MüLler’S Muscle-Conjunctival Resection-Ptosis Procedure Combined with Upper Blepharoplasty
Allen M. Putterman
INTRODUCTION
Often, patients who present for cosmetic rejuvenation of the upper periorbita are found on physical examination to have both dermatochalasis and upper eyelid ptosis. In these situations, it is both possible and preferable to combine an upper blepharoplasty with ptosis surgery. Although this technique is commonly performed through an external approach with levator aponeurosis advancement or resection, many cosmetic surgeons do not appreciate the possibility of combining an internal Müller’s muscle-conjunctival resection with an external upper blepharoplasty, especially when the skin and orbicularis oculi muscle are excised and an eyelid crease is reconstructed.
The Müller’s muscle-conjunctival resection-ptosis procedure is a technique in which Müller’s muscle in the upper eyelid is partially resected and advanced. The mechanism by which the correction of ptosis is achieved is probably due to a number of effects that include resection and advancement of Müller’s muscle as well as the secondary effects of advancing the levator aponeurosis to the superior tarsal border. The classic approach to the treatment of a variety of ptosis presentations has been mostly through variations of an external (skin-muscle incision) approach through the upper eyelid crease whereby the anatomic “defect” is visualized and presumably repaired. This approach, however, more often requires the cooperation of the patient during the surgical procedure and heralds a host of potential variables that include, but are not limited to, sedative effects, local anesthetic effects, edema, and performance anxiety on the part of both the patient and the surgeon. On the contrary, the Müller’s muscle conjunctival resection can be performed with continuous IV sedation or even general anesthesia as it does not require the intraoperative cooperation of the patient. The procedure is used to treat a variety of upper eyelid ptosis and can be combined with an upper blepharoplasty with or without crease reconstruction via a skin flap or a skin-muscle flap approach. This technique has many advantages over other “posterior approach” lid ptosis procedures and the external approaches, which includes the preservation of upper eyelid tarsus (which creates less risk of suture-induced keratopathy and theoretically preserves structural and functional aspects of the upper eyelid), repositioning of the elevated (involutional) eyelid crease to a lower positioned and more youthful level, and can more predictably improve upper eyelid position (margin reflex distance, MRD) and contour. In addition, the excision of skin-muscle and adipose tissue that is performed for a host of reasons, including adequate exposure of the levator aponeurosis (that can be volume depleting to the upper eyelid), can be avoided if desired. This procedure can be applied in most types of ptosis presentations, and there is rarely any need for additional surgery to treat residual ptosis or overcorrections.
Simply stated, I have found that this combined procedure produces both superior results compared with the levator aponeurosis procedure with upper blepharoplasty, especially in the patients who desire a lower positioned upper eyelid crease and/or whose upper eyelids elevate to normal levels after administration of phenylephrine.
HISTORY
The surgeon should question the patient about illnesses, medications, allergies, and edema. Emphasis is placed on ruling out thyroid disease, heart failure, hypertension, bleeding tendencies, glaucoma, and unusual swelling. Patients with thyroid disease may look as if they need cosmetic surgery, but the treatment is frequently medical—not surgical. Side effects, such as myocardial infarction and hypertension, have been reported on rare occasion after instillation of phenylephrine drops. Therefore, it is important to determine the presence of any significant cardiac risk factors. If such elements are of significant concern, the patient’s primary care physician or cardiologist should be consulted as these issues will reemerge during consultation for surgery. Additionally, if there is a history of glaucoma, it may be prudent to contact their ophthalmologist regarding any concerns of pupillary dilation prior to a phenylephrine test.
A focused history with regard to the presence of lid ptosis is of considerable importance. Various classification models have been developed with reference to acquired, neurogenic, mechanical, and congenital origins. Each can help to organize one’s approach in an evaluation. With all patients, I inquire about any history of trauma, previous surgeries, chronic ocular conditions, contact lens use, and lid fatigue.
Patients should also be questioned about intake of medications, in particular aspirin or anti-inflammatory medications such as ibuprofen, vitamin E, anticoagulants, and herbal remedies. These drugs must be discontinued for several weeks preoperatively to avoid the possibility of complications of bleeding during and after surgery.
PHYSICAL EXAMINATION
In the physical examination, multiple anatomic elements must be considered in the evaluation to ensure ocular rejuvenation and functional restoration. The mindful surgeon must assess the presence of brow ptosis, excessive upper eyelid skin, herniated orbital adipose tissue, abnormal creases, lid retraction, ptosis, and lacrimal gland herniation in each patient undergoing evaluation for surgery. Additionally, asymmetries of the eyebrows, eyelids, and possible dystopia should be reviewed with the patient while the patient is holding a mirror.
The evaluation of brow ptosis is important, as this condition is responsible for excessive eyelid folds created by brow descent into the infraorbital region. Often patients present with complaints of excess eyelid skin that is impairing the visual field or creating an aged appearance. Brow ptosis must be excluded as surgical excision of the upper eyelid skin only minimally improves eyelid appearance and visual fields.
Examination of the upper eyelid and the amount of excess skin and adipose tissue present is a subtle, but very important part of the clinical exam. It is important not only to determine the amount of excess eyelid skin but also to determine which regions have greater redundancy. Uniform skin redundancy is not a common rule in the aging periocular complex. Additionally, the evaluation of herniated adipose tissue is also performed at this time with notations in upper eyelid fullness. Confirmation of adipose tissue herniation is performed with manual elevation of the brow and pressure upon the lower eyelid. Herniation of adipose tissue worsens with this maneuver, while lid edema remains unchanged.
Evaluation of the eyelid crease is performed by elevating the brow complex and having the patient look downward. At this point, the surgeon evaluates the distance from the observed crease at the central point of the eyelid to that of the lid/lash margin. This marginal crease distance (MCD) is 9 to 11 mm in average patient. Measurements of much higher dimension should raise suspicion of levator aponeurosis disinsertion and concomitant eyelid ptosis. This is different from retraction of the upper eyelid, commonly seen in thyroid ophthalmopathy, in which the MRD1 is excessive (see Preoperative Planning).
If fullness is discovered along the lateral aspect of the upper eyelid, the examiner should consider the possibility of a prolapsed lacrimal gland as there is no notable orbital fat that occupies the temporal region of the upper eyelids. As with the examination of herniation of adipose tissue, elevation of the brow and pressure on the lower eyelid helps to determine the presence of this condition and aid in surgical planning.
INDICATIONS
This procedure is primarily used to treat blepharoptosis in patients whose upper eyelids elevate after administration of phenylephrine. Candidates commonly have minimal congenital contribution to their ptosis, may present with varying degrees of acquired unilateral or bilateral ptosis, and may have had a prior external approach to surgically correct their lid ptosis. The procedure is especially useful in those individuals who have had upper blepharoplasty where the correction of the 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 phenylephrine.
CONTRAINDICATIONS
Surgically speaking, this procedure is contraindicated in patients whose upper eyelids do not elevate closely to a normal level with the phenylephrine test and in patients who have had a previous levator resection. Holistically speaking, the surgeon should also try to find out why the patient wants surgery now. In this way, the surgeon can differentiate patients who have realistic, mature reasons for requesting surgery from those who do not.
PREOPERATIVE PLANNING
Two tests are done preoperatively to determine optimal candidates for the Müller’s muscle-conjunctival resection procedure:
Margin reflex distance 1 (MRD1) measurement
Phenylephrine test
MRD1 Test
The MRD1 measurement is used to assess the upper eyelid levels (Fig. 2.1). It should be performed both before and during the phenylephrine test. The difference in MRD1 between the normal and ptotic sides indicates the degree of ptosis. The normal MRD1 ranges from approximately 3.0 to 4.5 mm, and this value is used as a reference in bilateral cases. The MRD1 measurement has the advantage of being able to quantify the ptosis alone without the palpebral fissure width. This is preferred because there is a Müller’s muscle in the lower eyelid that can also respond to phenylephrine. Measuring the palpebral fissure width would lead to an erroneous interpretation of the upper eyelid level after instillation of phenylephrine.
Phenylephrine Test
In patients with ptosis that is 2 mm or less, a phenylephrine test is an important tool in evaluating for the presence of an active Müller’s muscle. The MRD1 is measured before and after the instillation of 2.5% or 10% phenylephrine drops. The patient can be partially reclined, and their head is tilted backward, the upper eyelid is lifted, and the patient is instructed to gaze downward. Several drops of phenylephrine are dripped between the upper eyelid and the globe. To minimize the entry of phenylephrine into the nasal cavity, the examiner may digitally compress the canaliculi for 10 seconds. Topical anesthetic is often useful to reduce or avoid the stinging that can occur with application of neosynephrine. This step may be repeated immediately two more times. Three to five minutes after instillation of the phenylephrine, the MRD1 is measured. If the MRD1 increases by 1.5 mm or more, an active Müller’s muscle (positive test) is present and the patient is a candidate for a Müller’s muscle-conjunctival resection-ptosis procedure. During this process, the contralateral eye should also be evaluated in patients with unilateral ptosis. The development of ptosis in the nontest eye commonly relates to the presence of bilateral ptosis and a clinical confirmation of Herring’s law.
Patients should be warned about pupillary dilation after this test, which may yield transient photophobia and visual blurring. It is also 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.
 FIGURE 2.1 The margin reflex distance 1 (MRD1) is useful for determining the amount of ptosis. This is the distance from the light reflex on the patient’s cornea to the central upper eyelid as the patient gazes in the primary position. The difference in MRD1 between the normal and ptotic lid determines the amount of ptosis. |
SURGICAL TECHNIQUE
Anesthesia
Local anesthesia is preferred in adults. The upper eyelid skin to be removed is marked. A line is drawn with a methylene blue marking pen, beginning at the lateral canthus and extending in a horizontal direction of approximately 1 cm. This line marks the site of the lower lateral canthal incision. The site of the predetermined eyelid crease is then marked. When the surgeon is drawing the eyelid crease marks, the eyebrow must be elevated to reduce the excess upper eyelid skin fold and to make the upper eyelid skin taut and the lashes slightly everted. If this is not done, the crease may result in being much higher than desired because the skin is usually loose before it is marked.
The temporal, central, and nasal crease sites are marked by placing a millimeter ruler so that the zero line is at the eyelid margin. The distances above the eyelid margin can then be viewed and marked with a specially designed marking instrument. In women, the temporal mark usually is placed 10 mm above the upper eyelid margin; the central mark, 11 mm above the margin; and the nasal mark, 9 mm above the margin. In men, the marks are usually 9 mm temporally, 10 mm centrally, and 8 mm nasally. The temporal, central, and nasal marks are then connected and are extended with a line, which begins at the punctum and ends at the lateral canthus. The line sweeps laterally approximately 1 cm temporally to the lateral canthus in a slightly upward direction. There should be at least 5 mm of skin between this line and the line placed for the lower lateral incision.
A smooth forceps is used to grasp the crease line at the center of the eyelid with one blade. The other blade is used to pinch upper eyelid skin at various positions until, when the forceps is closed, all the redundant upper eyelid skin is eliminated and there is no eversion of the lashes and no lifting of the eyelid from its apposition to the lower eyelid margin. Once this position is determined, a dot is made with the marking pen at the top blade of the forceps. Similar marks are made nasally and temporally after the amounts of extra skin are determined in these positions. The three superior dots are connected and joined with the nasal and temporal ends of the eyelid crease line. The opposite eyelid is marked in the same manner. To ensure symmetry, the surgeon then compares the measurements of the eyelid crease and the amount of skin to be excised temporally, nasally, and centrally in the two eyelids (Fig. 2.2A).
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