The levator muscle combined with Müller′s muscle shortening for treatment of mild and moderate congenital blepharoptosis / 中华整形外科杂志

Objective@#To investigate the therapeutic effect of levator muscle combined with Müller′s muscle shortening for treatment of mild and moderate congenital blepharoptosis.@*Methods@#Thirty-one cases (38 eyes) with mild or moderate congenital blepharoptosis were treated through both skin and conjunctiva approach. The levator muscle was exposed through skin approach. The Müller′s muscle was separated from conjunctiva through conjunctiva approach. The combined flap of levator muscle and Müller′s muscle was freed from the upper edge of tarsus and shortened. Then the combined flap was fixed on the upper 2/3 portion of tarsus to correct the ptosis.@*Results@#All the patients were followed up for 6-24 months with satisfactory result . The result was graded as good 12 eyes, generally 21 eyes, inadequate correction 3 eyes, over-correction 1 eye, and nvalid correction 1 eye. The effective rate was 86.8%.@*Conclusions@#The levator muscle combined with Müller′s muscle shortening is a very simple and practicle method for mild to moderate congenital blepharoptosis with satisfactory result.

Eyelid Contour Analysis Following Müller's Muscle-conjunctival Resection and Levator Aponeurosis Advancement in Mild to Moderate Belpharoptosis

PURPOSE: To analyze both the effects and the eyelid contour of Müller's muscle-conjunctival resection and levator aponeurosis advancement in patients with mild to moderate belpharoptosis. METHODS: We conducted a retrospective cross-sectional study including 20 eyes of 16 patients who underwent Müller's muscle-conjunctival resection and 25 eyes of 17 patients who underwent levator aponeurosis advancement from January 2012 to December 2015, where each patient was followed up for at least 6 months. Surgical success was defined as either a marginal reflex distance 1 (MRD₁) elevation greater than 2.5 mm postoperatively or a bilateral MRD₁ difference less than 0.5 mm. Both the conventional and 12 oblique mid-pupil lid distances were measured every 15 degrees using custom software developed in the MATLAB program (MathWorks, Natick, MA, USA). RESULTS: The average correction of Müller's muscle-conjunctival resection was 1.1 mm, while that of levator aponeurosis advancement was 0.9 mm. There was no significant difference in MRD₁, MRD₂, function of levator palpebrae muscle, or lid contour in the preoperative status between the Müller's muscle-conjunctival resection group and the levator aponeurosis advancement group. The surgical success rate was 85% in the Müller's muscle-conjunctival resection group and 84% in the levator aponeurosis advancement group, but this difference was not significant. The postoperative lid contour (superomedial side, 15°) was more effective in the Müller's muscle-conjunctival resection group (p < 0.05). CONCLUSIONS: Overall, both types of blepharoptosis surgery were effective at correcting mild to moderate blepharoptosis. The correction of mild to moderate blepharoptosis using Müller's muscle-conjunctival resection is an effective technique for elevating the eyelid and normalizing the eyelid contour.

A Case of Intramuscular Muller Muscle Hemangioma of Upper Eyelid Mimicking Sarcoidosis

PURPOSE: We report a case of Muller muscle intramuscular hemangioma in the upper eyelid mimicking dacryoadenitis. CASE SUMMARY: A 21-year-old male patient presented with a 2-year history of upper eyelid swelling in his right eye and no symptom relief with oral corticosteroid. Increased angiotensin-converting enzyme (ACE) was noted in the laboratory findings. However, lid inflammation was not improved and the patient underwent incisional biopsy. CONCLUSIONS: Microscopically, the lesion was composed of proliferating vessels of various sizes between the individual smooth muscle fibers. Intramuscular hemangioma rarely presenting as a benign tumor in the head and neck region can present as diffuse swelling mimicking sarcoidosis or dacryoadenitis.

Three methods of surgical treatment for upper eyelid retraction / 局解手术学杂志

objective To explore a reasonable treatment for upper eyelid shrinking. Methods All 15 patients with upper eyelid retrac-tion were divided in group A,group B and group C. Group A with 9 eyes received botulinum toxin type A,group B with 10 eyes were corrected by central aponeurosis disinsertion,group C with 9 eyes upper eyelid were corrected by the lengthening of the levator muscle and Müller's muscle. And the data was summarized and analyzed. Results Five cases (9 eyes) with upper eyelid shrinking obviously were improved 72 h after injecting botulinum toxin type A,but the eyelids returned to previous states 4~6 months later. The shape of postoperative eyelid was good and the eyelids structure was natural in group B,recurrence was in 2 cases. Patients in group C had satisfactory results. And there was no recurrence and complications after 3~24 months of follow-up. Conclusion The three treatments have effect on upper eyelid shrinking at quiescence phase. The method of injecting botulinum toxin type A is simple,with reliable curative effect and short duration,while it was nee-ded repeated injections. The method of central aponeurosis disinsertion is simple but difficult to quantify properly. The lengthening of the leva-tor muscle is not only simple but also with reliable effect and less complications.

Clinical Outcomes of Conjunctiva-Muller Muscle Resection and Factors Which Affect Success

PURPOSE: To investigate clinical outcomes and to analyze the factors of successful treatment of conjunctiva-Muller muscle resection (CMMR) in patients with mild to moderate ptosis. METHODS: The medical records of 22 patients (30 eyes) with upper lid ptosis were retrospectively reviewed. All patients underwent conjunctiva-Muller muscle resections, and four patients (seven eyes) underwent concurrent upper lid blepharoplasty. The mean follow-up period was 81.62 +/- 21 days. Pre- and post-operative MRD1, IPF and pupil to brow distance were measured using the Image J program. A preoperative phenylephrine test and a pathologic examination were performed to analyze the presence of Muller's muscle and the tear secreting glands from the CMMR specimens. RESULTS: The overall success rate of the procedure was 93%. Postoperatively, the MRD1 increased on average by 1.47 mm (p = 0.00) and increased by an average of 1.72 mm when the phenylephrine test response was greater than 2 mm and by 0.99 mm when the response less than 2 mm. The Muller muscle was observed in every specimen. CONCLUSIONS: Conjunctiva-Muller muscle resection is an effective and safe method for treating mild to moderate ptosis, for which the preoperative phenylephrine test result is the most important factor for surgical success.

Blepharoptosis Correction with Stitch Method

There are various methods to correct mild ptosis and to make a double fold. However, all pre-existing methods have similar disadvantages, such as long-lasting swelling and down time. Recently, many patients prefer more convenient and minimal invasive methods with faster recovery. So we have devised a new technique to correct mild ptosis. Our technique is very similar to other non-incisional stitch methods. We try to correct ptosis through Muller's muscle tucking using the non-incisional stitch method. We think this method could be applied to mild degree ptosis. We hope to report the long-term follow up data of our cases and analysis with more efficient technique in the near future.

Correction of Blepharoptosis using Posterior Check Ligament Sling

There are various options on proper surgical repair for blepharoptosis. We have treated 7 patients with posterior check ligament sling and evaluated the advantages of this method from September 2006 to July 2009. These patients were blepharoptosis with moderate to severe ptosis with poor levator function. Through the blepharoplasty incision, the upper half of tarsal plate was exposed and the orbital septum was opened to show the levator aponeurosis. The M?ller's muscle was dissected from the upper border of the tarsal plate and from the posteriorly located conjunctiva. We exposed the posterior check ligament and fixed it on approximately upper one third of the tarsal plate. We obtained satisfactory result for more than 18 months with blepharoptosis corrected with all cases with no significant complications: among satisfactory degrees of all blepharoptosis patients, 4 were "Excellent" and 3 were "Good". The correction of blepharoptosis using posterior check ligament sling showed less traumatic to levator and The M?ller's muscle and more naturally correcting vector, compared with other methods. Especially in patients who had insufficient correction of blepharoptsis, the correction of blepharoptosis using posterior check ligament sling appears to be a good alternative method.

Treatment of Blepharoptosis by the Advancement Procedure of the Muller's Muscle-Levator Aponeurosis Composite Flap

PURPOSE: Even in a small levator resection for blepharoptosis, 10-13mm of Muller's muscle and levator aponeurosis is resected. To solve the problem, Muller's muscle was detached from the superior tarsal border and conjunctiva, and the muscle with overlying levator aponeurosis was advanced on the upper tarsus as a composite flap. The purpose of this study is to evaluate the effectiveness of the Muller's muscle-levator aponeurosis complex advancement technique for the correction of blepharoptosis. METHODS: From 2003 to 2008, 107 patients(183 eyes) underwent the advancement procedure of the Muller's muscle-levator aponeurosis composite flap for blepharoptosis. The advanced composite flap was fixed 3 mm below the superior tarsal border and 2-3mm of distal flap stump was left after trimming up to 5mm. The results of the operations were evaluated. RESULTS: The mean age of the patients was 35.2 years and 83 patients(145 eyes) were followed up for a mean of 16.7 months. 128 eyes(88.3%) showed a normal level of upper eyelid margin(MRD1 4.1-5.0mm) or less than 1mm ptosis(MRD1 3.1-4.0mm). 10 eyes(6.9%) showed 1-2mm ptosis(MRD1 2.1-3.0mm). 7 eyes(4.8%) showed more than 2mm ptosis which required secondary correction. About 80% of the 183 eyes needed no trimming of the flap stump with 5-6mm of composite flap advancement and 20% had about 3mm of the flap stump trimmed with 8-9mm of composite flap advancement (shortening of the levator complex). CONCLUSION: Muller's muscle-levator aponeurosis complex advancement technique offers several advantages: There is no, or minimal, sacrifice of the normally functioning Muller's muscle; it is more physiological; it is reproducible and it is predictable-with gratifying results for blepharoptosis.

Results of Conjunctiva-Muller Muscle Resection in Mild Eyelid Ptosis

PURPOSE: To assess surgical outcomes after adjusting the amount of resection of the conjunctiva and the Muller muscle according to 10% phenylephrine test results. METHODS: The charts of 32 patients (32 eyes) with mild upper eyelid ptosis were reviewed retrospectively. They all had conjunctiva-Muller muscle resections. A preoperative 10% phenylephrine test was performed to determine the resection amount of the Muller muscle and conjunctiva. An 8 mm resection was performed when phenylephrine raised the ptotic lid to the same level as that of the contralateral lid. A 7 mm resection was performed when the ptotic lid was raised to a level higher than that of the contralateral lid. A 9 mm resection was performed when the ptotic lid was raised to a level not quite to the level of the contralateral lid. RESULTS: Of the 32 patients, 28 were female and 4 were male. The mean age of the patients was 30.8+/-10.2 years. Patients were followed up for an average of 40.2+/-36.8 days, postoperatively. Postoperative upper lid positions were exactly symmetrical in 26 of the 32 patients. Five patients showed undercorrection, and 1 patient showed overcorrection. CONCLUSIONS: Excellent results were obtained by resecting the conjunctiva and Muller muscle according to the phenylephrine reaction of a ptotic eyelid.

Clinical Effects of Conjunctiva-Muller Muscle Resection in Anophthalmic Ptosis

PURPOSE: To evaluate the clinical effects of conjunctiva-Muller muscle resection through conjunctival incision in anophthalmic patients with mild ptosis. METHODS: Conjunctiva-Muller muscle resection was performed by one surgeon in 8 patients (8 eyes) who had received evisceration or enucleation and responded to 10% phenylephrine solution to correct ptosis. The average age of the patients was 35.87+/-13.4 years. Ptosis was seen from 1 to 34 months after evisceration or enucleation. The preoperative MRD 1 was -2 to 0.5 mm (average: -0.25+/-1.10 mm) and the difference of MRD 1 between before and after 10% phenylephrine use was 2.56+/-0.98 mm. The Muller muscle was resected 7.5 to 9 mm through conjunctival incision during surgery to match the MRD 1 of sound eye. Mean follow-up period after the operation was 2 to 16 months (average: 8.1 months). RESULTS: Postoperatively, the MRD 1 increased by 1.81+/-0.88 mm on the average, corresponding to the improvement in lid elevation after the use of 10% phenylephrine performed before resection. Surgery was successful in most patients, and postoperative difference in MRD 1 was less than 1 mm from the sound eye. No special postoperative complication was observed. CONCLUSIONS: Conjunctiva-Muller muscle resection is one of the effective methods of correcting mild ptosis in anophthalmic patients.

Clinical Effects of Conjunctiva-Muller Muscle Resection in Anophthalmic Ptosis

PURPOSE: To evaluate the clinical effects of conjunctiva-Muller muscle resection through conjunctival incision in anophthalmic patients with mild ptosis. METHODS: Conjunctiva-Muller muscle resection was performed by one surgeon in 8 patients (8 eyes) who had received evisceration or enucleation and responded to 10% phenylephrine solution to correct ptosis. The average age of the patients was 35.87+/-13.4 years. Ptosis was seen from 1 to 34 months after evisceration or enucleation. The preoperative MRD 1 was -2 to 0.5 mm (average: -0.25+/-1.10 mm) and the difference of MRD 1 between before and after 10% phenylephrine use was 2.56+/-0.98 mm. The Muller muscle was resected 7.5 to 9 mm through conjunctival incision during surgery to match the MRD 1 of sound eye. Mean follow-up period after the operation was 2 to 16 months (average: 8.1 months). RESULTS: Postoperatively, the MRD 1 increased by 1.81+/-0.88 mm on the average, corresponding to the improvement in lid elevation after the use of 10% phenylephrine performed before resection. Surgery was successful in most patients, and postoperative difference in MRD 1 was less than 1 mm from the sound eye. No special postoperative complication was observed. CONCLUSIONS: Conjunctiva-Muller muscle resection is one of the effective methods of correcting mild ptosis in anophthalmic patients.

Blepharoptosis Correction with Muller Tuck Method

There are several methods for blepharoptosis correction. Many complication of blepharoptosis induced by operation. Lid lag and lagophthalmos is especially, a difficult problem to resolve. So, many plastic surgeons make an effort to prevent lid lag or lagophthalmos. One of blepharotposis correction methods, we have used Muller's muscle tucking method since 2004. The author's method is Muller's muscle tuck with fixation to the tarsal plate and pretarsal fascia with nylon #6-0 and aponeurosis sutured with pretarsal orbicularis muscle or pretarsal area dermis. We have found this method to show good results, with resulting no or only mild lagophthalmos than previous ptosis corrective methods. This method yield results with more post-operative predictability than aponeurosis surgery due to preservation of the aponeurosis gliding plane. If this method is applied to mild and moderate ptosis, it is one of good method of ptosis correction.

Muller's Muscle-Levator Aponeurosis Advancement Procedure for Blepharoptosis

Muller's muscle-levator aponeurosis advancement procedure was performed to correct mild to moderate congenital blepharoptosis with moderate to good levator function and to correct severe aquired blepharoptosis with poor levator function. Through the blepharoplasty incision, the upper half of the tarsal plate was exposed and the orbital septum was opened to show the levator aponeurosis. The Muller's muscle was dissected from the superior margin of the tarsal plate and from the posteriorly located conjunctiva with sharp scissors. The Muller's muscle and levator aponeurosis were advanced on the anterior surface of the tarsal plate as a composite flap and fixed approximately 3 to 4mm inferior to the upper edge of the tarsal plate with three horizontal 6-0 nylon mattress sutures. The amount of advancement of the composite flap was controlled by the location of the upper eyelid margin 2mm below the upper limbus in primary gaze after the first suture in the middle portion of the flap. The excess flap was trimmed off with scissors, but trimming was usually not necessary in cases of mild to moderate ptosis. Nine cases underwent this Muller's muscle-levator aponeurosis advancement procedure from September 2003 to September 2004. Five cases were congenital blepharoptosis with 2-4mm ptosis and more than 5mm of levator function, but three of the four acquired ptosis cases had more than 4mm ptosis with poor levator function. The age of the patients ranged from 7 to 81 years. In operative results, all patients except one traumatic case were within 1mm of the desired eyelid height in primary gaze. This procedure can provide not only tightening of the Muller's muscle but also advancement and firm fixation of the levator aponeurosis to the tarsal plate, yielding predictable results.

Management of the upper eyelid retraction by severing of the Levator & Muller Muscle in upper eyelid / 나학회지

The surgical treatment of long duration lagaphthalmos was traditionally conducted using the Gillies (1934) method of temporal muscle transfer. This method has been effective in cases of simultaneous lagaphthalmos in the upper eyelid and ectropion in the lower eyelid. In the past, we treated 18 leprosy patients who suffered complications of ptosis in the upper eyelid and ectropion in the lower eyelid after the application of the Gillies method. To treat these complications, we removed the fascia strips emplaced during temporal muscle transfer from the upper and lower eyelid. Thereafter, we implanted a 1.0 gram gold plate in the upper eyelid and either a conchal cartilage graft. In the treatment of Lagaphthalmos over the past seven years, we have applied gold plate lid loading in 120 cases. However, in five of these cases, patients suffered from exposure of the gold plate due to paralytic orbicularis oculi muscle tearing. Recently, to correct this, we covered the gold plate with AlloDerm tissue to protect and support the muscle. In the treatment of ectropion over the last six years, we have had over 30 cases of cartilage grafts (over 35mm in length and 5mm in breadth) in the lower eyelid. However, the end of the cartilage graft would warp and create new partial ectropion several months later. Because of this, we shifted from cartilage to AlloDerm. We applied 40mm (length) and 7mm (breadth) to the lower border of the tarsus and fixed at each end with medial and canthal ligament. From 1997 to 2002, in the Institute of Leprosy Research, we operated on 25 patients suffering from Lagaphthalmos and Ectropion using a newer treatment to correct ectropion more effectively. The levator muscle of the upper eyelid loses the funtion of its antagonistic muscle, namely the orbicularis oculi due to facial nerve palsy, and results in retraction of the upper eyelid. To correct upper eyelid retraction, we severed the levator and muller muscle from the superior tarsal border and discontinued the use of gold lid loading which is visually evident. This method does not result in ptosis and the eye is more normal in appearance.

Upper Eyelid Retraction Repaired Without Using Spacer

A combined technique for lid retraction that includes levator recession and Mullerectomy without spacers and levator and Muller muscle recession without spacers was presented. Eight procedures on eight patients were reviewed. Four patients with lid retraction had hyperthyroidism, one patient showed idiopathic lid retraction,and three patients was due to overcorrection of ptosis. Three patients showed excellent cosmetic appearance during the follow-up period of 6 to 22 months; but four patients mild limitation in elevation, and one patient insufficent correction.

Anatomic Characteristics of Upper Eyelid Structures Important in Ptosis Surgery

Exact understanding of the upper eyelids is essential to the success of an anterior surgical approach for the correction of blepharoptosis. Therfore, we undertook this study using cadaver dissection, histologic sections, surgical observations, and review of MRI findings to gain a better understanding of the anatomical characteristics of the orbital septum and associated connective tissue structures which are important in ptosis surgery. The basic distinction of the upper eyelid structures between Oriental and Occidental is the relationship of the orbital septum and the levator aponeurosis. The orbital septum appears as a thick multilayered connective tissue originating just inside the superior orbital rim, but its inferior extension become thin progressively and blends with levator aponeurosis on an average of 1.6mm below the superior tarsal horder. Therefore the preaponeurotic fat is allowed to proceed to the anterior tarsal surface, resulting in a characteristic appearance of oriental eyelids. The levator aponeurosis maintains its thick and obvious structure continuously to the anterior tarsal surface near the lower margin of the upper lid. We resected levator aponeurosis with Muller's muscle which plays a important role in lid elevation for the correction of congenital htepharoptosis, and obtained excellent results.