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External Levator Advancement versus Müller Muscle–Conjunctival Resection for Aponeurotic Blepharoptosis: A Randomized Clinical Trial

Saonanon, Preamjit M.D.; Sithanon, Supapan M.D.

Plastic and Reconstructive Surgery: February 2018 - Volume 141 - Issue 2 - p 213e-219e
doi: 10.1097/PRS.0000000000004063
Cosmetic: Original Articles

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 resection. The primary outcome was marginal reflex distance 1 at 1 month after surgery. Secondary outcomes were cosmetic outcome, complications, and operating room time.

Results: Forty patients were enrolled, six men and 34 women, with an average 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 postoperative 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.


Bangkok, Thailand

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.

Disclosure:The authors have no financial interest to declare in relation to the content of this article.

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Preamjit Saonanon, M.D., 1873, Rama 4 Road, Pathumwan, Bangkok10330, Thailand,

Copyright © 2018 by the American Society of Plastic Surgeons