Side effects, such as myocardial infarction and hypertension, have been reported after instillation of phenylephrine drops,² but are exceedingly rare. Therefore, it is important to determine that the patient does not have a significant cardiac risk before the phenylephrine test is performed. In our collective experience this has, however, rarely posed a problem but if there is ever a significant concern then the patient’s primary care physician or cardiologist should be consulted.

Glatt and Putterman ³ have compared test results using 2.5 percent and 10 percent phenylephrine. It appears that both solutions are effective in determining candidates for the Müller’s muscle–conjunctival resection procedure, but that the 2.5 percent solution may theoretically result in fewer vasoactive side effects. Our experience has been primarily with the 10 percent solution. Patients should be warned regarding the likely pupillary dilation after this test which may yield transient photophobia and visual blurring. If there is a history of glaucoma, it may be prudent to contact their ophthalmologist regarding any concerns of pupillary dilation. Finally, regarding other symptomatology after these tests, it is not uncommon for patients to experience transient ocular irritation that might relate to dryness or exposure symptoms and indicate to the surgeon the possibility of dry eye symptoms after surgery.

Indications

The procedure is primarily used to treat blepharoptosis in patients whose upper eyelids elevate after phenylephrine administration as described. Candidates for this procedure usually have minimal congenital contribution to their ptosis, may present with varying degrees of acquired unilateral or bilateral ptosis, or may have had prior unsuccessful external approach lid ptosis surgery. The procedure is especially useful in those individuals who have had upper blepharoplasty where the lid ptosis was unsuccessful or not addressed, and where additional external approach surgery may be both difficult and/or risky. In rare situations, this procedure can be performed with good results in those people who respond poorly to neosynephrine. It is our preferred method of upper lid ptosis correction in those individuals who demonstrate ptosis and also present for upper blepharoplasty.

Goal of the operation

The procedure should result in highly cosmetically acceptable upper eyelid levels and contours on both sides, restoration of the youthful eyelid crease, as well as improvement of vision in those with demonstrable visual loss related to upper eyelid malposition, especially on downgaze during reading. It provides a more global aesthetic periorbital solution for individuals who present for cosmetic blepharoplasty and exhibit the varying degrees of unilateral or bilateral blepharoptosis.

Surgical technique

Anesthesia

Local anesthesia is preferred in adults. The upper eyelid skin to be removed is marked according to the technique for upper blepharoplasty with crease reconstruction (see Chapter 7) or without crease reconstruction (see Chapter 8) (Fig. 11-1A). A frontal nerve block is used with local anesthesia to avoid swelling and bruising of the upper eyelid by local infiltration, which would make the operation more difficult and inexact.⁴

Figure 11-1 A, Outline of skin or skin and orbicularis oculi muscle to be excised.

B, Administration of anesthesia before the Müller’s muscle–conjunctival resection. A 4-cm, 23-gauge retrobulbar needle is inserted along the central orbital roof to its full length. An injection of 1.5 ml of 2 percent lidocaine with epinephrine achieves a frontal nerve block and avoids infiltration of the eyelid.

C, A second injection of 0.5 ml of 2 percent lidocaine with epinephrine is given subcutaneously over the central upper eyelid above the lashes.

D, Scratch incision over marked upper eyelid.

E, The upper eyelid is everted over a Desmarres retractor, and a 6-0 black silk marking suture is placed through conjunctiva 4–9.5 mm above the superior tarsal border. One suture bite is taken centrally, and one bite is made 7 mm nasal and temporal to the central bite.

F, A toothed forceps is used to separate the conjunctiva and Müller’s muscle from its loose attachment to the levator aponeurosis at various sites between the upper tarsal border and the marking suture.

G, A clamp is positioned so that each tooth of one blade engages each site of the marking suture; the other blade is above the superior tarsal border.

H, As the Desmarres retractor is gradually released through rotation, the other clamp blade slides over tarsus as its teeth engage conjunctiva and Müller’s muscle above the superior tarsal border.

I, Before locking the clamp, the surgeon slides out any entrapped tarsus.

J, The closed clamp includes 4–9.5 mm of conjunctiva and Müller’s muscle just above the superior tarsal border. Clamp and skin are pulled in opposite directions to ensure that the levator aponeurosis is not caught in the clamp.

K and L, A 5-0 plain catgut mattress suture runs in a temporal to nasal direction about 1.5 mm distal to the clamp; each suture bite includes upper tarsus, Müller’s muscle, and conjunctiva.

M, Conjunctiva–Müller’s muscle is excised by running a No. 15 surgical blade against the edge of the clamp.

N, The nasal suture arm runs continuously in a nasal to temporal direction through the edges of conjunctiva, Müller’s muscle, and tarsus.

O, Each arm of the suture passes through conjunctiva and Müller’s muscle and exits through the temporal incision; the suture arms are tied.

P, Excision of outline ellipse of skin and orbicularis muscle with a disposable cautery.

Q, Placement of three 6-0 polyglactin (Vicryl) sutures uniting skin and levator aponeurosis. A 6-0 continuous silk suture closes the skin. Parts B, C, and E–O,

Modified from Putterman AM, Fett DR: Müller’s muscle in the treatment of upper eyelid ptosis: A ten-year study. Ophthalmic Surg 1986; 17:354–356. With permission.

After the upper eyelid is marked for blepharoplasty and the chosen sedative is administered, a 23-gauge retrobulbar needle is inserted into the superior orbit, entering just under the midsuperior orbital rim lateral to the supra-orbital notch (Fig. 11-1B). The needle hugs the roof of the orbit during insertion until a depth of up to 4 cm is reached; then 1.5 ml of 2 percent lidocaine (Xylocaine) with epinephrine is injected. Alternately, bupivicaine (Marcaine) may be used to prolong the anesthetic effect. Another 0.5 ml of the anesthetic solution is injected subcutaneously over the central upper eyelid just above the lid margin (where a traction suture of 4-0 silk is placed), and a small amount may be injected under the lines marked on the upper eyelid (Fig. 11-1C).

Marking areas of excision and resection

A scratch incision is made over the marked upper blepharoplasty demarcations (Fig. 11-1D). A 4-0 black silk traction suture is inserted through skin, orbicularis muscle, and superficial tarsus 2 mm above the lashes at the center of the upper eyelid. Care must be taken to avoid a full thickness penetration with this maneuver and injury to the corneal surface. A medium-sized Desmarres lid retractor is used to evert the upper eyelid and to expose the palpebral conjunctiva from the superior tarsal border to the superior fornix. Topical tetracaine drops may be applied over the upper palpebral conjunctiva especially when light or no sedation is administered.

A caliper set at the determined amount of resection (i.e. 8.5 mm in a unilateral repair in those whose neosynephrine test restored the upper eyelid to the desired position), with one arm at the superior tarsal border, facilitates insertion of a 6-0 black silk suture through the conjunctiva 8.5 mm above the superior tarsal border (Fig. 11-1E). One suture bite centrally and two others approximately 7 mm nasal and temporal to the center mark the site. The preferred placement of the 6-0 black silk marking suture is 8.5 mm above the superior tarsal border (in those individuals with unilateral ptosis whose neosynephrine test brings them to a symmetric and satisfactory postion), but the suture may be placed 4.0–9.5 mm above the border if the response of the upper eyelid level to the phenylephrine test is slightly greater or less than desired. The smaller resections (in the 4.0–6.0 mm range) are typically more technically difficult to administer using the prescribed clamp, described below. The placement of this marking suture should be through conjunctiva only as penetration to and through Müller’s muscle may cause significant bleeding.

Separation of Müller’s muscle from the levator aponeurosis

A toothed forceps is used to grasp conjunctiva and Müller’s muscle between the superior tarsal border and the marking suture and to separate Müller’s muscle from its loose attachment to the levator aponeurosis (Fig. 11-1F). This maneuver is possible because Müller’s muscle is firmly attached to conjunctiva but only loosely attached to the levator aponeurosis (see Chapter 5).

Clamp application

Although this procedure can be performed with a variety of clamps and other instruments, it is much more easily and precisely performed with a particular instrument made for this procedure. One blade of this specially designed Müller’s muscle–conjunctival resection–ptosis clamp (Bausch & Lomb Storz Company, Manchester, MO) should be placed at the level of the marking suture. Each tooth of this blade engages each suture bite that passes through the palpebral conjunctiva (Fig. 11-1G).

The Desmarres retractor is then slowly released (with the handle of the retractor brought from the resting cephalad postion to a caudal position) as the other blade of the clamp engages conjunctiva and Müller’s muscle adjacent to the superior tarsal border (Fig. 11-1H).

Any entrapped tarsus is then released from the clamp with the surgeon’s finger (Fig. 11-1I). The clamp is compressed, and the handle is locked. This leads to the incorporation of conjunctiva and Müller’s muscle between the superior tarsal border and the marking suture.

The upper eyelid skin is pulled in one direction while the clamp is pulled simultaneously in the opposite direction (Fig. 11-1J). During this maneuver, the surgeon may feel a sense of attachment between the skin and the clamp. If this occurs, a greater amount of the levator aponeurosis may have been inadvertently trapped in the clamp. In this situation, the clamp should be released and reapplied into its proper position. This maneuver is possible because the levator aponeurosis sends extensions to orbicularis muscle and skin to form the lid crease (see Chapter 5).

Suturing and resection of conjunctiva and Müller’s muscle

With the clamp held straight up/vertically, a 5-0 double-armed plain catgut mattress suture is run 1.5 mm below the clamp along its entire width in a temporal to nasal direction in a horizontal mattress fashion, through the upper margin of the tarsus on one side and through Müller’s muscle and conjunctiva on the other side, and vice versa (Fig. 11-1K and L). The sutures are placed approximately 2–3 mm from each other. The surgeon uses a No. 15 surgical blade to excise the tissues held in the clamp by cutting between the sutures and the clamp. The knife blade is rotated slightly, with its sharp edge hugging the clamp (Fig. 11-1M).

As the tissues are incised and separated from the clamp, the surgeon and the assistant watch to ensure that the plain catgut sutures on each side are not inadvertently severed by this maneuver. Bleeding will likely be encountered after this incision and almost always ceases once the conjunctiva is closed. Injudicious use of cautery at this point might also result in an inadvertent severing of the plain catgut suture which will prove problematic and therefore should be avoided.

The Desmarres retractor is used again to evert the eyelid while gentle traction is applied to the 4-0 black silk centering suture. The nasal end of the suture is then run continuously in a temporal direction; the suture passes should be about 2 mm apart through the edge of superior tarsal border, Müller’s muscle, and conjunctiva (Fig. 11-1N). Commonly, this suture just connects the edges of conjunctiva.

During continuous closure with the 5-0 plain catgut suture, the surgeon must be careful to avoid cutting the original mattress suture. This is facilitated by the surgeon’s using a small suture needle (S-14 Spatula, Ethicon) in addition to observing the mattress suture position during each suture bite during the conjunctival closure, and by the assistant’s applying continuous suction or swabbing with cotton-tip applicators along the incision edges. If the original horizontal mattress placement is too close to the clamp edge (within 1.5 mm or so) then this will be more difficult. The 5-0 plain catgut suture ends are passed through each side of the conjunctiva and Müller’s muscle before they exit through the temporal end of the incision (Fig. 11-1O). Once each arm of the suture reaches the temporal end of the eyelid, the suture ends are connected with a serrefine clamp. This is done to ensure that this suture is not inadvertently cut with the skin-muscle flap of the upper blepharoplasty procedure to follow and, if so, it can be more easily identified. Alternately, if a skin flap upper blepharoplasty (without muscle excision) is performed, the suture can be tied (described below) at this time.

Upper blepharoplasty

Several milliliters of same anesthetic solution is injected subcutaneously over the upper eyelids. Then an upper eyelid blepharoplasty is performed (as described in Chapters 7 and 8) through the steps of skin⁵ or skin and orbicularis muscle resection, excision of fat, and completion of hemostasis (Fig. 11-1P); however cautery should be minimized to avoid cutting the plain suture. If not already performed, the eyelid is again everted with a Desmarres retractor, the 5-0 plain catgut suture arms are tied with 4–5 knots, and the ends are cut close to the knot. In this way, the knot can be buried subconjunctivally, lessening postoperative keratopathy and surface irritation.

After this step, the crease sutures are placed and the skin is closed (see Chapter 7) (Fig. 11-1Q). If no crease is reconstructed, the skin is sutured at this time, as described in Chapter 8.

Postoperative care

Patients are observed postoperatively, as with blepharoplasty in general, to make sure that there is no excessive bleeding or possibility of retrobulbar hemorrhage, which has the potential for causing blindness. The patient applies cold compresses to the eyelids for the first 24 hours postoperatively. A topical antibiotic such as gentamicin (Garamycin) or a combination antibiotic/corticosteroid (TobraDex) ophthalmic ointment on the eye can be used once or twice a day for the first week or two. The patient may also use a sterile eyewash applied to cotton pads to wipe over the eyelids twice a day for 2 weeks after surgery. Patients are instructed for the first 2 weeks after surgery to bathe or shower only from the neck down and to wash their hair so as to avoid an abundant contact of soap and water with the eyes.

Results

The average follow-up is 3.3 months, but varies from 2 weeks to 7 years. Follow-up generally lasts until the patient’s eyelids cease to change. The MRD₁ at stabilization of lid levels is considered the final result.

In most patients with acquired ptosis (90 percent in the experience of AMP), the final eyelid level after treatment is within 2 mm of the opposite eyelid. In 88 percent of these treated eyelids, an MRD₁ of 1.5–5 mm is achieved.⁶

Patients with congenital ptosis have a final eyelid level after treatment within 1.5 mm of the opposite eyelid. In 84 percent of these treated eyelids, an MRD₁ of 2.5–5 mm is achieved.

Rarely, in less than 2 percent of patients, additional surgery may be required to treat residual ptosis. This is most often achieved with a levator aponeurosis procedure (see Chapter 10). However in rare situations an internal-approach resection may be repeated.

Occasionally, the upper eyelid is too high (overcorrection). If this elevation occurs, the patient massages the upper eyelid downward while simultaneously fixating the brow 2–4 times each day for 1–4 weeks. If a gross overcorrection is encountered in the first 7–10 days, the plain suture can either simply cut or cut and excised followed by massage until the satisfactory eyelid position is achieved. If massage is ultimately ineffective or does not bring the upper lid to an optimum level, an external levator recession may be performed.

Alternative techniques

The Müller’s muscle–conjunctival resection procedure has an advantage over the Fasanella–Servat procedure because it allows the tarsus to be preserved.^7,⁸ This also carries less risk of suture keratopathy because the sutures are at the superior tarsal border instead of 3–4 mm closer to the eyelid margins, as in the Fasanella procedure. This operation is also superior to the levator aponeurosis advancement/resection procedures because results are much more predictable and there is less need for subsequent surgery.^8,⁹

We have collectively performed this procedure on more than 2000 upper eyelids. In a report of results in 232 of the treated lids, 230 lids had levels that were considered cosmetically acceptable (Figs 11-2, 11-3, 11-4, 11-5, 11-6).⁶