• Correction of acquired ptosis may be performed in a number of different ways.
• It is sometimes helpful to divide the surgical approaches into either an

1. internal approach (underneath/inside the eyelid)
2. external approach (via a skin incision)

• Both techniques have their advantages and disadvantages.

Internal Approach:

Müller's Muscle-Conjunctival Resection Procedure

• The Müller’s muscle-conjunctival resection procedure, first described in 1975 by Putterman and Urist (1) is a technique in which Müller’s muscle in the upper eyelid is partially resected and advanced.
• It is used to treat upper eyelid ptosis and may be combined with an excision of upper eyelid excess skin, orbicularis oculi muscle, and herniated orbital fat with reconstruction of the upper eyelid crease (1,2).
• The Müller’s muscle-conjunctival resection procedure is used in the treatment of blepharoptosis in patients whose upper eyelid elevates to a normal level when 10% phenylephrine drops are applied to their upper ocular fornix (the phenylephrine test).
• Candidates for this procedure usually have minimal congenital ptosis and varying degrees of acquired ptosis.
• If the eyelid elevates to a normal level with the phenylephrine test, 8.25 mm of Müller’s muscle and conjunctiva are resected.
• If the upper eyelid elevates slightly higher, less Müller’s muscle is resection is performed (6.25-8.00 mm), and if the upper eyelid rises slightly less, additional Müller’s muscle (8.50-9.75 mm) resection is performed.
• The correlation between the phenylephrine test results and the amount of Müller’s muscle resection was reported by Fett and Putterman (3)

External Approach:

Patient undergoing upper eyelid surgery Marking of the skin: Lid crease at 10 mm from the lid margin Skin incision made with a steel blade, an Ellman RF cutting unit or a CO2 laser Forceps are holding the levator on the bottom aspect of the image Levator (eyelid muscle to elevate the eyelid) has been advanced, and sutured to the tarsal plate. Eyelids immediately following 2-layer closure with sutures. Photograph of the eyelid as it appears just AFTER closure. Photograph at the END of surgery Steri-strips in place over skin incision.