Open-sky isolated subtotal Muller’s muscle resection for ptosis surgery: a review of over 300 cases and assessment of long-term outcome

Abstract

Purpose To evaluate short-and long-term success rates on isolated subtotal Muller resection in over 300 cases of ptosis over a 10-year period. Methods Clinical records were retrospectively evaluated for aetiology and severity of ptosis, levator function, response to phenylephrine, pre-and postoperative margin reflex distance of the upper lid (MRD1), postoperative lid contour and symmetry, complications and follow-up duration. Main outcome measures: change in MRD1 and eyelid contour. Surgical success: postoperative MRD1 Z2 and r4.5 mm, symmetry to within 1.0 mm and satisfactory contour. All patients were also sent patient satisfaction questionnaires, and invited to attend for a longer-term assessment of their surgical outcome. Results In total, 92 and 95% of 309 eyelids met all three criteria for success after an average follow-up of 4 and 47 months, respectively. Mean improvement in MRD1 was 2.56 mm. In all, 97% had postoperative MRD1 of Z2 and r4.5 mm and over 99% had an excellent contour. Altogether, 95 and 89% were within 1.0 and 0.5 mm symmetry of the fellow eye, respectively. In total, 51% of eyelids continued to rise, 17% maintained the same initial postoperative height, and 32% dropped by 1 mm or less. In all, 92% felt that their initial postoperative eyelid height had been maintained. Only 2% required repeat surgery and minor complications occurred in 4%. Conclusions Isolated subtotal Muller's resection is safe and effective for the repair of the majority of ptosis with moderate-togood levator function. It results in a more predictable height, which is maintained over time, less frequent contour abnormalities, and lower re-operation rates compared with anterior levator advancement.

Minimal incision posterior approach levator plication for aponeurotic ptosis

“…18,22,23 Varying responses to phenylephrine may have been caused by different severity of fatty degeneration of Muller's muscle and viability of its adrenergic receptors. 24 Although it would have been useful to compare the phenylephrine response-positive with the response-negative group, the sample size in this study was too small for statistically significant result. However, the principle of our technique was to allow direct visualization of the eyelid anatomy with subsequent intraoperative lid height and contour adjustments.…”

“…If undercorrection was noticed in the early postoperative period, reoperation using the same technique but placing more sutures and aiming for slight intraoperative lid height overcorrection yielded successful results. Peter et al 24 reported 92% of patients felt that their initial postoperative lid height was maintained over the long-term, in contrast to anterior aponeurosis surgery in which lid height tends to drop over time. The outcome of our study in the early postoperative period is encouraging, and further long-term observation is required to evaluate whether the lid height improvement could be maintained over time.…”

“…[24][25][26][27] Peter et al, 24 in a large retrospective cohort of over 300 patients who were followed from 4-47 months, reported over 90% of cases met the success criteria. Most of the eyelids (96%) with severe ptosis of MRDo1 mm also achieved target lid height.…”

“…This technique was also found to be effective in phenylephrine-negative patients, because its success did not rely on the amount of Muller's muscle resected but rather from the consequent advancement of the levator. 24,26,27 However, 6% required augmentation of a subtotal Muller resection by either a small tarsectomy or conversion to posterior approach levator resection as described by Collin. 3,24 None of the eyelids in our study required augmentation surgery.…”

“…24,26,27 However, 6% required augmentation of a subtotal Muller resection by either a small tarsectomy or conversion to posterior approach levator resection as described by Collin. 3,24 None of the eyelids in our study required augmentation surgery. In severe blepharoptosis, the vertical incisions could be extended towards the fornix to allow plication of the levator that was located superior to the aponeurosis without the need to dissect a large conjunctiva and Muller's muscle flap.…”