Objective: Patients with blepharoptosis caused by disinsertion of the levator aponeurosis or Horner syndrome require surgical repair. Often, the motivation is mainly cosmetic. It is therefore important to obtain a harmonious result with overall symmetry of the palpebral aperture, the level of the lid crease, and the lid contour. The Muller muscle conjunctival resection, as described by Putterman, is very effective for raising the lid. However, its use is tricky when a Hering dependence exists or when the phenylephrine test does not provide a symmetrical opening. Fifty-one consecutive patients who underwent a Muller muscle-conjunctival resection by a single surgeon between October 2003 and January 2005 (64 eyelids) were retrospectively analyzed in order to refine the technique and indications by answering four questions: Is the phenylephrine test 100% reliable? In case of under- or overcorrection with the phenylephrine test, can surgery be graduated in its effects? When a Hering dependence occurs, is it always detected by the phenylephrine test? Is this technique more predictable than alternative techniques?
Patients and method: Objective criteria (measurement of the palpebral aperture and the margin reflex distance [MRD]) and subjective criteria, much more accurate because they take into account the lid contour and the position of the lid crease, were used with photographs. The technique was used as described by Putterman.
Results: A reduction of the ptosis with an asymmetry inferior or equal to 1mm was obtained in 90% of the cases. According to the subjective criteria, 56% were classified as excellent with a perfect symmetry, 32% were classified as good with a slight asymmetry but without any cosmetic impact, 10% were classified as average, with a visible imperfection, and 2% (one patient) were classified as poor, resulting from an obvious cosmetic imperfection with an irregular contour requiring reoperation. In 55% of the cases, the palpebral aperture was at less than 0.5 mm of that obtained with the phenylephrine test. In 21% of the cases, the position was quite unexpected, with a gap of more than 1mm. In 14% of the results, the level was inferior to the test because of a voluntary limited resection. In 9% of the cases, a bilateral and symmetrical drop occurred because of the relaxation of the frontalis muscle after the operation. A Hering dependence was found in 46% of unilateral cases with a drop of the contralateral eyelid inferior or equal to 1mm (2mm in one case only). Among these cases, 62% were predictable with the phenylephrine test; in one case, a drop foreseen by the test did not occur. When the test produced an overcorrection, the resection was lowered by 1 or 2mm, which worked well in 10 cases out of 12. When the test produced an undercorrection, the resection was at its maximum (10 mm), but was efficient in only one out of six cases.
Conclusion: In 21% of the cases, the phenylephrine test was not efficient in predicting the surgical result. A resection of a part of the tarsus is necessary in case of undercorrection with the phenylephrine test. Almost half of the of the cases with a Hering dependence remained undetected after the test. The Muller's muscle resection give a better result than the classical aponeurosis shortening with an anterior cutaneous approach. However, it is absolutely essential, in order to select patients and to measure surgical process, to put into effect the phenylephrine test with strict identical requirements to detect the bilateral and asymmetrical forms and a possible Hering dependence, and to standardize the surgical technique, developing one's own graphs through the analysis of postoperative results.