Original Investigation
Mueller’s Muscle Conjunctival Resection With Skin-Only Blepharoplasty: Effects on Eyelid and Eyebrow Position Grant H. Moore, M.D.*, Daniel B. Rootman, M.D.*, Justin Karlin, B.S.†, and Robert A. Goldberg, M.D.* *Jules Stein Eye Institute, UCLA, Los Angeles, California, U.S.A.; and †Tel Aviv University, Tel Aviv, Israel
Purpose: To determine the effect of concurrent blepharoplasty and Mueller’s muscle conjunctival resection (MMCR) surgery on eyelid position and eyebrow height. Methods: Clinical data from 274 eyes that met inclusion criteria for this study were reviewed. Mueller’s muscle conjunctival resection surgery was performed alone in 198 eyes and was performed with concurrent blepharoplasty in 76 cases. In this study blepharoplasty consisted of only skin removal, leaving the muscle, fat, and tarsus intact. Preoperative and postoperative pupil to eyebrow, and eyelid margin to eyebrow distances were calculated and compared. Results: Preoperative margin reflex distance 1 (MRD1) was similar for both groups of patients (p > 0.05) as was the postoperative MRD1 (p > 0.05). The change in MRD1 was similar between patients undergoing MMCR alone versus those undergoing MMCR with blepharoplasty (1.5 mm vs. 1.3 mm, respectively, p = 0.36). For similar amounts of tissue resection, the postoperative change in MRD1 was similar for patients undergoing MMCR-only surgery and MMCR with blepharoplasty (p > 0.05). Eyebrow height significantly decreased following both MMCR with blepharoplasty (0.73 mm, p < 0.05) and MMCRonly surgery (0.87 mm, p < 0.05), and this change in eyebrow height was not significantly different between the 2 groups. Conclusion: Combining MMCR surgery with skin-only blepharoplasty does not significantly alter eyelid height when compared with MMCR surgery alone for the correction of upper eyelid ptosis. This may assist in preoperative planning for combined MMCR with skin-only blepharoplasty. (Ophthal Plast Reconstr Surg 2015;31:290–292)
O
riginally described by Putterman and Urist,1 the Mueller’s muscle conjunctival resection (MMCR) has been conventionally used for the correction of mild to moderate upper eyelid ptosis in the setting of good levator function. Since its inception, MMCR surgery has routinely been performed concurrently with upper eyelid blepharoplasty for additional correction of dermatochalasis.1,2 Mueller’s muscle conjunctival resection requires diligent preoperative planning, as it does not typically allow for intraoperative adjustment. Several factors are considered in the determination of tissue resection length, including the preoperative eyelid position, the effect of phenylephrine instillation on eyelid position, and eyebrow compensatory position. Accepted for publication July 25, 2014. The authors disclose no financial or conflicts of interest. Address correspondence and reprint requests to Grant H. Moore, M.D., Jules Stein Eye Institute, UCLA, 100 Stein Plaza, Rm 2-267, Los Angeles, CA 90095. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000312
290
One additional factor in this determination is the effect of blepharoplasty in cases of combined MMCR with blepharoplasty. Brown and Putterman3 noted up to a 1-mm decrease in anticipated postoperative eyelid height among patients undergoing combined MMCR and blepharoplasty compared with those undergoing MMCR only. Their series involved patients undergoing MMCR with blepharoplasty that included muscle resection, fat removal, and eyelid crease reconstruction. In contrast, other studies have found no discrepancy in postoperative eyelid height among the 2 groups.4,5 The aim of the current study is to determine the effect on eyelid position and eyebrow height of MMCR surgery when combined with concurrent blepharoplasty.
METHODS A retrospective review of all patients undergoing MMCR for upper eyelid ptosis either with or without upper eyelid blepharoplasty between January 1, 2000 and June 1, 2013 was performed. The data retrieved included age, gender, type of surgery, tissue resection amount in millimeters, and pre- and postoperative photos. Patients with follow up ranging from 1 month to 1 year were included in the current study. This range was chosen to minimize the bracketing effects of postoperative swelling and long-term remodeling. Pre- and postoperative comparisons were made based on standard photographs obtained at each patient’s presurgical evaluation and most recent follow-up visit. For patients to be included in the current study, they must have undergone MMCR alone or concomitant MMCR and blepharoplasty, without any other concurrent surgery. Primary position photographs of sufficient quality at pre- and postoperative evaluations were also required for inclusion. Patients were excluded if they had a history of any previous eyelid or eyebrow surgery, botulinum toxin treatment within the last 5 months, or any condition that could influence eyelid position such as thyroid-associated orbitopathy, neurodegenerative disease, or neuromuscular dysfunction. Cases in which a tarsal resection was performed were also excluded. All surgeries were performed by 2 surgeons (R.A.G. and C.J.H.). This study complied with the policies and principles set forth by the University of California—Los Angeles Institutional Review Board. All measurements were made based on pre- and postoperative patient photographs. ImageJ software (U.S. National Institutes of Health, Bethesda, MD, U.S.A.) was used to make all photo measurements. In the current study, we used the average corneal diameter for women (11.64 mm) and men (11.77 mm), measured by Rüfer et al.,6 as a reference point to set the relative measurement scale in millimeters. Margin reflex distance 1 (MRD1) was measured from the center of the pupil to the eyelid margin. Similarly, pupil to eyebrow height was measured in a perpendicular plane from the center of the pupil to the lowest eyebrow hair present and, when possible, the same hair in postoperative photos. Pre and postoperative values were calculated for each of these measures. Four millimeters of Mueller’s muscle resection was performed for every 1 mm of desired upper eyelid elevation. If MMCR was
Ophthal Plast Reconstr Surg, Vol. 31, No. 4, 2015
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 4, 2015
Blepharoplasty With Ptosis Repair: Affects on Eyelid and Eyebrow
performed with concurrent blepharoplasty, the ptosis repair was performed after the skin flap was excised. Statistical analysis was performed with Statistical Package for the Social Sciences version 22.0 (SPSS Inc., Chicago, IL, U.S.A.).
RESULTS Two hundred seventy-four upper eyelids (99men, 175women) had MMCR surgery in the study period. Seventy-six eyelids underwent concomitant blepharoplasty. Demographic variables are summarized in Table 1. The amount of tissue resected during MMCR, preoperative MRD1, preoperative pupil-to-eyebrow distance, and preoperative levator function did not vary between the 2 surgical groups (p = 0.75) (Table 2). Following surgery, all patients experienced a significant increase in MRD1 (p < 0.05, paired sample t test), and this increase was not significantly different between the patients undergoing MMCR alone versus those undergoing MMCR with blepharoplasty (p = 0.36). In patients undergoing MMCR alone, MRD1 increased by an average of 1.5 mm (±1.1) (p < 0.001), and in patients undergoing MMCR with blepharoplasty, MRD1 increased by an average of 1.3 mm (±1.1) (p < 0.001) (Fig. 1). Similarly, when change in MRD1 was examined alongside the amount of tissue resected in MMCR, there were no significant differences in postoperative change in eyelid height between the 2 groups (p > 0.5, between groups analysis of variance), as shown in Fig. 2. For patients undergoing MMCR alone and MMCR with blepharoplasty, there was a significant decrease in mean pupil-to-eyebrow distance following surgery (Fig. 1). In patients undergoing MMCR alone, pupilto-eyebrow distance decreased significantly at an average of 0.87 mm (±2.6) (p < 0.001). In patients undergoing MMCR with blepharoplasty, pupil-to-eyebrow distance also decreased significantly at an average of 0.73 mm (±3.0) (p < 0.039). The change in pupil-to-eyebrow distance was not significantly different between the two groups (p = 0.65).
DISCUSSION The current study contrasts the previously reported finding that the performance of concurrent blepharoplasty TABLE 1. Patient demographics and follow-up time N = 274 Gender Eye
Men Women Right Left
Age Follow up (months)
MMCR
MMCR + blepharoplasty
Total
74 124 95 103 70.0 (±11.2)
25 51 37 39 69.4 (±6.6)
99 (36.1%) 175 (63.9%) 132 (48.2%) 142 (51.8%) 69.79 (±10.0)
3.8 (±2.1)
3.8 (±2.0)
3.8 (±2.1)
MMCR, Müller’s muscle conjunctival resection.
TABLE 2. Preoperative measurements and tissue resection amount
Levator excursion Preoperative MRD1 Preoperative pupil-to-eyebrow distance Tissue resected
MMCR (mm)
MMCR + blepharoplasty (mm)
p
13.8 (±1.8) 1.4 (±1.0)
14.3 (±2.7) 1.7 (±0.8)
0.23 0.06
17.4 (±4.8) 6.8 (±1.5)
17.4 (±4.8) 6.9 (±1.6)
0.95 0.75
MMCR, Mueller’s muscle conjunctival resection; MRD1, margin reflex distance 1.
with MMCR reduces anticipated postoperative eyelid height when compared with MMCR performed alone. This may be due to a difference in surgical technique. In Brown and Putterman’s3 original series, excess skin, orbicularis muscle, and fat were removed, and the upper eyelid crease was also reconstructed. These authors hypothesized that the decrease in MRD1 response was due to increased edema or increased intraeyelid scarring leading to restriction of eyelid elevation. In the current study, only skin was removed during blepharoplasty. In the context of the hypothesis developed by Brown and Putterman, skin-only blepharoplasty may create less tissue disruption and thus cause less edema and scarring, which subsequently leads to decreased restriction of upper eyelid elevation. The findings here support earlier work from this institution.5 Several studies have commented on the effect of blepharoplasty on eyebrow position, with some authors indicating that blepharoplasty leads to a decrease in eyebrow height and others indicating that blepharoplasty does not affect eyebrow height.7–11 This study does not support the contention that blepharoplasty specifically influences eyebrow height, as the change in eyebrow height did not differ between the 2 groups of MMCR patients assessed here. Lee et al.12 have examined the effect of ptosis surgery on eyebrow height. In a 60-patient study, pupil-to-eyebrow height was noted to be significantly lower postoperatively (–2.05 mm, p < 0.05) in patients undergoing external levator advancement, and this change was noted to be significantly larger than the postoperative change in pupil-to-eyebrow height for patients undergoing blepharoplasty. Notably, the change in postoperative pupil-to-eyebrow height was not significant for patients undergoing blepharoplasty. The authors found a similar significant overall decrease in central eyebrow height following MMCR alone or MMCR with blepharoplasty, but did not find a significant difference in postoperative eyebrow height change between the 2 surgical groups. Although the change in eyebrow height was statistically significant for both groups, the clinical significance of this finding is unclear, as both groups experienced a decrease in eyebrow height less than 1 mm postoperatively. In any case, the average eyebrow height did decrease postoperatively, and this finding is relevant to preoperative planning, given that a decrease in postoperative eyebrow height could lead to worsening of preexisting eyebrow ptosis or an improvement of eyebrow compensation occurring secondary to upper eyelid ptosis. Further subgroup analysis examining patients with varying postoperative changes in eyebrow height is subject to further investigation but is outside the scope of the current study. Measurements of MRD1 and pupil-to-eyebrow height were made based on a relative scale that used average central corneal diameter as a reference point, and this could be considered a limitation of this study. Although average corneal diameter is relatively constant throughout the population, individual variance does exist. Hence, for men with corneal diameters significantly larger or smaller than 11.77 mm and for women with corneal diameters varying from 11.64 mm, the subsequent measures defined by this scale may contain some error. Although as the distribution of corneal diameters in this population is expected to be normal despite adding some noise to the data, it should not affect the overall statistical conclusions. Another limitation of this study included the dynamic nature of eyebrows. Eyebrows change with grooming and subtle facial expression changes. These factors may influence some of the measurements, although again these changes should be normally distributed.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
291
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 4, 2015
G. H. Moore et al.
FIG. 1. Pre- and postoperative values for margin reflex distance 1 (mm) and pupil-to-eyebrow distance (mm) is shown via box plots. Margin reflex distance 1 increased significantly following surgery for both groups. Pupil-to-eyebrow distance decreased significantly following surgery for both groups.
FIG. 2. Change in margin reflex distance 1 (mm) according to tissue resection amount (mm) shown via box plots. The amount of tissue resected did not lead to a difference in postoperative margin reflex distance 1 change between the 2 groups.
In summary, the current study highlights 2 factors that may affect preoperative planning for surgeons performing MMCR for upper eyelid ptosis repair. Concomitant skin-only blepharoplasty likely does not lead to a decrease in the mean effect of surgery on MRD1. The current study also further elucidates the effect of MMCR on eyebrow position, showing that both MMCR with and without blepharoplasty have an overall mean effect of lowering eyebrow position postoperatively, both approximately equally.
REFERENCES 1. Putterman AM, Urist MJ. Müller muscle-conjunctiva resection. Technique for treatment of blepharoptosis. Arch Ophthalmol 1975;93:619–23. 2. Putterman AM, Urist MJ. Müller’s muscle-conjunctival resection ptosis procedure. Ophthalmic Surg 1978;9:27–32. 3. Brown MS, Putterman AM. The effect of upper blepharoplasty on eyelid position when performed concomitantly with Müller muscleconjunctival resection. Ophthal Plast Reconstr Surg 2000;16:94–100. 4. Ben Simon GJ, Lee S, Schwarcz RM, et al. External levator advancement vs Müller’s muscle-conjunctival resection for correction of upper eyelid involutional ptosis. Am J Ophthalmol 2005;140:426–32.
292
5. Ben Simon GJ, Lee S, Schwarcz RM, et al. Muller’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;9:413–7. 6. Rüfer F, Schröder A, Erb C. White-to-white corneal diameter: normal values in healthy humans obtained with the Orbscan II topography system. Cornea 2005;24:259–61. 7. Fagien S. Eyebrow analysis after blepharoplasty in patients with brow ptosis. Ophthal Plast Reconstr Surg 1992;8:210–4. 8. Flowers RS, Caputy GG, Flowers SS. The biomechanics of brow and frontalis function and its effect on blepharoplasty. Clin Plast Surg 1993;20:255–68. 9. Frankel AS, Kamer FM. The effect of blepharoplasty on eyebrow position. Arch Otolaryngol Head Neck Surg 1997;123:393–6. 10. Starck WJ, Griffin JE Jr, Epker BN. Objective evaluation of the eyelids and eyebrows after blepharoplasty. J Oral Maxillofac Surg 1996;54:297–302; discussion 302–3. 11. Troilius, C. A comparison between subgaleal and subperiosteal brow lifts. Plast Reconstr Surg 1999;104:1079–90; discussion 1091–2. 12. Lee JM, Lee TE, Lee H, et al. Change in brow position after upper blepharoplasty or levator advancement. J Craniofac Surg 2012;23:434–6.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Mueller’s Muscle Conjunctival Resection With Skin-Only Blepharoplasty: Effects on Eyelid and Eyebrow Position Grant H. Moore, M.D.*, Daniel B. Rootman, M.D.*, Justin Karlin, B.S.†, and Robert A. Goldberg, M.D.* *Jules Stein Eye Institute, UCLA, Los Angeles, California, U.S.A.; and †Tel Aviv University, Tel Aviv, Israel
Purpose: To determine the effect of concurrent blepharoplasty and Mueller’s muscle conjunctival resection (MMCR) surgery on eyelid position and eyebrow height. Methods: Clinical data from 274 eyes that met inclusion criteria for this study were reviewed. Mueller’s muscle conjunctival resection surgery was performed alone in 198 eyes and was performed with concurrent blepharoplasty in 76 cases. In this study blepharoplasty consisted of only skin removal, leaving the muscle, fat, and tarsus intact. Preoperative and postoperative pupil to eyebrow, and eyelid margin to eyebrow distances were calculated and compared. Results: Preoperative margin reflex distance 1 (MRD1) was similar for both groups of patients (p > 0.05) as was the postoperative MRD1 (p > 0.05). The change in MRD1 was similar between patients undergoing MMCR alone versus those undergoing MMCR with blepharoplasty (1.5 mm vs. 1.3 mm, respectively, p = 0.36). For similar amounts of tissue resection, the postoperative change in MRD1 was similar for patients undergoing MMCR-only surgery and MMCR with blepharoplasty (p > 0.05). Eyebrow height significantly decreased following both MMCR with blepharoplasty (0.73 mm, p < 0.05) and MMCRonly surgery (0.87 mm, p < 0.05), and this change in eyebrow height was not significantly different between the 2 groups. Conclusion: Combining MMCR surgery with skin-only blepharoplasty does not significantly alter eyelid height when compared with MMCR surgery alone for the correction of upper eyelid ptosis. This may assist in preoperative planning for combined MMCR with skin-only blepharoplasty. (Ophthal Plast Reconstr Surg 2015;31:290–292)
O
riginally described by Putterman and Urist,1 the Mueller’s muscle conjunctival resection (MMCR) has been conventionally used for the correction of mild to moderate upper eyelid ptosis in the setting of good levator function. Since its inception, MMCR surgery has routinely been performed concurrently with upper eyelid blepharoplasty for additional correction of dermatochalasis.1,2 Mueller’s muscle conjunctival resection requires diligent preoperative planning, as it does not typically allow for intraoperative adjustment. Several factors are considered in the determination of tissue resection length, including the preoperative eyelid position, the effect of phenylephrine instillation on eyelid position, and eyebrow compensatory position. Accepted for publication July 25, 2014. The authors disclose no financial or conflicts of interest. Address correspondence and reprint requests to Grant H. Moore, M.D., Jules Stein Eye Institute, UCLA, 100 Stein Plaza, Rm 2-267, Los Angeles, CA 90095. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000312
290
One additional factor in this determination is the effect of blepharoplasty in cases of combined MMCR with blepharoplasty. Brown and Putterman3 noted up to a 1-mm decrease in anticipated postoperative eyelid height among patients undergoing combined MMCR and blepharoplasty compared with those undergoing MMCR only. Their series involved patients undergoing MMCR with blepharoplasty that included muscle resection, fat removal, and eyelid crease reconstruction. In contrast, other studies have found no discrepancy in postoperative eyelid height among the 2 groups.4,5 The aim of the current study is to determine the effect on eyelid position and eyebrow height of MMCR surgery when combined with concurrent blepharoplasty.
METHODS A retrospective review of all patients undergoing MMCR for upper eyelid ptosis either with or without upper eyelid blepharoplasty between January 1, 2000 and June 1, 2013 was performed. The data retrieved included age, gender, type of surgery, tissue resection amount in millimeters, and pre- and postoperative photos. Patients with follow up ranging from 1 month to 1 year were included in the current study. This range was chosen to minimize the bracketing effects of postoperative swelling and long-term remodeling. Pre- and postoperative comparisons were made based on standard photographs obtained at each patient’s presurgical evaluation and most recent follow-up visit. For patients to be included in the current study, they must have undergone MMCR alone or concomitant MMCR and blepharoplasty, without any other concurrent surgery. Primary position photographs of sufficient quality at pre- and postoperative evaluations were also required for inclusion. Patients were excluded if they had a history of any previous eyelid or eyebrow surgery, botulinum toxin treatment within the last 5 months, or any condition that could influence eyelid position such as thyroid-associated orbitopathy, neurodegenerative disease, or neuromuscular dysfunction. Cases in which a tarsal resection was performed were also excluded. All surgeries were performed by 2 surgeons (R.A.G. and C.J.H.). This study complied with the policies and principles set forth by the University of California—Los Angeles Institutional Review Board. All measurements were made based on pre- and postoperative patient photographs. ImageJ software (U.S. National Institutes of Health, Bethesda, MD, U.S.A.) was used to make all photo measurements. In the current study, we used the average corneal diameter for women (11.64 mm) and men (11.77 mm), measured by Rüfer et al.,6 as a reference point to set the relative measurement scale in millimeters. Margin reflex distance 1 (MRD1) was measured from the center of the pupil to the eyelid margin. Similarly, pupil to eyebrow height was measured in a perpendicular plane from the center of the pupil to the lowest eyebrow hair present and, when possible, the same hair in postoperative photos. Pre and postoperative values were calculated for each of these measures. Four millimeters of Mueller’s muscle resection was performed for every 1 mm of desired upper eyelid elevation. If MMCR was
Ophthal Plast Reconstr Surg, Vol. 31, No. 4, 2015
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 4, 2015
Blepharoplasty With Ptosis Repair: Affects on Eyelid and Eyebrow
performed with concurrent blepharoplasty, the ptosis repair was performed after the skin flap was excised. Statistical analysis was performed with Statistical Package for the Social Sciences version 22.0 (SPSS Inc., Chicago, IL, U.S.A.).
RESULTS Two hundred seventy-four upper eyelids (99men, 175women) had MMCR surgery in the study period. Seventy-six eyelids underwent concomitant blepharoplasty. Demographic variables are summarized in Table 1. The amount of tissue resected during MMCR, preoperative MRD1, preoperative pupil-to-eyebrow distance, and preoperative levator function did not vary between the 2 surgical groups (p = 0.75) (Table 2). Following surgery, all patients experienced a significant increase in MRD1 (p < 0.05, paired sample t test), and this increase was not significantly different between the patients undergoing MMCR alone versus those undergoing MMCR with blepharoplasty (p = 0.36). In patients undergoing MMCR alone, MRD1 increased by an average of 1.5 mm (±1.1) (p < 0.001), and in patients undergoing MMCR with blepharoplasty, MRD1 increased by an average of 1.3 mm (±1.1) (p < 0.001) (Fig. 1). Similarly, when change in MRD1 was examined alongside the amount of tissue resected in MMCR, there were no significant differences in postoperative change in eyelid height between the 2 groups (p > 0.5, between groups analysis of variance), as shown in Fig. 2. For patients undergoing MMCR alone and MMCR with blepharoplasty, there was a significant decrease in mean pupil-to-eyebrow distance following surgery (Fig. 1). In patients undergoing MMCR alone, pupilto-eyebrow distance decreased significantly at an average of 0.87 mm (±2.6) (p < 0.001). In patients undergoing MMCR with blepharoplasty, pupil-to-eyebrow distance also decreased significantly at an average of 0.73 mm (±3.0) (p < 0.039). The change in pupil-to-eyebrow distance was not significantly different between the two groups (p = 0.65).
DISCUSSION The current study contrasts the previously reported finding that the performance of concurrent blepharoplasty TABLE 1. Patient demographics and follow-up time N = 274 Gender Eye
Men Women Right Left
Age Follow up (months)
MMCR
MMCR + blepharoplasty
Total
74 124 95 103 70.0 (±11.2)
25 51 37 39 69.4 (±6.6)
99 (36.1%) 175 (63.9%) 132 (48.2%) 142 (51.8%) 69.79 (±10.0)
3.8 (±2.1)
3.8 (±2.0)
3.8 (±2.1)
MMCR, Müller’s muscle conjunctival resection.
TABLE 2. Preoperative measurements and tissue resection amount
Levator excursion Preoperative MRD1 Preoperative pupil-to-eyebrow distance Tissue resected
MMCR (mm)
MMCR + blepharoplasty (mm)
p
13.8 (±1.8) 1.4 (±1.0)
14.3 (±2.7) 1.7 (±0.8)
0.23 0.06
17.4 (±4.8) 6.8 (±1.5)
17.4 (±4.8) 6.9 (±1.6)
0.95 0.75
MMCR, Mueller’s muscle conjunctival resection; MRD1, margin reflex distance 1.
with MMCR reduces anticipated postoperative eyelid height when compared with MMCR performed alone. This may be due to a difference in surgical technique. In Brown and Putterman’s3 original series, excess skin, orbicularis muscle, and fat were removed, and the upper eyelid crease was also reconstructed. These authors hypothesized that the decrease in MRD1 response was due to increased edema or increased intraeyelid scarring leading to restriction of eyelid elevation. In the current study, only skin was removed during blepharoplasty. In the context of the hypothesis developed by Brown and Putterman, skin-only blepharoplasty may create less tissue disruption and thus cause less edema and scarring, which subsequently leads to decreased restriction of upper eyelid elevation. The findings here support earlier work from this institution.5 Several studies have commented on the effect of blepharoplasty on eyebrow position, with some authors indicating that blepharoplasty leads to a decrease in eyebrow height and others indicating that blepharoplasty does not affect eyebrow height.7–11 This study does not support the contention that blepharoplasty specifically influences eyebrow height, as the change in eyebrow height did not differ between the 2 groups of MMCR patients assessed here. Lee et al.12 have examined the effect of ptosis surgery on eyebrow height. In a 60-patient study, pupil-to-eyebrow height was noted to be significantly lower postoperatively (–2.05 mm, p < 0.05) in patients undergoing external levator advancement, and this change was noted to be significantly larger than the postoperative change in pupil-to-eyebrow height for patients undergoing blepharoplasty. Notably, the change in postoperative pupil-to-eyebrow height was not significant for patients undergoing blepharoplasty. The authors found a similar significant overall decrease in central eyebrow height following MMCR alone or MMCR with blepharoplasty, but did not find a significant difference in postoperative eyebrow height change between the 2 surgical groups. Although the change in eyebrow height was statistically significant for both groups, the clinical significance of this finding is unclear, as both groups experienced a decrease in eyebrow height less than 1 mm postoperatively. In any case, the average eyebrow height did decrease postoperatively, and this finding is relevant to preoperative planning, given that a decrease in postoperative eyebrow height could lead to worsening of preexisting eyebrow ptosis or an improvement of eyebrow compensation occurring secondary to upper eyelid ptosis. Further subgroup analysis examining patients with varying postoperative changes in eyebrow height is subject to further investigation but is outside the scope of the current study. Measurements of MRD1 and pupil-to-eyebrow height were made based on a relative scale that used average central corneal diameter as a reference point, and this could be considered a limitation of this study. Although average corneal diameter is relatively constant throughout the population, individual variance does exist. Hence, for men with corneal diameters significantly larger or smaller than 11.77 mm and for women with corneal diameters varying from 11.64 mm, the subsequent measures defined by this scale may contain some error. Although as the distribution of corneal diameters in this population is expected to be normal despite adding some noise to the data, it should not affect the overall statistical conclusions. Another limitation of this study included the dynamic nature of eyebrows. Eyebrows change with grooming and subtle facial expression changes. These factors may influence some of the measurements, although again these changes should be normally distributed.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
291
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 4, 2015
G. H. Moore et al.
FIG. 1. Pre- and postoperative values for margin reflex distance 1 (mm) and pupil-to-eyebrow distance (mm) is shown via box plots. Margin reflex distance 1 increased significantly following surgery for both groups. Pupil-to-eyebrow distance decreased significantly following surgery for both groups.
FIG. 2. Change in margin reflex distance 1 (mm) according to tissue resection amount (mm) shown via box plots. The amount of tissue resected did not lead to a difference in postoperative margin reflex distance 1 change between the 2 groups.
In summary, the current study highlights 2 factors that may affect preoperative planning for surgeons performing MMCR for upper eyelid ptosis repair. Concomitant skin-only blepharoplasty likely does not lead to a decrease in the mean effect of surgery on MRD1. The current study also further elucidates the effect of MMCR on eyebrow position, showing that both MMCR with and without blepharoplasty have an overall mean effect of lowering eyebrow position postoperatively, both approximately equally.
REFERENCES 1. Putterman AM, Urist MJ. Müller muscle-conjunctiva resection. Technique for treatment of blepharoptosis. Arch Ophthalmol 1975;93:619–23. 2. Putterman AM, Urist MJ. Müller’s muscle-conjunctival resection ptosis procedure. Ophthalmic Surg 1978;9:27–32. 3. Brown MS, Putterman AM. The effect of upper blepharoplasty on eyelid position when performed concomitantly with Müller muscleconjunctival resection. Ophthal Plast Reconstr Surg 2000;16:94–100. 4. Ben Simon GJ, Lee S, Schwarcz RM, et al. External levator advancement vs Müller’s muscle-conjunctival resection for correction of upper eyelid involutional ptosis. Am J Ophthalmol 2005;140:426–32.
292
5. Ben Simon GJ, Lee S, Schwarcz RM, et al. Muller’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;9:413–7. 6. Rüfer F, Schröder A, Erb C. White-to-white corneal diameter: normal values in healthy humans obtained with the Orbscan II topography system. Cornea 2005;24:259–61. 7. Fagien S. Eyebrow analysis after blepharoplasty in patients with brow ptosis. Ophthal Plast Reconstr Surg 1992;8:210–4. 8. Flowers RS, Caputy GG, Flowers SS. The biomechanics of brow and frontalis function and its effect on blepharoplasty. Clin Plast Surg 1993;20:255–68. 9. Frankel AS, Kamer FM. The effect of blepharoplasty on eyebrow position. Arch Otolaryngol Head Neck Surg 1997;123:393–6. 10. Starck WJ, Griffin JE Jr, Epker BN. Objective evaluation of the eyelids and eyebrows after blepharoplasty. J Oral Maxillofac Surg 1996;54:297–302; discussion 302–3. 11. Troilius, C. A comparison between subgaleal and subperiosteal brow lifts. Plast Reconstr Surg 1999;104:1079–90; discussion 1091–2. 12. Lee JM, Lee TE, Lee H, et al. Change in brow position after upper blepharoplasty or levator advancement. J Craniofac Surg 2012;23:434–6.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
