chapitre de la MRD2 (p = 0,36) ni de la PS (p = 0,33) lors de la RMM initiale. L'intervalle moyen entre les interventions était de 12,8 mois (fourchette : 2,3–48,0), tandis que la durée du suivi après la reprise de la RMM était de 2,3 mois. La durée totale moyenne du suivi après la RMM initiale était de 15,1 mois. L’élévation moyenne de la MRD1 après la reprise de la RMM était de 1,0 mm (é.-t. = 0,8 mm; p < 0,002). La diminution moyenne de la TPS se chiffrait à 1,0 mm (p = 0,03). On n'a noté aucune différence au chapitre de la MRD2 (p = 0,90) ni de la PS (p = 0,53). La reprise de la RMM n'a entraîné aucune complication clinique ni de complication signalée spontanément, qu'il s'agisse d'entropion, de raccourcissement du fornix ou d'apparition de signes ou de symptômes de sécheresse oculaire.
La reprise de la RMM a permis une amélioration significative du ptosis récurrent ou résiduel de la paupière après la RMM initiale, sans qu'il se produise d'effets indésirables significatifs. Le degré d’élévation obtenu lors de la reprise était moindre qu'au moment de la RMM initiale.
Factors that influence the postoperative upper eyelid position following surgery for involutional blepharoptosis
2022, Journal of Plastic, Reconstructive and Aesthetic Surgery
External levator advancement is commonly performed for involutional blepharoptosis repair; however, it is difficult to predict the postoperative upper eyelid position (UEP) accurately in blepharoptosis surgery. The purpose of this study was to determine the factors that influence postoperative UEP following surgery for involutional blepharoptosis. We retrospectively studied 40 Japanese women (80 eyelids) who underwent bilateral external levator advancement surgery. We used digital analysis software to measure the UEP and the eyebrow position from straight-gaze view photographs. Statistical analysis was performed to determine the correlation between postoperative UEP and related factors, including age, levator function, amount of levator advancement, anatomical fixed position, and preoperative and intraoperative UEP. We also compared UEP changes in mild, moderate, and severe ptosis groups. Levator function affected both preoperative and postoperative UEP. The amount of levator advancement and the anatomical fixation position on the aponeurosis did not affect the postoperative UEP. However, both preoperative (r = 0.49) and intraoperative (r = 0.55) UEPs affected the postoperative UEP. In cases of severe ptosis, there was significant re-drooping after surgery, while in cases with mild ptosis, the intraoperative eyelid position was maintained or slightly elevated. In involutional blepharoptosis, the degree of preoperative and intraoperative UEP contributed to the postoperative eyelid position. These data suggested that the levator muscle function is a major contributing factor in the pathogenesis of involutional blepharoptosis.
Comparison of postoperative recurrence rates between levator aponeurosis advancement and external Müller's muscle tucking for acquired blepharoptosis
2021, Journal of Plastic, Reconstructive and Aesthetic Surgery
Treatment options for acquired blepharoptosis include levator resection, levator aponeurosis advancement (LAA), Müller's muscle-conjunctival resection (MMCR), and frontalis suspension. Previously, we reported a technique called external Müller's muscle tucking (EMMT) using the Müller's muscle as a power source. In this study, we compare LAA with EMMT and evaluate the recurrence and reoperation rates. LAA was performed on 96 eyelids in 51 patients. The average follow-up period was 12.2 months, recurrence occurred in four eyelids (4.2%) of three patients, and reoperation was required in one eyelid of one patient (2.0%). EMMT was performed on 94 eyelids in 51 patients, the mean follow-up period was 10.5 months, recurrence occurred in 14 eyelids (15%) of 10 patients, and reoperation was required in three eyelids of two patients (3.9%). A comparison of LAA and EMMT recurrence showed that EMMT was associated with a significantly higher recurrence rate (P = 0.0021). The causes of EMMT recurrence included thinning and fatty degeneration of Müller's muscles, necrosis of ligated Müller's muscles, and less postoperative scar formation. There was no correlation between EMMT recurrence and the severity of the blepharoptosis.
Blepharoptosis Repair: External Versus Posterior Approach Surgery: Why I Select One over the Other
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Citation Excerpt :
MRD1 is typically in the range of 0 to 3 mm with good levator function (>12 mm excursion). In such cases, we consider MMCR to be a good first choice for surgery because it is more predictable, provides better cosmetic outcome in terms of eyelid contour and symmetry, has a lower rate of reoperation for undercorrection or overcorrection, and very rarely leads to lagophthalmos and/or eyelid retraction above the limbus.56,86 Furthermore, should a second surgery be required, it is less complicated to perform this surgery (ie, MMCR, tarsectomy, or ELR), due to less scarring and disruption of tissue planes in the eyelid.

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Original articleExternal Levator Advancement vs Müller’s Muscle–Conjunctival Resection for Correction of Upper Eyelid Involutional Ptosis

Purpose

Design

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Ophthalmology

Ophthalmology

Ophthalmology

Am J Ophthalmol

Ophthalmology

The levator aponeurosisattachments and their clinical significance

Arch Ophthalmol

Involutional blepharoptosisa histopathological study

Arch Ophthalmol

The cure of ptosis by aponeurotic repair

Arch Ophthalmol

Loss of vertical palpebral fissure height on downgaze in acquired blepharoptosis

Arch Ophthalmol

Hering’s law and eyebrow position

Ophthal Plast Reconstr Surg

Unilateral ptosis and Hering’s law

Neurology

Müller’s muscle in the treatment of upper eyelid ptosisa ten-year study

Ophthalmic Surg

A clamp for strengthening Müller’s muscle in the treatment of ptosis. Modification, theory, and clamp for the Fasanella-Servat ptosis operation

Arch Ophthalmol

Müller muscle-conjunctiva resection. Technique for treatment of blepharoptosis

Arch Ophthalmol

Surgery for minimal ptosisthe Fasanella-Servant operation

Trans Ophthalmol Soc U K

An external minimal ptosis procedureexternal tarsoaponeurectomy

Trans Sect Ophthalmol Am Acad Ophthalmol Otolaryngol

Original article
External Levator Advancement vs Müller’s Muscle–Conjunctival Resection for Correction of Upper Eyelid Involutional Ptosis