Muller's Muscle-conjunctival Resection Research Articles

Müller muscle-Conjunctival Resection (MMCR) Surgery: A Comprehensive Literature Review.

This literature review aims to provide a comprehensive overview of the current understanding, indications, techniques, outcomes, and complications of Müller muscle-conjunctival resection (MMCR) surgery. It also addresses areas of debate with MMCR such as predictability concerning Phenylephrine response as well as the amount of muscle resection required. This literature review was compiled based on the available evidence from PubMed from 1975 to August 2023. The success rate of MMCR ranges from 72% to 95%, with high patient satisfaction reported in most studies. The exact range of eyelid elevation after MMCR is variable, with a reported average of 2.1 mm MRD1 elevation. MMCR is a well-established surgical technique used to correct upper eyelid ptosis that results from dysfunction or attenuation of the levator aponeurosis. MMCR proved to be a safe and effective procedure with a high patient satisfaction rate and low risk of complications.

Hemorrhage Following Muller's Muscle Conjunctival Resection: Description and Case-Control Study.

The purpose of this study was to report a series of patients with postoperative hemorrhage after Muller's muscle conjunctival resection surgery and compare risk factors and outcomes with a control population. In this case-control study, records of patients who underwent Muller's muscle conjunctival resection over 5 years were reviewed for a history of postoperative hemorrhage occurring >24 hours after surgery. A 4:1 control population was matched for age and sex. Clinical data collected included demographics, medical history, medications, and subsequent surgery. Preoperative and 3-month postoperative marginal reflex distance 1 were measured digitally using ImageJ. The hemorrhage and control groups were compared using Fisher's exact tests for categorical variables and independent samples t tests for continuous variables. The hemorrhage group contained 10 patients (mean age 66.4 ± 18.5 years). The control group consisted of 40 age and sex-matched controls. Of 350 charts reviewed, there were 10 cases of postoperative hemorrhage (incidence 2.9%). Hemorrhage occurred a mean of 4.2 ± 1.3 (range 2-7) days after surgery and lasted for a mean of 29.3 ± 19.1 (range 12-72) hours. In all 10 cases, the bleeding resolved with conservative measures. There was no difference between the hemorrhage and control groups in terms of medical conditions, blood thinners, and surgical revision. Preoperative, postoperative, and change in marginal reflex distance 1 did not differ between the hemorrhage and control groups. Hemorrhage occurs approximately 4-5 days postoperatively in a small percentage of patients undergoing Muller's muscle conjunctival resection surgery. This investigation did not identify any consistent risk factors, and outcomes in this patient population appear no different than controls.

The Long-Term Effect on Dry Eye of Posterior Approach Ptosis Surgery Vs. Upper Eyelid Blepharoplasty

Purpose To examine the long-term effect of combined blepharoplasty and Müller muscle-conjunctival resection (MMCR) compared to an upper blepharoplasty procedure on dry eye syndrome. Methods This is a Prospective comparative case series. Two groups of patients participated in this study: the blepharoplasty group included adult patients that underwent blepharoplasty at least 3 years earlier and the ptosis group consisting of adult patients that underwent MMCR with blepharoplasty at least 3 years earlier. The parameters that were compared for all patients before the procedure, on postoperative day 90, and at the long-term follow-up were: Schirmer-test 2, tear break-up time (TBUT), fluorescein staining, and lissamine green (LG) staining. Results The participants included 25 post-MMCR patients with a mean follow-up of 4.94 ± 0.64 years and 15 post-blepharoplasty patients with a mean follow-up of 4.22 ± 0.32 years. There was a significant increase in the postoperative LG and fluorescein staining scores compared to the preoperative scores in the ptosis group (p < .01 and p < .01, respectively) as well as a decrease in postoperative TBUT compared to the preoperative values (p = .044). Those parameters were not significant in the blepharoplasty group. Conclusions Patients who underwent MMCR, but not those following upper blepharoplasty, showed signs of dry eye compared to the preoperative status after long-term follow-up. Dry eye signs should be examined before MMCR surgery, and patients should be aware of the high risk of developing dry eye and the need for long-term treatment. Surgeons should carefully consider performing MMCR for patients with severe dry eye.

The results of Muller Muscle Conjunctival Resection versus Levator Advancement for mild to moderate ptosis.

Purpose: To compare the surgical outcomes of Muller muscle conjunctival resection (MMCR) and levator advancement (LA) in patients with mild to moderate blepharoptosis. Methods: A retrospective review of patients who underwent surgery for mild to moderate ptosis between 2015 and 2020 was performed. The degree of ptosis was graded based on the amount of upper eyelid drooping: mild ≤ 2 mm and moderate < 4 mm. Surgical success was defined as post-operative marginal reflex distance 1 (MRD1) ≥ 4.0 and ≤ 5.0 mm, and a satisfactory eyelid contour. Results: A total of 82 eyes of 65 patients underwent ptosis repair surgeries. MMCR was performed in 48 eyes and LA in 34 eyes. Under-correction was detected in 8.3% and 11.8% of the patients in MMCR group and LA group respectively. There was no patient with over-correction in the MMCR group postoperatively, 3 patients in the LA group had over-correction (0% vs. 8.8% respectively). The success rate in our study was found to be 91.7% in the MMCR group and 72.2% in the LA group. Conclusions: The MMCR and LA procedures are effective approaches in treating patients with mild to moderate eyelid ptosis in our population. Each procedure had its superiority in selected groups of patients. However, the complication rate and duration of surgery were found to be lower in MMCR group. Abbreviations: LA = Levator Advancement, LF = Levator Function, MMCR = Muller Muscle Conjunctival Resection, MRD 1 = Marginal Reflex Distance.

Predictability of the Phenylephrine Test in Congenital Ptosis: Ten Years of Experience.

To assess the predictability of phenylephrine testing for congenital ptosis and review outcomes of Müller's Muscle-conjunctival resection (MMCR) for congenital ptosis across ten years of follow-up. In this retrospective case series, all patients who underwent MMCR for congenital ptosis at a single institution between 2010 and 2020 were identified. Exclusion criteria included patients who had not undergone preoperative testing with 2.5% phenylephrine in the superior fornix; patients who underwent revision surgery; and patients who had a broken suture in the early postoperative period. Demographics, margin-reflex distance 1 (MRD1) values pre- and postphenylephrine, millimeters of tissue resected intraoperatively, and final postoperative MRD1 were recorded. A total of 28 patients were included; 19 patients received MMCR and 9 patients received a combined MMCR plus tarsectomy. The amount of tissue resected ranged from 5 to 11 mm. There was no significant difference between median postphenylephrine MRD1 and median final postoperative MRD1 in either surgical group. Neither patient age nor levator function was significantly associated with a change in MRD1 in either group. The addition of a tarsectomy had no bearing on the final MRD1 value. MMCR is a viable option for patients with congenital ptosis and moderate levator function with a response to phenylephrine. In these patients, MRD1 after 2.5% phenylephrine testing correlates to the final postoperative MRD1 outcome within 0.5 mm.

Sutureless Conjunctiva-Sparing Posterior Ptosis Repair Surgery: A Novel Technique

Müller muscle-conjunctival resection (MMCR) is a popular posterior/internal surgical approach to cases of mild to moderate blepharoptosis with good levator function. MMCR necessitates the removal of healthy conjunctiva and exposes the cornea to suture material. The goal of this study is to describe a novel sutureless conjunctiva-sparing Müllerectomy (CSM) surgery and demonstrate its long-term efficacy, efficiency, and safety. IRB approved retrospective study of patients undergoing sutureless conjunctiva-sparing posterior ptosis repair surgery. The medical records of 100 patients (171 eyes) who underwent sutureless CSM with a minimum follow-up interval of 6 months were retrospectively reviewed. Photographs were analyzed using ImageJ software. Outcome measures were derived from margin reflex distance 1 (MRD1) and palpebral fissure height (PFH) at various postoperative timepoints. Mean ΔMRD1 and ΔPFH at 6 months were 2.85 ± 0.98 mm and 2.60 ± 1.38 mm, respectively. Symmetry within 1 mm was observed 91% of cases. Sutureless CSM took 4.42 minutes on average compared to 8.45 minutes for traditional MMCR. There were no corneal abrasions or ocular complications. The reoperation rate was 2.3% (1 case of overcorrection and 3 cases of undercorrection) per eye. Sutureless CSM is a promising alternative to traditional MMCR and sutured CSM based on long-term outcomes, symmetry, shorter operative time, and low complication rate. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Müller Muscle-Conjunctival Resection for Treatment of Contralateral Ptosis following Unilateral External Levator Advancement.

One of the main causes of unsatisfactory outcomes after unilateral blepharoptosis surgery is asymmetry of the upper eyelid height, which occurs as a result of a contralateral eyelid droop. Therefore, the authors evaluated the efficacy of Müller muscle-conjunctival resection (MMCR) for the treatment of contralateral ptosis following unilateral external levator advancement (ELA). This study analyzed 26 eyelids of 26 patients with upper eyelid height asymmetry following unilateral ELA who underwent contralateral MMCR retrospectively. The phenylephrine test was performed before ELA and before MMCR. The main outcome measures were symmetry outcomes and clinical outcomes. The mean patient age was 55.81 ± 7.98 years (range, 44 to 70 years); 15 were female (57.7%). The Hering dependency was observed in 13 of the patients (50%) before ELA. An adequate response to phenylephrine was observed before MMCR but not before ELA. Symmetry outcomes after MMCR were perfect (<0.5 mm), good (≥0.5 mm and <1 mm), and fair (≥1 mm) in seven, 17, and two patients, respectively. An optimal upper eyelid height was noted in 47 of the 52 eyelids after the MMCR, whereas three of the 52 eyelids had minimal overcorrection, and two eyelids had undercorrection. The mean change in marginal reflex distance 1 of the contralateral eyelid droop was greater for patients with than without the Hering dependency ( P < 0.0001) after ELA but not after MMCR. Two patients (7.6%) underwent revision ELA surgery. MMCR and use of the phenylephrine test to predict the eyelid position may represent an alternative approach in patients who require management of contralateral ptosis following unilateral ELA. Therapeutic, IV.

Muller's muscle conjunctival resection versus external levator advancement for ptosis repair: systematic review and meta-analysis.

To compare the outcome of Muller's muscle conjunctival resection (MMCR) versus external levator advancement (ELA) in patients undergoing ptosis surgery. A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, and a search of electronic information was conducted to identify all comparative studies of MMCR versus ELA in ptosis repair. The primary outcome measures were the post-operative marginal reflex distance (MRD1), ptosis under-correction, over-correction, and re-operation rate. Secondary outcome measures included cosmetic appearance, complications, operative time, and learning curve. Fixed-effect modelling was used for the analysis. Seven studies that enrolled 1038 eyelids were identified in the literature. There was no statistically significant difference between the MMCR and ELA groups in post-operative MRD1 (Mean Difference [MD] = 0.13, P = 0.28) and the rate of under-correction odds ratio [OR] = 0.49, P = 0.14). However, ELA had a significantly higher rate of over-correction (OR = 0.17, P = 0.04) and re-operations (OR = 0.26, P = 0.0001) compared to MMCR. For secondary outcomes, MMCR had an improved cosmetic appearance, lower total number of complications and shorter operation time (MD = -10.96, P < 0.00001). Finally, the two techniques had no significant difference in the learning curves. Both MMCR and ELA are effective techniques for the surgical correction of ptosis; however, MMCR surgery is a more predictable and robust technique compared to, ELA with lower rates of over-correction and re-operation.

Optimizing Management of Asymmetric Ptosis: A Comparison of Three Posterior Approach Resection Algorithms.

The purpose of this study was to compare the efficacy of 3 resection algorithms in the management of patients with asymmetric ptosis. Patients undergoing bilateral Muller's muscle-conjunctival resection (MMCR) were identified. Standardized preoperative clinical photographs were examined and margin reflex distance 1 (MRD1) was measured using ImageJ. Patients presenting with ≥1 mm of asymmetry in MRD1 were included. Three groups were identified: variable (4:1 ratio, with the lower side receiving a greater resection), fixed (7 mm resection bilaterally), and tarsectomy (7 mm bilaterally + 1 mm of tarsus resected on the lower preoperative side). Postoperative MRD1 was measured from photographs obtained 3 months after surgery. The primary outcome was postoperative asymmetry. A total of 95 patients with a mean age of 71.0 ± 11.0 years were included. There was no significant difference in age ( p = 0.277) or length of follow-up ( p = 0.782) between the groups. Although the fixed tarsectomy group had significantly greater preoperative asymmetry ( p = 0.001), there was no significant difference in postoperative asymmetry ( p = 0.166). On multivariate analysis, preoperative asymmetry was the only significant predictor of postoperative asymmetry ( p < 0.001). Specifically, the surgical group was not a predictor of the primary outcome ( p = 0.723). Resection amount and technique did not predict postoperative outcomes in cases of asymmetric ptosis. This may support the hypothesis that changes in eyelid position and symmetry following MMCR is due to a dynamic system, rather than as a result of purely mechanical forces.

Efficacy of Müller's Muscle-conjunctival Resection With or Without Suturing for the Correction of Ptosis.

The purpose of this study was to compare the efficacy of Müller muscle-conjunctival resection (MMCR) with or without suturing for the correction of ptosis. A retrospective chart review was performed of 30 patients (56 eyelids) undergoing sutureless (sMMCR) (34 eyelids) or conventional MMCR (cMMCR) (22 eyelids). Primary outcome measures were the change in MRD1 and vertical eyelid height (VLH). Secondary outcome measures were the amount of resection of MMCR (rMMCR) and postoperative symmetry of 1 mm or less. In total, 49 eyelids (87.5%) had involutional ptosis and 7 (12.5%) had contactlens induced ptosis. The age and follow up between the sMMCR and cMMCR groups was, respectively, 65.1 ± 11.0 versus 65.5 ± 11.0 years and 4.0 ± 2.5 versus 6.5 ± 2.1 months. Preoperatively there were no significant differences noted between the sMMCR and cMMCR groups. Postoperatively there was a statistically significant difference in change of MRD1 between the sMMCR and cMMCR groups, 2.74 ± 0.20 mm and 2.02 ± 0.25 mm ( p = 0.026). The difference in change of VLH and rMMCR was not significant between the sMMCR and cMMCR groups, 2.28 ± 0.13 mm and 2.14 ± 0.15 mm ( p = 0.49) and 9.29 ± 2.14 versus 9.46 ± 1.97 mm ( p = 0.83). There were no significant differences in postoperative symmetry. The sMMCR and cMMCR techniques demonstrated equal effectiveness for the correction of ptosis. The rapid sMMCR could become the procedure of choice for the correction of involutional and contact lens induced ptosis.

Effect of Muller's muscle-conjunctival resection on the upper eyelid crease position in Asian eyelids: a retrospective cohort study

PurposeInvestigating the effect of Muller’s muscle-conjunctival resection (MMCR) on the eyelid crease position.MethodsThis retrospective study included patients with unilateral acquired blepharoptosis who underwent MMCR during October 2018–December 2021. The following factors were recorded: preoperative, after phenylephrine, postoperative marginal reflex distance1 (MRD1) and tarsal platform show (TPS) of bilateral eyelids. The primary outcome was to measure the change in TPS and evaluate the factors associated with post-operative TPS. The secondary outcomes included exploring the rate of MRD1 and TPS symmetry after the operation.ResultsForty patients were included in the final analysis. The mean MRD1 of the ptotic eye was 1.28 ± 0.78 mm, 2.79 ± 0.66 mm and 3.20 ± 0.67 mm before, after phenylephrine and after the operation, respectively. The mean TPS of the ptotic eye was 5.90 ± 1.86 mm, 3.96 ± 1.49 mm and 2.79 ± 1.63 mm before, after phenylephrine and after the operation, respectively. Changes in mean TPS after the phenylephrine test and post-operation were statistically significant (p < 0.001). The linear regression model revealed that the absolute change in TPS after phenylephrine drop and absolute change in MRD1 post-operation were significantly correlated with the absolute change in TPS post-operation. Besides, the ratio of symmetry in MRD1 and TPS was greatly improved post-operation (82.5% and 70.0% respectively).ConclusionMMCR is an effective surgical method for ptosis correction as it can not only correct the eyelid crease position but also narrow the wide TPS. This method is particularly beneficial to patients with both mild to moderate ptosis and an asymmetric crease height.

Revision ptosis surgery for under-correction after Müller muscle conjunctival resection

Müller muscle conjunctival resection (MMCR) may be more likely to lead to under- rather than over-correction. The choice of revision surgery is not clearly defined. MMCR patients were included if the post-operated eyelid(s) demonstrated margin reflex distance-1 (MRD1) less than 3.5mm, or if MRD1 asymmetry was greater than 0.5mm, and if they underwent subsequent revision surgery. MRD1 was the primary outcome measure and complications were secondary outcome measures. Two groups were defined: patients who underwent MMCR then repeat MMCR (M-M) and those who underwent MMCR followed by external levator resection (ELR) surgery (M-L). 18 eyelids (16 patients) were included, 12 in M-M and 6 in M-L. Mean (SD) preoperative MRD1 was 1.84mm (0.97), range -0.41 to 3.39mm. There was no difference (p=0.70) in preoperative MRD1 between M-M and M-L. In the M-M group, mean (SD) MRD1 was 1.77mm (1.12) preoperatively, 2.35mm (0.66) after the first surgery, and 3.44mm (0.31) after revision. Mean MRD1 was significantly higher after revision, compared to preoperatively (p<0.05) and after first surgery (p<0.05). In the M-L group (n=6), mean (SD) MRD1 was 1.98mm (0.90) preoperatively, 1.99mm (0.56) after the first surgery and 3.44mm (1.24) after revision. The difference between preoperative and post revision surgery MRD1 was significant (p<0.05). For patients with insufficient elevation of MRD1 or with asymmetry after MMCR, revision by MMCR or by ELR are both reasonable options.

Conjunctival changes following Muller's muscle conjunctival resection.

To analyze the conjunctival changes, especially goblet cell populations, following Muller's muscle conjunctival resection (MMCR) by histologically evaluating pre and post-MMCR specimens. This is a retrospective analysis of conjunctival samples sent for histologic evaluation from two patient populations: those who had previously undergone a MMCR and required repeat surgery and controls who underwent a MMCR surgery in a previously unoperated eyelid. Specimens underwent hematoxylin and eosin (H&E) and periodic acid-Schiff (PAS) staining to accentuate goblet cell identification and were evaluated by two ocular pathologists to quantify goblet cell populations and note other anatomical changes. Statistical analysis of goblet cell populations was then performed. Four samples were identified for each group: (1) post-MMCR and (2) control. The mean age was 67years in the post-MMCR group and 66years in the control group. The mean goblet cell population was 7 ± 5 cells/mm in the post-MMCR conjunctiva and was 39 ± 16 cells/mm in the control group, which was statistically significant (p = 0.01). Samples from both groups demonstrated scarring and inflammatory cell infiltrate. While there was a relative loss of goblet cell populations in the conjunctiva overlying the region of surgery following MMCR, the lack of dry eye symptoms or changes in tear production reported in prior studies suggests that there may be enough goblet cell population reserve in the remaining accessory lacrimal glands and in the unaltered conjunctiva to provide sufficient lubrication and ocular protection.

Muller muscle conjunctival resection or external levator advancement; a quantitative comparison of symmetry in unilateral ptosis.

To compare muller muscle conjunctival resection (MMCR) and external levator advancement (ELA) in terms of objective and subjective symmetry in unilateral ptosis. The patients who underwent unilateral MMCR (group1, n = 25) and ELA (group2, n = 25) were reviewed retrospectively. With the written algorithm, margin reflex distance-1 (MRD1), localization of the contour peak, and the percentage of overlapping curvatures (POC) of both upper eyelid curves were calculated. Semi-automated measurements were compared with the manual measurements. The correlation between objective and subjective symmetry was evaluated. Preoperative levator functions were similar in both groups (13.93 ± 3.25 mm and 13.3 ± 2.86 mm, respectively). We found strong correlations between manual and semi-automated measurements (ICC: 0.942, 95% CI = 0.924-0.956, p < 0.001). Preoperative MRD1 (2.15 ± 0.90 vs 1.51 ± 1.01, p = 0.022) and POC was lower in group 2 (66% vs 47.2%, p = 0.01). In the postoperative period, the increase in MRD1 and POC were similar in both groups (p = 0.2 and p = 0.7 respectively), and the contour peak displaced temporally (p < 0.01) providing a symmetric peak in both groups. Subjective symmetry increased as the difference in MRD1 between two eyes decreased (r = -0.456, p = 0.001), and POC increased (r = 0.396, p = 0.004). Besides subjective symmetry, MMCR and ELA are equally effective in ensuring symmetry objectively, as measured with MRD1 and contour peak symmetry and POC in unilateral ptosis. POC may be used as a criterion of symmetry in the evaluation of ptosis.

Changes in Tear Meniscus Analysis After Ptosis Procedure and Upper Blepharoplasty.

To quantitatively evaluate dry eye test and tear measurements following oculoplastic surgery. This comparative prospective clinical study comprised three groups of adult patients: the 1) blepharoplasty group: those with dermatochalasis; and 2) the blepharoplasty + Muller's muscle-conjunctival resection and 3) blepharoplasty + anterior levator resection groups: those with dermatochalasis and ptosis showing significant improvement after 10% phenylephrine administration. Ocular Surface Disease Index, tear film break-up time, corneal staining, and Schirmer test values were recorded. Tear meniscus area and height were measured using anterior segment-optical coherence tomography. This study comprised 56 patients (18 males, 38 females). The blepharoplasty group included 40 eyes of 20 patients. The blepharoplasty + MMCR group included 21 eyes of 16 patients. The blepharoplasty + ALR group included 30 eyes of 20 patients. No significant differences resulted between the preoperative and postoperative dry eye test and tear measurements in the blepharoplasty group (P> 0.005/for all). Significant increases were seen in the corneal staining, TMH, TMA, and Schirmer test values were significantly decreased compared to those postoperatively in the blepharoplasty + MMCR group (P= 0.018, P< 0.001, P= 0.033 and P= 0.030, respectively). In the blepharoplasty + ALR group, the TMH and TMA were significantly decreased (P= 0.031, P= 0.036). No changes resulted in dry eye tests following blepharoplasty in patients without dry eye symptoms. Changes were more pronounced following ptosis surgery, especially MMCR. Patients should be carefully examined for dry eye and treated during follow-up. This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Giant Fornix Syndrome: How Much Conjunctiva Should Be Resected?

To characterize clinical profiles of Chinese patients with giant fornix syndrome (GFS), compare surgical outcomes with amount of Müller's muscle-conjunctival resection (MMCR), and elicit risk factors for those who have prolonged recovery after MMCR. Retrospective, observational, interventional cohort study on GFS eyes. Two treatment groups were established: limited MMCR-as defined by 8 mm or less resection; maximal MMCR-as defined by 10-12 mm resection. Good responders were defined as eyes exhibiting disease resolution within 3 months after surgery. Primary outcome was disease resolution, secondary outcome was ptosis improvement. Mean age was 81.9 years old (range, 76-89), with 6 (75%) females and 2 (25%) males. All 10 eyes presented with discharge, partial ptosis, and conjunctival injection. In the limited MMCR group, time to symptom resolution was longer at 5.56 months, while maximal MMCR group was 2.02 months (p = 0.004). Limited MMCR group also had lower primary surgical success and required additional surgery compared with maximal MMCR group (p = 0.008). At mean follow up of 34.4 months (range, 11-65 months), all eyes achieved disease resolution, no recurrence, and ptosis improvement. In the largest series on Chinese eyes with GFS to date, GFS is mainly a disease in elderly females. Maximal MMCR has a higher rate of surgical success with no additional complications. For those who underwent MMCR, additional treatment such as topical steroids and fortified antibiotics do not affect time to recovery. These findings may help ophthalmologists consider maximal MMCR as a definitive surgical treatment in GFS eyes.

Cumulative Sum Analysis of the Learning Curve of Ptosis Surgery: External Levator Advancement versus Müller Muscle-conjunctival Resection.

PurposeEven though it is stated that external levator advancement (ELA) has a much longer learning curve than Müller muscle-conjunctival resection (MMCR) in the treatment of aponeurotic ptosis, there is no study in the literature regarding the learning curves of these two surgical techniques. We aimed to objectively determine the length of the learning curves of ELA and MMCR using cumulative sum (CUSUM) analysis.MethodsThe first 30 unilateral ELA and the first 30 unilateral MMCR consecutively performed by a single surgeon were retrospectively reviewed. The CUSUM method was used to analyze the learning curves of ELA and MMCR based on operation times of consecutive surgeries and the clinical outcomes were compared.ResultsCUSUM analyses revealed that the operation time stabilized after around 11 ELA surgeries and 12 MMCR surgeries and R2 value for ELA and MMCR were 0.93 and 0.91, respectively. There was no significant difference in these stratified analyses. Mean operation time was 45.7 minutes in the ELA group and 34.1 minutes in the MMCR group (p = 0.002). Total number of intraoperative complications was 37 in the ELA group and 16 in the MMCR group (p = 0.015). Symmetry success rate was significantly higher (p < 0.0001) and reoperation rate was significantly lower in the MMCR group (p = 0.045).ConclusionsEven though ELA is more challenging than MMCR, comparable learning curves indicate that surgeons in training need to be encouraged to perform both techniques. The challenges and obstacles that the surgeons in training face in these two techniques need to be analyzed in detail.

Challenging the current treatment of residual postoperative ptosis: safety and efficacy of repeat Müller's muscle conjunctival resection

ObjectiveTo determine if repeat Müller's muscle conjunctival resection (MMCR) is a viable approach in the treatment of recurrent or residual eyelid ptosis. MethodsA retrospective review of patients who underwent repeat MMCR was performed using external photos obtained preoperatively, postoperatively, and at last follow-up. The marginal reflex distances (MRD1 and MRD2), brow position (BP), and tarsal platform show (TPS) were evaluated with digital image analysis. The change in upper eyelid height (MRD1) and TPS following repeat ptosis repair were the outcome measures. ResultsRepeat MMCR was performed on 12 eyelids of 11 patients. Mean MRD1 elevation after initial MMCR was 1.6 mm (standard deviation [SD] = 1.0mm, p < 0.00001). Mean decrease in TPS was 1.9 mm (p = 0.04). There was no significant change in MRD2 (p = 0.36) or BP (p = 0.33) with initial MMCR. Mean interval between procedures was 12.8 months (range 2.3–48.0) and follow-up after repeat MMCR was 2.3 months. Total average follow-up after initial MMCR was 15.1 months. Mean elevation in MRD1 after repeat MMCR was 1.0 mm (SD = 0.8 mm, p < 0.002). Mean decrease in TPS was 1.0 mm (p = 0.03). There was no difference in MRD2 (p = 0.90) or BP (p = 0.53). There were no complications of repeat MMCR noted clinically or spontaneously reported, including no entropion, fornix foreshortening, or development of dry eye signs or symptoms. ConclusionRepeat MMCR significantly improves recurrent or residual ptosis after initial MMCR without significant adverse consequences. The degree of elevation with repeat MMCR was diminished when compared with initial MMCR.

Comparison of postoperative recurrence rates between levator aponeurosis advancement and external Müller's muscle tucking for acquired blepharoptosis

Treatment options for acquired blepharoptosis include levator resection, levator aponeurosis advancement (LAA), Müller's muscle-conjunctival resection (MMCR), and frontalis suspension. Previously, we reported a technique called external Müller's muscle tucking (EMMT) using the Müller's muscle as a power source. In this study, we compare LAA with EMMT and evaluate the recurrence and reoperation rates. LAA was performed on 96 eyelids in 51 patients. The average follow-up period was 12.2 months, recurrence occurred in four eyelids (4.2%) of three patients, and reoperation was required in one eyelid of one patient (2.0%). EMMT was performed on 94 eyelids in 51 patients, the mean follow-up period was 10.5 months, recurrence occurred in 14 eyelids (15%) of 10 patients, and reoperation was required in three eyelids of two patients (3.9%). A comparison of LAA and EMMT recurrence showed that EMMT was associated with a significantly higher recurrence rate (P = 0.0021). The causes of EMMT recurrence included thinning and fatty degeneration of Müller's muscles, necrosis of ligated Müller's muscles, and less postoperative scar formation. There was no correlation between EMMT recurrence and the severity of the blepharoptosis.

The Effect of Upper Eyelid Muller Muscle Conjunctival Resection Surgery on Lower Eyelid Position

ABSTRACT Purpose: To examine whether Müller’s-muscle-conjunctival-resection (MMCR) changes the position of the lower eyelid. Methods: Retrospective controlled-cohort study. All patients who underwent MMCR (study group) or blepharoplasty (control group) between January 2016 and September 2018 were recruited. The data retrieved from the patients’ medical records included demographics, visual-acuity, eyelid parameters and dry-eye parameters before and 3 months after surgery. Frontal photographs of the patient’s eyes in primary position were taken preoperatively and at 3 months postoperatively. The margin-reflex-distance 1 (MRD1) and MRD2 were evaluated. The preoperative and 3 months postoperative MRD1, MRD2,and dry-eye signs and symptoms were compared. Results: Sixty-nine patients underwent MMCR and 54 patients underwent blepharoplasty during the study period. There were significant changes in MRD2 after MMCR surgery compared to preoperative values (P < .01, paired t-test), but no significant changes in MRD2 after blepharoplasty surgery (P = .091, paired t-test). The mean changes in MRD2 (delta MRD2) were 0.51 in the MMCR group versus (−0.10) in the blepharoplasty group (P = .04, t-test). Conclusions: The position of the lower eyelid was altered significantly in patients that underwent MMCR surgery. This sequela should be discussed with the patients before surgery and should be considered by physicians when planning ptosis surgery.