Müller’s Muscle-Conjunctival Resection (MMCR) Blepharoptosis Repair
Introduction in 1975 as a modification of the Fasanella-Servat procedure, which includes the excision of 3mm tarsus, MMCR is another posterior eyelid ptosis repair technique which spares the tarsus. Obviously, the advantage being that tarsus is saved, possibly for use in later procedures if needed, the tarsal Meibomian glands remain undisturbed, and it maintains the normal eyelid contour, although some suggest that good eyelid contour can still be achieved with tarsectomy in MMCR. There have been several modifications on the technique originally described, and there are is a significant amount of literature regarding how much resection should be done via interpretation of the phenylephrine test. The mechanism by which MMCR elevates the lid has been a matter of some contention. Some authors state that the effect of the MMCR is actually from advancement of levator aponeurosis. Other authors question this theory and claim that MMCR lid elevation results from a shortening of the posterior lamella, plication (not resection) of the levator aponeurosis, and internal advancement of the levator palpebrae superioris. They make this claim as the Muller’s muscle is easily separated from the aponeurosis, no histologic evidence of levator aponeurosis has been found in histologic specimens of MMCR lids, and plication of the levator aponeurosis was appreciated in histologic specimens. and is cosmetically valuable as it is a posterior ptosis repair with the incision being through the conjunctiva and not through skin, leaving no visible scar behind.
This procedure is a good choice for a mild to moderate amount of ptosis, good levator function and a response to phenylephrine. Since it is a posterior approach and leaves no visible scar, MMCR is a great tool in a cosmetic surgeon’s repertoire for ptosis repair
After the surgeon determines that a patient has ptosis, the surgeon must determine if the patient is a good candidate for MMCR. An ideal candidate for this procedure has a small amount of ptosis (approx. 2-3mm) and has good levator function.
If the patient has poor levator function (i.e. <10mm), involutional ptosis may be the etiology of the patient’s presentation, and MMCR surgery may not adequately correct his ptosis. Instead, the surgeon should consider an external levator resection for ptosis repair. Also, if excess skin is present, this is often removed by a blepharoplasty surgery that is separate from the conjunctivo-mullerectomy procedure.
Phenylephrine test (PE test)
Müller's muscle is a smooth muscle in the upper eyelid that is innervated by the sympathetic nervous system, and when the muscle is contracted, it elevates the lid approximately 2.5mm. Phenylephrine is an adrenergic stimulant which stimulates the sympathetically innervated Müller’s muscle to contract and thus elevate the lid.
A comparison between 2.5% and 10% phenylephrine did find a difference in the elevation of the upper lid of less than 0.4 mm between the two concentrations but such a small difference is not felt to be significant enough to cause a change in the surgical outcome.To perform the PE test, first measure the MRD1 prior to instilling any drops. Now, place topical proparacaine or tetracaine drops into the eyes, tilt the patients head back, elevate the upper lid, and instruct the patient to look downwards. A drop of 2.5% or 10% Phenylephrine is then placed into the superior fornix, repeating 2-3 times within 1 minute and then a final drop one minute later.  Allow 5 mins to pass after receiving the last drop of phenylephrine, and re-measure the MRD1. The degree of improvement of the MRD1 from the pre-PE test MRD1 is the amount of desired resection.
Keep in mind that the PE test can be used to unmask contralateral ptosis as well, and the surgeon should be aware of the existence of contralateral ptosis masked by Hering’s law of equal innervation.
PE Test Formulae
There are several formulas devised attempting to correlate the amount of resection performed for the amount of desired lid elevation from the PE test:
- Putterman and Fett: 8.5mm resection if 10% phenylephrine raises the lid to exactly where you want it, adding or subtracting 1mm of resection for every 0.5mm of desired increased of decreased lid height desired, up to a range of 6.5mm to 9.5mm
- Weinstein and Buerger: 8mm resection for each 2mm of desired lid elevation and add or subtract 1mm resection for each 0.25mm height difference change in final lid position
- Dresner: 4mm resection for 1mm of ptosis, 6mm for 1.5mm, 8mm for 2, 10mm for 3mm, 11-12mm for >3mm If PE test undercorrected, the ptosis, 1-2mm more of resection was included. It is hypothesized that perhaps in these cases, the MM has undergone fatty infiltration and is not as responsive.(6)
- Perry et al: 9mm resection + X mm of tarsus excision (x = distance of undercorrection after ptosis correction. Authors feel that 9mm of resection should result in similar lid height as 10% PE test. Thus, any decrease in height during the PE can be accounted for by tarsal excision (up to a max of 2.5mm of excised tarsus).
If the surgeon chooses, the landmarks of the eyelid can be marked prior to any injection or induction of anesthesia which some claim would distort these landmarks and lead to larger than desired resection.
Local anesthesia consists of creating wheals of anesthetic via injecting 2% lidocaine with 1:100,000 Epi for hemostasis into the upper lid palpebral conjunctiva and also the skin of the upper eyelid (Figure 1). General anesthesia can also be used if necessary because, unlike in levator resections, the procedure does not require the patient to be awake to make intra-operative adjustments.
Now that local anesthesia has been allowed to take effect, a 4-0 Silk traction suture (Figure 2A) is placed in the middle of upper lid at its margin passing through conjunctiva, tarsus and skin, and the upper lid is then everted over a Desmarres retractor or cotton-tip applicator (Figure 2B,C), exposing the upper lid palpebral conjunctiva overlying the tarsus and Müller’s muscle (Figure 2D).
The superior border of the everted tarsus is marked with electrocautery or a marking pen (Figure 3A).
In this example, a 10mm resection is desired. Calipers are used to measure half of the distance (5mm in this example) of the desired resection starting from the superior border of the tarsus (Figure 3B).
After measuring this distance, three marks 5mm (one medial, one lateral and one middle) equidistant from the superior border of the tarsus are placed with electrocautery or marking pen on the palpebral conjunctiva. A 6-0 Silk running suture is then passed superficially through these marks through the conjunctiva and superficial Müller’s muscle (Figure 4). This suture is then pulled ventrally towards the ceiling, elevating conjunctiva and Müller’s muscle (Figure 5).
NOTE: With Müller’s muscle firmly adherent to conjunctiva, Müller’s muscle should separate easily from the levator aponeurosis to which it is loosely adherent, ensuring that during the resection very little levator aponeurosis is removed. Thus, it is felt that the main reason this procedure works is that there is shortening of the posterior lamella, advancement of the levator palpebrae superioris muscle and plication (not resection) of the levator aponeurosis.
Now elevating the conjunctiva and Müller’s muscle with the suture, A Putterman Müller’s muscle–conjunctival resection clamp is placed at the border of the superior tarsus and clamped shut, sandwiching the conjunctiva and Müller’s muscle (Figure 6A).
This clamp has three needles which penetrate through the squeezed conjunctiva and Müller’s muscle so that they do not slip out of the clamp, ensuring the correct desired amount of tissue will be resected (Figure 6B).
Occasionally, tarsus may inadvertently be incorporated into the clamp which is not desired (Figure 6C). If the tarsus has been incorporated, the margin of the lid may be distorted. To evaluate for this, the Desmarres retractor or q-tip is removed, the lid is inverted back into normal position, and the contour of the margin is assessed. If the contour is not normal, tarsus may have been inadvertently grasped by the clamp; therefore, using gentle digital traction, any tarsus is pulled free from the clamp.Similarly, to ensure levator aponeurosis has not been incorporated, the clamp is then pulled inferiorly while lid skin is pulled superiorly. If there is any tightness, levator aponeurosis may have inadvertently been incorporated, and if this is the case, the clamp needs to be disengaged and placed again.
To prevent rubbing of the suture knot on the globe surface, we externalize the suture knot. This can be done with or without the use of a bolster to help reduce local skin complications.
Alternatively, if a blepharoplasty is also being performed, the suture can be passed through the wound of the blepharoplasty.
With the clamp successfully in place, the clamp is pulled ventrally to the ceiling, elevating the tuft of conjunctiva and Müller’s muscle. (Figure 7A-B) A 6-0 plain gut suture is then sewn first through skin laterally right above the upper eyelid crease, full thickness through the lid, exiting the conjunctiva near the lateral edge of the superior border of the tarsus. This 6-0 plain gut is then sewn medially in a running fashion 1.5-2.0mm below the inferior margin of the clamp passing full thickness through the conjunctiva and Müller’s muscle. Once the suture reaches the medial edge of the clamp, the suture is then sewn back laterally, again in a running fashion to the lateral edge of the clamp (Figure 7C-D). Alternatively, a nonabsorbable suture, such as 6-0 prolene, can be passed under the clamp once and tied over the skin to avoid running the suture back.
A #15 or #11 blade (Figure 8) is used to excise the Müller’s muscle-conjunctivo complex enclosed within the clamp from the lid by cutting the complex between the clamp and the sutures, taking care NOT to incidentally cut the sutures with the blade by cutting juxtaposed to the clamp.
The suture is then passed back through the palpebral conjunctiva, exiting through the skin near where the suture enters. The Desmarres’ retractor or cotton-tip is then used to re-evert the lid, and closure of conjunctiva defects is completed via tightening and tying down the 6-0 running plain gut suture to ensure the borders of the conjunctival wound are approximated. The traction suture is then removed from the upper eyelid (Figure 9)
If being performed, blepharoplasty can be completed at this point
Antibiotic ophthalmic ointment is placed in the eye at this point
Post-operative care consists of placing antibiotic ophthalmic ointment into the eye and to the suture at the skin three times per day for a total of one week and the patients will follow up for their first post-operative visit after one week.
- Putterman AM, Urist MJ. Müller’s muscle-conjunctival resection. Arch Ophthalmol. 1975;93(8):619-623.
- Fasanella RM, Servat J. Levator resection for minimal ptosis: another simplified operation. Arch Ophthalmol. 1961;65:493-496.
- Choudhary MM, Chundury R, McNutt SA, Perry JD. Eyelid Contour Following Conjunctival Müllerectomy With or Without Tarsectomy Blepharoptosis Repair. Ophthal Plast Reconstr Surg. 2016 Sep-Oct;32(5):361-5
- Mercandetti M, Putterman AM, Cohen ME, et al. Internal levator advancement by Müller’s muscle-conjunctival resection: technique and review. Arch Facial Plast Surg. 2001;3:104–10.
- Marcet MM, Setabutr P, Lemke BN et al. Surgical Microanatomy of the Müller Muscle-Conjunctival Resection Ptosis Procedure. Ophthal Plast Reconstr Surg. 2010Sep-Oct;26(5):360-4
- Dresner SC. Further modifications of the Müller’s muscle-conjunctival resection procedure for blepharoptosis. Ophthal Plast Reconstr Surg 1991;7:114–22.
- Allen RC, Saylor MA, Nerad JA. The current state of ptosis repair: a comparison of internal and external approaches. Curr Opin Ophthalmol. 2011 Sep;22(5):394-9.
- Sajja K, Putterman AM. Müller’s Muscle Conjunctival Resection Ptosis Repair in the Aesthetic Patient. Saudi J Ophthalmol. 2011 Jan;25(1):51–60
- Glatt HJ, Fett DR, Putterman AM. Comparison of 2.5% and 10% phenylephrine in the elevation of upper eyelids with ptosis. Ophthalmic Surg 1990; 21:173–176.
- Ben Simon GJ, Lee S, Schwarcz RM, McCann JD, Goldberg RA. Müller's muscle-conjunctival resection for correction of upper eyelid ptosis: relationship between phenylephrine testing and the amount of tissue resected with final eyelid position. Arch Facial Plast Surg. 2007 Nov-Dec;9(6):413-7.
- Putterman AM, Fett DR. Müller’s muscle in the treatment of upper eyelid ptosis: a ten-year study. Ophthalmic Surg. 1986;17(6):354-360.
- Weinstein GS, Buerger GF Jr. Modifications of the Müller’s muscle-conjunctival resection operation for blepharoptosis. Am J Ophthalmol. 1982;93(5):647-651
- Perry JD, Kadakia A, Foster JA. A new algorithm for ptosis repair using conjunctival Müllerectomy with or without tarsectomy. Ophthal Plast Reconstr Surg. 2002; 18(6):426-429.