Australian and New Zealand Journal of Ouhthalmology 1985; 13: 179-183 MULLERS MUSCLE-CONJUNCTIVAL RESECTION PTOSIS PROCEDURE ALLEN M. PUTTERMAN MD University Of lll~nois Eye and Ear Infirmary, Michael Reese Hospftal and Medical Centre. Illinois Abstract The Mullers muscle-conjunctival resection procedure is a relatively simple means of relieving upper eyelid ptosis. Candidates for the operation are chosen by placing several drops of 70% phenylephrine hydrochloride into the upper ocular fornix. If the upper lid efevates close to a normal level after five minutes, the patient is selected for the operation. A specially designed clamp is applied to 6.5 to 9.5 mm of conjunctiva and Mullers muscle above the superior tarsal border. A suture is run distal to the clamp, connecting conjunctiva and Mullers muscle to the superior tarsal border, and then the tissues held in the clamp are resected. The mullers muscle-conjunctival resection has advantages over the Fasanella procedure, because tarsus is preserved. and over the levator aponeurosis advancement and tuck procedures, because the results are much more predictable. Key words: Mullers muscle, blepharoptosis, phenylephrine. The Mullers muscle-conjunctival resection ptosis procedure was described by Urist and me in 1975.' The procedure has produced consistently good results in the ten years of experience using it. TECHNIQUE General anaesthesia is used in children and local anaesthesia is preferred in adults. A frontal nerve block is used with local anaesthesia to avoid swelling of the eyelid by local infiltration, which would make the operation more difficult and inexact.* A No. 23 gauge, 1.5 inch (4 cm) retrobulbar type needle is inserted into the superior orbit, entering just under the midsuperior orbital rim. The roof of the orbit is hugged during insertion of the needle until a depth of 4 cm is reached. First 1.5 ml of 2% lignocaine with adrenaline (epinephrine) is injected, then 0.5 ml of 2% lignocaine with adrenaline is injected subcutaneously over the central upper eyelid just above the lid margin. A 4-0 black silk traction suture is inserted through skin, orbicularis muscle, and superficial tarsus 2 mm above the lashes at the centre of the upper eyelid. A large Desmarres retractor everts the upper eyelid and exposes the palpebral conjunctiva from the superior tarsal border to the superior fornix (Figure IA). Topical amethocaine (tetracaine) drops are applied over the upper palpebral conjunctiva. A caliper set at 8.25 mm, with one arm at the superior tarsal border, facilitates insertion of a 6-0 black silk suture through the conjunctiva 8.25 mm above the superior tarsal border (Figure IA). One bite centrally and two others, approximately 7 mm nasal and temporal to the centre, mark the site. (We usually place the suture 8.25 mm above the superior tarsal border, but may place it 6.5 mm to 9.5 mm above it if the response of the upper eyelid level to the phenylephrine test is slightly more or less than desired.) Reprint requests: Allen M. Putterman MD, 11 1 North Wabash, Chicago, Illinois 60602, USA. MULLERS MUSCLE-CONJUNCTIVAL RESECTION 179
Figure IA: Upper eyelid is everted over Desmarres retractor to expose upper eyelid palpebral conjunctiva. A 6-0 black silk marking suture is placed through conjunctiva 6.5 to 9.5 above superior tarsal border. Figure ID: Closed clamp includes 6.5 to 9.5 mm of conjunctiva and Miillers muscle just above superior tarsal border. Clamp and skin are pulled in opposite directions to ensure that levator aponeurosis is not caught in clamp. Figure IB: Toothed forceps separates conjunctivamiillers muscle from its loose attachment to levator aponeurosis at various sites between upper tarsal border and marking suture. Figure IE: Mattress suture runs in temporal to nasal direction about 1.5 mm distal to the clamp; each bite includes upper tarsus. Figure IC: Clamp is positioned so that one blade engages marking suture and the other blade is above superior tarsal border. Figure IF: Conjunctiva-Miillers muscle is excised by running a No. 15 surgical blade against the edge of the clamp. 180 AUSTRALIAN AND NEW ZEALAND JOURNAL OF OPHTHALMOLOGY
Figure IG: Nasal suture arm runs continuously nasally to temporally through edges of conjunctiva, Miillers muscle, and tarsus. A toothed forceps grasps conjunctiva and Mullers muscle between the superior tarsal border and marking suture and separates Mullers muscle from its loose attachment to the levator aponeurosis (Figure 1B). (This manoeuvre is possible because Miillers muscle is firmly attached to conjunctiva but only loosely attached to the levator aponeurosis.) We place one blade of a specially designed clamp* at the level of the marking suture. Each tooth of this blade engages each suture bite that passes through the palpebral conjunctiva (Figure 1C). The Desmarres retractor is then slowly released as the other blade of the clamp engages conjunctiva and Miillers muscle adjacent to the superior tarsal border. Figure IH: Each arm of suture passes through the temporal wound, and sutures are tied. MULLERS MUSCLE-CONJUNCTIVAL RESECTION The clamp is compressed and the handle locked. This leads to the incorporation of conjunctiva and Mullers muscle between the superior tarsal border and the marking suture (Figure ID). The upper eyelid skin is then pulled in one direction while the clamp is pulled simultaneously in the opposite direction (Figure ID). If the surgeon feels a sense of attachment between the skin and clamp during this manoeuvre, this means that the levator aponeurosis has been inadvertently trapped in the clamp. If this occurs the clamp should be released and reapplied in its proper position. (This manoeurvre is possible since the levator aponeurosis sends extensions to the skin to form the lid crease.) A 5-0 double-armed, plain catgut mattress suture runs, with clamp held straight up, 1.5 mm below the clamp along its entire width in a temporal to nasal direction, through the upper margin of the tarsus and through Mullers muscle and conjunctiva on the other side and vice versa (Figure 1E). A No. 15 surgical blade is used to excise the tissues held in the clamp by cutting between the sutures and the clamp. The cutting should be done close to the clamp, with the surgeon watching the stitches on each side of it to avoid cutting them (Figure 1F). The Desmarres retractor again everts the eyelid while gentle traction is applied to the 4-0 black silk centreing suture. The nasal end of the suture is then run continuously in a temporal direction with the stitches about 2 mm apart through the edges of superior tarsal border, Miillers muscle, and conjunctiva (Figure IG). Once the sutures are both at the temporal end of the lids, each arm of the suture is passed through conjunctiva and Mullers muscle and exits through the temporal end of the wound (Figure 1H). The suture arms are then tied with approximately four to five knots and the ends are cut close to the knot. In this way the knot is buried subconjunctivally, thereby lessening postoperative keratopathy. * The Miillers muscle-conjunctival resection ptosis clamp is available through Karg Ilg and Company, 117 North Charles Street, Villa Park, Illinois 60181, USA. 1 8.1
' Figure 2A: Acquired bilateral upper lid ptosis preoperatively. Figure 28: Elevation of upper lids after phenylephrine instillation. The Mullers muscle-conjunctival resection procedure has advantages over the Fasanella procedure because tarsus is preser~ed.~.~ This leads to less risk of suture keratopathy since the sutures are at the superior tarsal border rather than 3 to 4 mm closer to the lid margin, as with the Fasanella procedure. The operation also has advantages over the levator apopeurosis advancement and tuck procedure because the results are much more predictable and there is 1 less need for re~peration.~,~ 1 Keratitis sicca is an unlikely complication of Figure 2C: Appearance of upper lids after bilateral this resection procedure. In the first 31 8 mm Mullers muscle-conjunctival resection ptosis consecutive specimens microscopically studied, procedure. few conjunctival goblet cells were found.' Also, a preoperative and postoperative Schirmer No. DISCUSSION 1 and basic secretion tear test in 46 patients Candidates for the Mullers muscle-conjunctival showed no significant difference between these resection ptosis procedure are chosen by placing measurements. several drops of 10% phenylephrine into the The Mullers muscle-conjunctival resection upper ocular fornix. If the upper lid elevates ptosis procedure has produced results within close to a normal level five minutes later, the 1 mm of normal in over 200 operated eyelids over patient is chosen for the procedure. (There has the last ten years (Figure 2). One patient been a highly significant correlation between the developed recurrent ptosis six years postupper lid level after the phenylephrine test operatively and required an internal vertical compared to the level following the Mullers eyelid shortening procedure.6 One patient had muscle-conjunctival resection.) slight postoperative lid retraction that resolved If the lid elevates to a normal level with the by downward upper lid massage. phenylephrine test, 8.25 mm of Mullers muscle The Mullers muscle-conjunctival resection and conjunctiva are resected. A 6.5 to 9.5 mm procedure has mainly been useful in patients with Mullers muscle resection is performed if the varying amounts of acquired ptosis. It has also upper eyelid elevates slightly higher or lower than been utilized in patients with minimal congenital the opposite lid, respectively. ptosis (1.5 to 2.5 mm) and excellent levator 182 AUSTRALIAN AND NEW ZEALAND JOURNAL OF OPHTHALMOLOGY
function in those whose upper lids elevate to a normal level with phenylephrine. ACKNOWLEDGEMENTS This paper is supported in part by core grant EY 1792, from the National Eye Institute, Bethesda, Md. Figure 1A-11 are reprinted with permission from Archives of Ophthalmology' and Advanced Ophthalmic Plastic and Reconstructive Surgery. ' References 1. Rutterman AM, Urist MJ. Mullers muscle-conjunctival resection: A method for treatment of blepharoptosis. Arch Ophthalmol 1975; 92: 619-623. 2. Hildreth HR, Silver B. Sensory block of the upper eyelid. Arch Ophthalmol 1976; 77: 202-231. 3. Fasanella RM, Servat J. Levator resection for minimal ptosis: Another simplified operation. Arch Ophthalmol 1961; 65: 4934%. 4. Putterman AM, Wrist MJ. Muller muscle-conjunctiva resection ptosis procedure. Ophthalmic Surg 1978; 9: 27-32. 5. Jones LT, Quickert MH, Wobig JL. The cure for ptosis by aponeurotic repair. Arch Ophthalmol 1975; 93: 629-634. 6. Putterman AM. Internal vertical eyelid shortening to treat surgically induced segmental blepharoptosis. Am J Ophthalmol 1976; 82: 122-128. 7. Katzen L, Putterman AM. Miillers muscle-conjunctival resection for the treatment of blepharoptosis. In Bosniak S, ed. Advanced ophthalmic plastic and reconstructive surgery, vol. 1. New York: Pergamon Press, 1982: 113-120. MULLERS MUSCLE-CONJUNCTIVAL RESECTION 183