COSMETIC

External Levator Advancement versus Müller

Muscle–Conjunctival Resection for Aponeurotic
Blepharoptosis: A Randomized Clinical Trial
Preamjit Saonanon, M.D.
Supapan Sithanon, M.D.
Bangkok, Thailand
Background: The purpose of this study was to compare the efficacy of external
levator advancement and Müller muscle–conjunctival resection in aponeurotic
blepharoptosis repair.
Methods: Mild to moderate blepharoptosis patients with good levator function
and a positive phenylephrine test were randomized to upper blepharoplasty
with either external levator advancement or Müller muscle–conjunctival resec-
tion. The primary outcome was marginal reflex distance 1 at 1 month after
surgery. Secondary outcomes were cosmetic outcome, complications, and op-
erating room time.
Results: Forty patients were enrolled, six men and 34 women, with an aver-
age age of 62.4 years. The mean preoperative marginal reflex distance 1 in
the levator group (39 eyes/20 subjects) and the Müller group (38 eyes/20
subjects) was 1.2 ± 0.8 mm and 1.5 ± 0.7 mm, respectively. The mean post-
operative marginal reflex distance 1 in the levator and Müller groups was
3.0 ± 1.0 mm and 3.2 ± 1.0 mm, respectively. The difference in the mean
change was 0.008, and was not statistically different (95 percent CI, −0.59 to
0.61; p = 0.978). The mean cosmetic outcome was 2.69 ± 0.81 for the levator
group and 3.07 ± 0.68 for the Müller group, with a mean difference of 0.373
(95 percent CI, 0.06 to 0.69; p = 0.020). The average operating room time
was 75 ± 19.2 minutes for the levator group and 71 ± 23.6 minutes for the
Müller group (p = 0.439). There were four eyes that underwent reoperation,
three in the levator group (7.7 percent) and one in the Müller group (2.6
percent).
Conclusions: External elevator advancement and Müller muscle–conjunctival
resection are both effective in correction of mild to moderate blepharoptosis.
However, Müller muscle–conjunctival resection yields a statistically significant
better cosmetic outcome and causes less eyelid asymmetry.  (Plast. Reconstr.
Surg. 141: 213e, 2018.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

A
poneurotic blepharoptosis is the most
common cause of ptosis that results from
levator aponeurosis dehiscence from the
anterior surface of the tarsus, thinning of levator
muscle, or both. Nowadays, there are various ways
of accomplishing aponeurotic blepharoptosis
From the Department of Ophthalmology, Faculty of ­Medicine,
Chulalongkorn University, King Chulalongkorn Memorial
Hospital, Thai Red Cross Society.
Received for publication April 1, 2017; accepted August 29,
2017.
Presented at the American Academy of Ophthalmology 2016
Annual Meeting, in Chicago, Illinois, October 15 through
18, 2016.
Copyright © 2018 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000004063
correction. External levator advancement and
Müller muscle–conjunctival resection are among
the most popular methods, and the superiority of
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.
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 Plastic and Reconstructive Surgery • February 2018
each procedure is still debated.1 Levator muscle
surgery for ptosis repair by the anterior approach
was described by Everbusch in 18832 and gained
more popularity after Jones et al. demonstrated
the levator aponeurotic defect in 1975.3 Müller
muscle–conjunctival resection was first described
by Putterman and Urist in 1975 by mechanisms
of shortening the posterior lamella to raise the
eyelid.4
External levator advancement addresses the
pathologic process of the aponeurotic ptosis,
which is suitable for all degrees of ptosis, and eye-
lid height can be adjusted intraoperatively. When
combined with upper blepharoplasty, this leaves
the conjunctival side of the eyelid intact. How-
ever, external levator advancement has a steep
learning curve and can sometimes yield unpre-
dictable postoperative eyelid position. Müller
muscle–conjunctival resection is fast and requires
less of a learning curve. The indication is limited
to mild to moderate ptosis. Disadvantages of this
procedure include removal of healthy conjunc-
tival tissue and intraoperative bleeding from the
raw surface. Both operations offer good outcome
and are usually selected solely by a surgeon’s own
preference.5 No randomized controlled trial com-
paring the efficacy of these two techniques has
been published before. In this study, we evaluated
the efficacy, cosmetic outcome, and operating
room time of external levator advancement com-
pared to Müller muscle–conjunctival resection in
patients with aponeurotic blepharoptosis.
PATIENTS AND METHODS
After institutional review board approval,
40 subjects were included in the study from the
Department of Ophthalmology, King Chulalong-
korn Memorial Hospital, from June 1, 2014, to
February 29, 2016. Study subjects were between
35 and 80 years old diagnosed with involutional
blepharoptosis (marginal reflex distance 1
<2.5 mm) and dermatochalasis. All subjects had
good levator function (levator function >10 mm)
and a positive phenylephrine test (before and
after phenylephrine, marginal reflex distance 1
difference of >2 mm). Exclusion criteria included
previous eyelid trauma or surgery, significant cor-
neal disease, and advanced glaucoma. The sample
size was calculated using the algorithm based on
an independent sample and noninferiority trial
with the noninferiority margin of 2. This research
followed the tenets of the Declaration of Helsinki.
The design of this study was approved by the Chu-
lalongkorn University Institutional Review Board.
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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
After informed consent was obtained, eyelid
examinations were performed and digital pho-
tographs were taken. Subject characteristic data
collected included age, gender, visual acuity, mar-
ginal reflex distance 1, marginal reflex distance
2, eyelid crease height, eyelid contour, and leva-
tor function. All 40 subjects were randomized
for blepharoplasty combined with external leva-
tor advancement or Müller muscle–conjunctival
resection by block-of-four randomizations. The
allocation ratio was 1:1 and the randomization was
performed per subject, and subjects with bilateral
ptosis would undergo the same ptosis correction
surgery for both eyes (Fig. 1). Procedure types
were concealed in opaque, sealed envelopes, and
sequentially numbered by the coordinator (S.S.)
so the surgeon (P.S.) was blinded to the type of
ptosis correction until the day of surgery. All sub-
jects underwent the procedure with local anesthe-
sia using 2% lidocaine with 1:80,000 epinephrine.
Upper blepharoplasty and preaponeurotic fat
removal were performed and properly adjusted
for each patient. In the levator group, the levator
aponeurosis was identified and dissected free from
the tarsus and Müller muscle underneath. The
levator aponeurosis was shortened and adjusted
to the level of the new marginal reflex distance 1
and reattached again at the upper tarsal border by
6-0 polyglycolic acid suture for one or two points.
(See Video, Supplemental Digital Content 1,
which demonstrates the external levator advance-
ment procedure, available in the “Related Videos”
section of the full-text article on PRSJournal.com
or, for Ovid users, at http://links.lww.com/PRS/
C546.) In the Müller group, after upper blepha-
roplasty, the eyelid was everted by a Desmarres lid
retractor, and Müller muscle–conjunctival resec-
tion was performed as described previously by
Weinstein and Buerger.6 A 4-0 silk marking suture
was placed through the conjunctiva and Müller
muscle 4 mm above the superior tarsal border.
The suture was used to tent up tissue and facili-
tate Putterman clamp placement. After the clamp
was placed and locked, tissue beneath the clamp,
including the tarsal plate, was secured with 6-0
polyglycolic acid suture in a simple continuous
pattern. The conjunctiva and Müller muscle were
then resected, and the amount of Müller muscle
resection was 8 mm for all subjects. (See Video,
Supplemental Digital Content 2, which demon-
strates the Müller muscle–conjunctival resection
procedure, available in the “Related Videos” sec-
tion of the full-text article on PRSJournal.com or,
for Ovid users, at http://links.lww.com/PRS/C547.)
Intraoperative data collected included type of
 Volume 141, Number 2 • Blepharoptosis Treatment Comparison
Fig. 1. Flow diagram of the progress through the phases of a parallel randomized trial of the external elevator advancement (ELA)
and Müller muscle–conjunctival resection (MMCR) groups.
operation, suture material, operating room time,
and complications.
Postoperative data collected at 1 week and 1
month included marginal reflex distance 1, mar-
ginal reflex distance 2, eyelid crease height, eyelid
contour, levator function, and degree of lagoph-
thalmos. Subject satisfaction score by the Thai
version of the Client Satisfaction Questionnaire
(CSQ-8) was also obtained at 1 month.7 The score
range was from 0 to the maximum value of 4. Sub-
ject preoperative and 1-month postoperative stan-
dardized photographs were scored for cosmetic
result from one oculoplastic surgeon and one
plastic surgeon. The cosmetic result was scored
based on eyelid position, eyelid crease, and eye-
lid symmetry as excellent (4), good (3), fair (2),
or poor (1) outcome. Each eye of the subject was
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
initially analyzed separately and then the overall
outcome of both eyes was evaluated. Complica-
tion data collected included postoperative infec-
tion, hemorrhage, exposure keratitis, asymmetry,
undercorrection, overcorrection, and reopera-
tion. The marginal reflex distance 1 asymmetry is
defined as the difference between eyes of greater
than or equal to 1 mm. Undercorrection defined
as marginal reflex distance 1 of less than 2 mm
and overcorrection defined as marginal reflex
distance 1 of more than 5 mm. The primary out-
come of the study was to compare the difference
between preoperative and postoperative marginal
reflex distance 1 in external elevator advance-
ment and Müller muscle–conjunctival resection.
Secondary outcomes were cosmetic outcomes and
operating room time.
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 Plastic and Reconstructive Surgery • February 2018

Video 1. Supplemental Digital Content 1 demonstrates the external

levator advancement procedure. After completion of upper blepha-
roplasty, the levator aponeurosis was identified and dissected free
from the tarsus and Müller muscle underneath. The levator aponeu-
rosis was shortened and adjusted to the level of the new marginal
reflex distance 1 and reattached again at the upper tarsal border,
available in the “Related Videos” section of the full-text article on PRS-
Journal.com or, for Ovid users, at http://links.lww.com/PRS/C546.

Video 2. Supplemental Digital Content 2 demonstrates the Mül-

ler muscle–conjunctival resection procedure. After completion of
upper blepharoplasty, the eyelid was everted and a marking suture
was placed through the conjunctiva and Müller muscle. The suture
was used to tent up tissue and facilitate Putterman clamp place-
ment. After the clamp was placed and locked, tissue beneath the
clamp was secured with suture in a simple continuous pattern. The
conjunctiva and Müller muscle were then resected, available in the
“Related Videos” section of the full-text article on PRSJournal.com or,
for Ovid users, at http://links.lww.com/PRS/C547.

Descriptive statistics were used to evaluate
baseline characteristics, with means and standard
deviations used for quantitative variables and
counts and percentages used for categorical vari-
ables. Linear mixed modeling was used to assess
differences in the primary outcome and cosmetic
outcomes over time. For models associated with
both outcomes, the observations were repre-
sented by patients’ eyes. Before considering the
cosmetic outcome satisfaction, evaluator agree-
ment was assessed using weighted kappa statistics,
and strong interrater agreement was observed

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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 141, Number 2 • Blepharoptosis Treatment Comparison

(κ = 0.75). Finally, the operative time was evalu- Table 1.  Baseline Characteristics of Study
ated using Kaplan-Meier curves and Cox propor- Participants with Aponeurotic Blepharoptosis
tional hazards regression. A value of p < 0.05 was ELA Group MMCR Group
considered statistically significant, and all analyses
Age, yr 62.3 ± 12.1 62.6 ± 9.9
were conducted using the R statistical package Female-to-male ratio 19:1 15:5
(R core team, version 3.3.2). VA, logMAR 0.3 ± 0.3 0.2 ± 0.2
MRD1, mm 1.2 ± 0.8 1.5 ± 0.7
MRD2, mm 5.8 ± 1.5 5.2 ± 1.1
RESULTS Levator function, mm 11.8 ± 3.0 12.7 ± 2.1
Eyelid crease height, mm 7.0 ± 3.0 6.0 ± 2.7
A total of 77 eyes from 40 subjects were ana- ELA, external levator advancement; MMCR, Müller muscle–conjunc-
lyzed, including 39 eyes/20 subjects in the leva- tival resection; VA, visual acuity; logMAR, log of the minimum angle
tor group and 38 eyes/20 subjects in the Müller of resolution; MRD, marginal reflex distance.
group. Of these, six were men and 34 were women,
with an average age of 62.4 years. Subject baseline
characteristics are summarized in Table 1.
The mean ± SD preoperative and postopera-
tive marginal reflex distance 1 was 1.2 ± 0.8 mm
and 3.0 ± 1.0 mm for the levator group and 1.5 ±
0.7 mm and 3.2 ± 1.0 mm for the Müller group
(Fig. 2). The mean marginal reflex distance 1
change difference between the levator and Mül-
ler groups was 0.008 (95 percent CI, −0.59 to
0.61; p = 0.978). The mean cosmetic outcome
by two evaluators was 2.69 ± 0.81 for the levator
group and 3.07 ± 0.68 for the Müller group and
was statistically different (mean difference, 0.373;
95 percent CI, 0.06 to 0.69; p = 0.020) (Fig. 3).
The mean ± SD Client Satisfaction Questionnaire
score was 3.36 ± 0.65 in the levator group and 3.63
± 0.35 in the Müller group (p = 0.30). The average
operating room time was 75 ± 19.2 minutes for
the levator group and 71 ± 23.6 minutes for the
Müller group. At any given time, the chance of
completion of an operation for the Müller group
was 1.28 times that of the levator group; however,
there was no significant difference in operating
room time between the groups (hazard ratio,
1.28; 95 percent CI, 0.68 to 2.4; p = 0.439) There Fig. 2. Box plot of marginal reflex distance 1 (MRD1) values. (Left)
were four eyes that underwent reoperation, three Preoperative Müller muscle–conjunctival resection (MMRC)
in the levator group (7.7 percent) and one in group. (Second from left) Postoperative Müller muscle–conjunc-
the Müller group (2.6 percent). In the levator tival resection group. (Second from right) Preoperative external
group, one was attributable to undercorrection levator advancement (ELA) group. (Right) Postoperative external
and two were attributable to unsatisfied eyelid levator advancement group.
crease height. In the Müller group, one reopera-
tion was attributable to undercorrection. Patients and two (10 percent) in the levator and Müller
with undercorrection underwent external leva- groups, respectively.
tor advancement 3 months after the first opera-
tion and were satisfied with the latter results.
Patients with unsatisfactory eyelid crease height DISCUSSION
underwent eyelid crease fixation surgery. There External levator advancement and Müller
were another four eyelid asymmetry subjects in muscle–conjunctival resection have both been
the levator group and one in the Müller group proven to be effective by previous studies for
who accepted the 1-mm difference, resulting in blepharoptosis correction. Operation success
denied reoperation. The total number of sub- rates ranged from 70 to 95 percent for external
jects with eyelid asymmetry was five (25 percent) levator advancement8–10 and 80 to 100 percent for

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 Plastic and Reconstructive Surgery • February 2018

Fig. 3. Preoperative and postoperative photographs of subjects who underwent bilateral upper blepharoplasty and external leva-
tor advancement (left) and Müller muscle–conjunctival resection (right).

Müller muscle–conjunctival resection.4,11,12 This is in severe ptosis correction. Surgical correction in

the first randomized controlled trial that shows
equally effective outcomes from external eleva-
tor advancement and Müller muscle–conjunctival
resection. All subjects included in the study were
eligible for Müller muscle–conjunctival resection.
They had mild to moderate blepharoptosis with
good levator function and positive phenyl-eph-
rine test results. In this group of patients, both
operations showed a good lifting effect, with a
lower reoperation rate compared with the previ-
ous article.4,8–13 From our observations, the Müller
muscle–conjunctival resection group had more
postoperative eyelid swelling and significantly
lower marginal reflex distance 1 at the first week
after surgery. Simultaneous cutaneous and con-
junctival incision created full-thickness eyelid lac-
eration and slower lymphatic drainage.
The cosmetic outcome by two independent
evaluators showed good agreement by the kappa
statistic. We found that the Müller group had a sta-
tistically significant better cosmetic outcome. The
previous case-control study showed good results
from both operations and also showed better eye-
lid contour, eyelid crease, and eyelid symmetry in
the Müller muscle–conjunctival resection group.13
However, external levator advancement was inten-
tionally chosen for more severe ptosis. Less pre-
dictability and poorer cosmetic result is ordinary
severe ptosis with horizontal eyelid laxity is usu-
ally more challenging, and the less-than-ideal cos-
metic outcome is usually acceptable in this group.
The subject satisfaction score by the Client Sat-
isfaction Questionnaire was high, and there was
no statistically significant difference between the
levator and Müller groups.
The Müller group showed a shorter operating
room time compared with the levator group, but
the result was not statistically significant by Kaplan-
Meier analysis. We intentionally chose operating
room time rather than the operative time, as it
reflects the true time invested in the procedure.
Previous studies experienced faster operative time
with the internal approach.14 However, the dura-
tion of the whole operating room time in our
study was confounded by many factors. In Müller
muscle–conjunctival resection, even though it is a
faster operation, intraoperative cold compression
to reduce bleeding before eye patching takes time.
Complete hemostasis is mandatory in Müller mus-
cle–conjunctival resection, as no cautery is applied
to the conjunctival surface. It is noteworthy that
blepharoplasty and skin closure in some cases
required more time for teaching purpose.
Reoperation rates were much higher in
the levator group. However, two of three eyes
that underwent reoperation did so because of

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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 141, Number 2 • Blepharoptosis Treatment Comparison
unsatisfactory eyelid crease height. One was a high
eyelid crease and the other was a faint medial eye-
lid crease. The rates of reoperation attributable to
undercorrection in the levator and Müller groups
were the same. Nevertheless, eyelid asymmetry
greater than or equal to 1 mm was higher in the
levator group. In East and Southeast Asian eyes,
marginal reflex distance 1 asymmetry, of even a
mild degree, is usually unacceptable. A previous
case-control study also showed a higher reop-
eration rate of 18 percent in the external levator
advancement group.13
Intraoperatively, we found three cases of leva-
tor aponeurosis disinsertion in the external levator
advancement group, and aponeurosis reattach-
ment was performed without any advancement
of the aponeurosis. All eyes with reattachment
showed excellent outcome, with no lagophthal-
mos. We would strongly prefer levator surgery in
this group of patients, but preoperative diagnosis
is difficult. Preservation of low eyelid crease is one
sign, as dermal extension of the aponeurosis is
usually intact. However, Müller muscle–conjunc-
tival resection was also shown to result in internal
levator advancement and might also reattach the
aponeurosis to the tarsus.15
Limitations of the study included neglect of
the effects of ptosis surgery on vision function-
ing and vision-related quality of life and a short
postoperative follow-up period. A sustained lift-
ing effect after 1 month of both external levator
advancement16 and Müller muscle–conjunctival
resection17 was proved previously; however, some
patients showed evidence of postoperative eyelid
swelling and ecchymosis at the 1-month follow-
up visit, and the marginal reflex distance 1 might
be slightly higher in this group of patients after
inflammation subsides. Further corrective surgery
was not required in any of the patients.
CONCLUSIONS
We conclude that external levator advance-
ment and Müller muscle–conjunctival resection
are both effective for correction of mild to mod-
erate ptosis. However, Müller muscle–conjunctival
resection yields a statistically significant better cos-
metic outcome and a lower reoperation rate and
produces less eyelid asymmetry.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Preamjit Saonanon, M.D.
1873, Rama 4 Road, Pathumwan
Bangkok10330, Thailand
psaonanon@gmail.com
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