20.1 Introduction

Early in my career, Dr. Martin Urist and I developed a procedure to treat thyroid upper eyelid retraction. It consisted of dissecting conjunctiva from the Müller’s muscle and then doing a graded severing of Müller’s muscle from superior tarsal border with dissection of Müller’s muscle from its loose attachments to the levator aponeurosis.

Shortly after this procedure was developed, I decided to prove that the Fasanella procedure corrected blepharoptosis by its resection of Müller’s muscle rather than resection of levator as Fasanella thought. I approached this with the same technique I used for thyroid lid retraction and found that the Müller’s muscle resection corrected upper eyelid ptosis. As the dissection of conjunctiva from Müller’s muscle was difficult for many residents and some ophthalmologists to do, Urist and I simplified the procedure to the Müller’s muscle–conjunctival resection (MMCR). ^{1 ,​ 2} It is an ideal procedure for patients that have aponeurotic ptosis, defined by decreased palpebral fissure, decreased palpebral fissure on downgaze, decreased margin reflex distance 1 (MRD1), increased margin crease and fold distances, and levator excursion >10 mm with a positive phenylephrine test.

20.2 Special Preoperative Considerations

Eyelid measurements guide surgical management. The two key indicators in deciding on whether to perform MMCR are the MRD1 and response to phenylephrine testing.

20.2.1 Margin Reflex Distance 1

Before performing the phenylephrine test, it is important to assess the upper eyelid levels with the MRD1 measurement (Fig. 20.1). ³ The surgeon holds a muscle light at eye level and shines it onto the patient’s eyes. The distance from the corneal light reflex to the central upper lid margin is the MRD1, measured in positive millimeters. If the eyelid is below the middle of the pupil, the surgeon elevates the lid until the light reflex is first seen; the estimated number of millimeters the lid is lifted is the MRD1, in negative millimeters. The difference in the MRD1, on the normal side compared with the ptotic side, indicates the degree of ptosis. The normal MRD1 is approximately 4.5 mm; this number is used as a reference in bilateral cases. The MRD1 measurement has the advantage of measuring the ptosis and not the palpebral fissure width. This is preferred because there is a Müller’s muscle in the lower lid that can also respond to the phenylephrine. Measuring the palpebral fissure width would lead to erroneous interpretation of the upper lid level after phenylephrine instillation.

20.2.2 Phenylephrine Test ⁴

To avoid precipitating any side effects, such as myocardial infarction, hypertension, and acute glaucoma, it is important to make sure that the patient does not have a cardiac problem or shallow anterior chamber before instilling phenylephrine drops. The patient’s head is tilted backward, the upper eyelid is lifted, and the patient is instructed to gaze downward. Several drops of 10% phenylephrine are dropped between the upper eyelid and the globe. During drop installation, the canaliculi are compressed with the examiner’s finger for 10 seconds to minimize the excretion of phenylephrine into the nasal cavity and the potential side effect of systemic absorption. This is repeated immediately two more times. One minute later, two additional drops are applied. Two to four minutes after instillation of the phenylephrine, the MRD1 is measured (Fig. 20.2).

20.3 Risks

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  Overcorrection.

  
  
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  Undercorrection.

  
  
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  Corneal abrasion.

  
  
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  Bleeding.

  
  
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  Conjunctival scarring and eye discomfort.

20.4 Benefits

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  Predictable and reproducible eyelid lift.

  
  
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  Easily done in an outpatient or office-based surgery setting.

20.5 Informed Consent

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  Include risks and benefits.

20.6 Contraindications

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  Cicatrizing conjunctival disease, i.e., mucous membrane pemphigoid.

  
  
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  Severe dry eye with exposure keratopathy.

  
  
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  Myopathic or neurogenic ptosis with poor response to phenylephrine.

  
  
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  Prior glaucoma surgery in patients with large avascular superior conjunctival blebs.

20.7 Instrumentation

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  Castroviejo needle driver.

  
  
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  Forceps.

  
  
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  Desmarres retractor.

  
  
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  #15 blade.

  
  
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  Caliper.

  
  
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  Putterman ptosis clamp.

  
  
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  Hemostat.

  
  
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  Sutures:

  
  
  
  
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    4–0 silk G-3, double-armed.

    
    
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    5–0 plain catgut, S-14 needle, double-armed.

    
    
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    6–0 silk suture, S-14 needle, double-armed.

20.8 Preoperative Checklist

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  Informed consent.

  
  
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  Instrumentation on hand.

  
  
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  Preoperative clinical photographs to verify the site of surgery.

  
  
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  Preoperative and postphenylephrine measurements and photographs.

20.9 Operative Technique

The procedure can be performed under local, monitored, or general anesthesia in an office-based procedure room, ambulatory operating room, or hospital-based setting.

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  Local anesthesia injection:

  
  
  
  
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    A frontal nerve block is used with local anesthesia to avoid swelling of the upper eyelid by local infiltration, which would make the operation more difficult and inexact. A 23-gauge retrobulbar-type needle is inserted into the superior orbit, entering just under the middle of the superior orbital rim (Fig. 20.3).

    
    
    
    
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      The needle should hug the roof of the orbit during insertion and is advanced until a depth of 4 cm is reached.

      
      
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      Approximately 1.5 mL of 2% lidocaine with epinephrine is injected.

    
    
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    Another 0.25 mL is injected subcutaneously over the center upper eyelid, just above the eyelid margin (Fig. 20.4).

  
  
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  A 4–0 black silk traction suture is inserted through skin, orbicularis muscle, and superficial tarsus 2 mm above the eyelashes at the center of the upper eyelid (Fig. 20.5).

  
  
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  A large- to medium-sized Desmarres retractor everts the upper eyelid and exposes the palpebral conjunctiva from the superior tarsal border to the superior fornix. In an awake patient, topical tetracaine drops are applied over the upper palpebral conjunctiva.

  
  
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  A caliper set at the desired amount of MMCR, with one arm at the superior tarsal border, facilitates insertion of a 6–0 black silk suture through the conjunctiva above the superior tarsal border (Fig. 20.6). One passage centrally and two others, approximately 7 mm nasal and temporal to the center, mark the site.

  
  
  
  
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    I usually place the suture 8.25 mm above the superior tarsal border, but it may be placed 6 to 10 mm above it if the response of the upper eyelid level to the phenylephrine test is slightly more or less than desired, respectively.

  
  
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  A toothed forceps grasps conjunctiva and Müller’s muscle between the superior tarsal border and marking suture and separates Müller’s muscle from its loose attachment to the levator aponeurosis (Fig. 20.7).

  
  
  
  
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    This maneuver is possible because Müller’s muscle is firmly attached to conjunctiva but only loosely attached to the levator aponeurosis.

  
  
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  One blade of a specially designed clamp (Putterman MMCR clamp, Storz Company, Manchester, MO) is placed at the level of the marking suture. Each tooth of this blade engages each suture bite that passes through the palpebral conjunctiva (Fig. 20.8a, b). The Desmarres retractor is then slowly released as the outer blade of the clamp engages conjunctiva and Müller’s muscle adjacent to the superior tarsal border (Fig. 20.8a, b). Any entrapped tarsus is pulled out of the clamp with the surgeon’s finger (Fig. 20.9). The clamp is compressed, and the handle is locked, incorporating conjunctiva and Müller’s muscle between the superior tarsal border and the marking suture.

  
  
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  The upper eyelid skin is then pulled in one direction while the clamp is pulled simultaneously in the opposite direction (Fig. 20.10).

  
  
  
  
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    If the surgeon feels a sense of attachment between the skin and clamp during this maneuver, the levator aponeurosis has been inadvertently trapped in the clamp. If this occurs, the clamp should be released and reapplied in its proper position.

    
    
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    This maneuver is possible because the levator aponeurosis sends extensions to orbicularis muscle and skin to form the lid crease.

  
  
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  With the clamp held straight up, 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, and through Müller’s muscle and conjunctiva on the other side and vice versa (Fig. 20.11a,b).

  
  
  
  
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    The sutures are placed approximately 2 to 3 mm apart.

  
  
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  A #15 surgical blade is used to excise the tissues held in the clamp by cutting between the sutures and the clamp (Fig. 20.12).

  
  
  
  
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    The knife blade is rotated slightly, with its sharp edge hugging the clamp. As the tissues are excised from the clamp, the surgeon and assistant watch to ensure that the suture on each side is not cut.

  
  
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  The Desmarres retractor again everts 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 stitches should be approximately 2 mm apart as they pass through the edges of superior tarsal border, Müller’s muscle, and conjunctiva (Fig. 20.13).

  
  
  
  
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    The surgeon must be careful to avoid cutting the original mattress suture during this continuous closure. Towards this end, the surgeon uses a small suture needle (S-14 spatula), observing the mattress suture position during each bite, and the assistant applies continuous suction along the incision edges.

  
  
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  Once each arm of the suture reaches the temporal end of the eyelid, it is passed through each side of the conjunctiva and Müller’s muscle before it exits through the temporal end of the incision (Fig. 20.14). The suture arms are then tied with approximately four to five knots, and the ends are cut close to the knot, thus burying the knot subconjunctivally upon eyelid re-eversion to lessen the risk of postoperative keratopathy from suture/cornea rub.