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Vol 2 | Issue 1 | Pages 7-12

Journal of Ophthalmic Surgery
Research Article

Ptosis Surgery with an Improved Method of Shortening
the Müller’s Muscle and the Levator Aponeurosis withTransconjunctival Threading
Kosuke Ogasawara*
Medical Corporation, Ogasawara Eye Clinic, Japan

Abstract
Purpose: To report an improved method of operative treatment for ptosis wherein shortening of the Müller’s muscle
and the levator aponeurosis could be performed with transconjunctival threading without making an incision in the tarsal
muscle.
Methods: 1) After ophthalmic anesthesia administration, the tarsus was pinched so that the tip of fixation forceps wasapproximately 5 mm from the eyelid, and the tarsus was reversed. 2) A small dose of local anesthesia (1% lidocaine) was
administered at a site approximately 5 mm from the tip of the pinched forceps, and a high-frequency scalpel was used tomake an incision approximately 5 mm wide in the conjunctiva. 3) A 7-0 nylon double-armed thread was passed throughthe Müller’s muscle on the tarsal side (approximately 3 mm from the eyelid margin) under direct vision. Furthermore,from the tarsal side, the thread was passed through the intra-tarsal layer (approximately 5 mm from the insertion pointof the needle) and subsequently, rethreading was performed through the incision point of the tarsus to the conjunctival
fornix. 4) At that site, the thread was passed from a site superior to the Müller’s muscle in a direction traversing thelevator aponeurosis, and suturing was performed. 5) After confirming the eyelid elevation was good and symmetrical,
bonding of the site of the conjunctival incision was performed with coagulation.
Results: The present procedure was performed in 17 patients with age-related ptosis. Postoperatively, satisfactory
aesthetic results were achieved in all cases. No particular complications were observed, and there was no case ofovercorrection or incomplete eyelid closure. Mean operative time was 11 minutes.
Conclusion: When the present procedure was used, the operative duration was shortened, patient burden was reduced,
and expansion of the indication range of age-related ptosis could be achieved, suggesting that the present operative
method may be a preferred method for initial surgery in age-related ptosis.

Keywords
Ptosis surgery, Transconjunctival threading, Müller’s muscle, Levator aponeurosis

Introduction

Subjects and Surgical Techniques

Along with the increase in the elderly population, thenumber of patients with age-related ptosis is also on the rise.
Various surgical procedures for treatment of ptosis have beenpreviously designed and reported [1]. The transconjunctival
method places little burden on patients compared withtranscutaneous ptosis surgery and involves low surgicalinvasiveness; thus, it is a simple surgical method to perform inelderly patients. In 2006, we devised and presented a method
to achieve a shortening effect of the levator palpebrae
superioris and tarsal muscles by suturing the Müller’s muscle
and the levator aponeurosis to the tarsus without incision
or excision of the tarsal muscle [2]. Subsequently, we have
improved the procedure to increase efficacy and expand theindicated cases. Here the new procedure and its efficacy inelderly patients have been reported.

Subjects
Age-related ptosis was diagnosed in 17 patients (men:*Corresponding author: Kosuke Ogasawara, M.D., Ph.D, Medical Corporation, Ogasawara Eye Clinic, 3-10-12, Takamatsu,
Morioka, 020-0114, Japan, Tel: +81-19-(662)-3223, Fax: +81-19(662)-7331
Accepted: January 29, 2019
Published online: January 31, 2019
Citation: Ogasawara K (2019) Ptosis Surgery with an Improved
Method of Shortening the Müller’s Muscle and the Levator
Aponeurosis with Transconjunctival Threading. J Ophthalmic
Surg 2(1):7-12

Copyright: © 2019 Ogasawara K. This is an open-access article distributed under the terms of
the Creative Commons Attribution License, which permits unrestricted use, distribution, andreproduction in any medium, provided the original author and source are credited.

Scholarly Pages

Open Access | Page 7 |Citation: Ogasawara K (2019) Ptosis Surgery with an Improved Method of Shortening the Müller’s Muscle and the Levator Aponeurosis withTransconjunctival Threading. J Ophthalmic Surg 2(1):7-12

A

A

B

B

Figure 1: A) A small dose of local anesthesia (1% lidocaine notcontaining sympathomimetic drug approximately 0.5 ml) was
administered from the conjunctival fornix; B) The tarsus was
pinched by using fixation forceps (INAMI® S-361) so that the tipof the fixation forceps came approximately 5 mm from the eyelid,
and the tarsus was reversed.

7 eyes of 5 patients; women: 22 eyes of 12 patients) with amean age of 72.3 (54-83) years. The degree of ptosis in thepatients was moderate; the margin reflex distance was 0-3mm, and the levator muscle function was 5-8 mm. The resultsof phenylephrine testing were positive for nine patients andnegative for eight patients. Preoperatively, we examined thepast medical history of the ptosis patients and confirmed that
ptosis was not congenital; neurological examinations showed
no brain abnormality, and the condition was not neurogenic.
Written informed consent was obtained from all thesubjects. The study was conducted as per the tenets of the
Declaration of Helsinki and with the approval of the medical
corporation of Ogasawara Eye Clinic’s ethical review board.

Surgical techniques•

Step 1 (Figure 1)

After ophthalmic anesthesia administration, the upper
eyelid was rotated, and a small dose of local anesthesia(1% lidocaine not containing a sympathomimetic drug;
approximately 0.5 mL) was administered from the conjunctival
fornix. The tarsus was pinched using fixation forceps (INAMI®
S-361) so that the tip of the fixation forceps was approximately
5 mm from the eyelid, and the tarsus was reversed.

•

Step 2 (Figure 2)

Ogasawara. J Ophthalmic Surg 2019, 2(1):7-12

C

Figure 2: A) A small dose of local anesthesia (1% lidocaine notcontaining sympathomimetic drug) was administered with caretaken not to damage Müller's muscle; B) Marking incision pointat the conjunctiva 5 mm from the edge of the pinched forceps;C) A high frequency scalpel (ellman® Surgitoron DualEMC90) wasused to make an incision as marking line approximately 5 mm in
the conjunctiva.

A small dose of local anesthesia (1% lidocaine) was
administered at a site approximately 5 mm from the tip of
the pinched forceps, with care taken not to damage the
Müller’s muscle. Thereafter, an approximately 5-mm wide
incision was made in the conjunctiva using a high-frequency
scalpel (ellman® Surgitoron DualEMC90). Use of scissors is
acceptable for making the incision in the conjunctiva.

•

Step 3 (Figure 3)

A 7-0 nylon thread (MANI® 3365, double-armed suture)
was passed through the Müller’s muscle on the tarsal side
(approximately 3 mm from the eyelid margin) under direct
vision. Furthermore, from the tarsal side, the thread wasOpen Access | Page 8 |Citation: Ogasawara K (2019) Ptosis Surgery with an Improved Method of Shortening the Müller’s Muscle and the Levator Aponeurosis withTransconjunctival Threading. J Ophthalmic Surg 2(1):7-12

A

B

C

D

Figure 3: A) A 7-0 nylon thread (MANI® 3365, double armed suture) was passed through Müller’s muscle and levator aponeurosis on
the tarsal side, approximately 3 mm from the eyelid margin; B) under direct vision; C) From the tarsal side, the thread was passed
through the intra-tarsal layer (approximately 5 mm from the insert point of the needle), and passed it through again on the tarsal side;D) Subsequently rethreading were reformed through the incision in the conjunctival fornix.

A

B

C

D

E

F

Figure 4: A) Finding after rethreading in the conjunctival fornix; B,C) The each thread was passed from superior to Müller’s muscle ina direction traversing the levator aponeurosis; D) Suturing was performed; E) Cutting the suture; F) Bonding of the site of conjunctival
incision was performed by coagulation.

passed through the intra-tarsal layer (approximately 5 mmfrom the insertion point of the needle) and passed throughOgasawara. J Ophthalmic Surg 2019, 2(1):7-12

again on the tarsal side; subsequently, we performed
rethreading through the incision in the conjunctival fornix.
Open Access | Page 9 |Citation: Ogasawara K (2019) Ptosis Surgery with an Improved Method of Shortening the Müller’s Muscle and the Levator Aponeurosis withTransconjunctival Threading. J Ophthalmic Surg 2(1):7-12

•

A
3mm
CJ
5mm

TarsusLA

At that site, the double-armed thread was passed from apoint superior to the Müller’s muscle in a direction traversing
the levator aponeurosis, and suturing was performed. Afterconfirming the eyelid elevation to be good as expected, thesuture was then cut and bonding of the site of the conjunctival
incision was performed with coagulation. To make symmetry
in both unilateral and bilateral ptosis, control of suturetightness was performed in all cases. Mean operative time inthis surgery was 11 minutes. A schematic illustration of thepresent procedures for a sagittal view was showed in Figure
5.
Postoperatively, antibiotic and anti-inflammatory (steroid)
ophthalmic eye solutions were administered four times a day
for 1 week.

MM

Forceps

Step 4 (Figure 4)

Results

B

Follow-up observation was performed for ≥ 3 months,
and satisfactory eyelid elevation effect was achieved in all
17 patients. On postoperative day 1, mild subcutaneous
hemorrhage was observed in one eye, and three patientscomplained of swelling of the upper eyelid several days
postoperatively; however, the swelling disappeared within
1 week following treatment with an ophthalmic solution.
There was no case of postoperative development of a corneal
disorder. Moreover, there were no cases of postoperative

LA
MM

A
C

CJ
LA

MM

sutureB

Figure 5: A) After incision in the conjunctiva (CJ) approximately 5mm from the edge of the pinched forceps, 7-0 nylon thread waspassed through Müller’s muscle (MM) and levator aponeurosis(LA) on the tarsal side 3 mm from the eyelid margin.
B) From the tarsal side, the thread was passed through the intratarsal layer (approximately 5 mm from the insert point of theneedle), and passed it through again on the tarsal side. Afterthen rethreading was performed through the incision in the
conjunctival fornix.
C) Finding after finishing the surgery using the present method.
Conjunctival incision was bonding by coagulation. Suture wasplaced in a point superior to Müller’s muscle (MM) in a direction
traversing the levator aponeurosis (LA).

Ogasawara. J Ophthalmic Surg 2019, 2(1):7-12

Figure 6: A 82-year-old man with aquired bilateral blepharoptosis
with phenylephrine testing negative. A) Preoperative and; B)
postoperative three months after surgery.
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Citation: Ogasawara K (2019) Ptosis Surgery with an Improved Method of Shortening the Müller’s Muscle and the Levator Aponeurosis withTransconjunctival Threading. J Ophthalmic Surg 2(1):7-12

entropion or ectropion and incomplete eyelid closure due toovercorrection.
Here we have presented two representative cases among
those in whom the procedure was performed (Figure 6 andFigure 7).

Discussion
The Müller’s muscle and levator aponeurosis shortening
using transconjunctival threading reported in the present
study appear to be effective for common age-related ptosis
and may exert the same effect as percutaneous upper
eyelid muscle tucking. The reasons for the success of the
improved surgical method are as follows: After making asmall conjunctival incision, a 7-0 nylon thread was passed
through the Müller’s muscle from the tarsal side under direct
vision, and the threading distance on the tarsal side wasapproximately 5 mm inside; moreover, after rethreading into
the incision of the conjunctival fornix, the eyelid lift force wasincreased by threading from a point superior to the Müller’smuscle in a direction traversing the levator aponeurosis.
However, this method is not indicated in cases ofcongenital ptosis or ptosis with complete loss of function of
the levator palpebrae superioris.
Although there was a risk for scratching of the cornea
due to exposure of the thread at the point of the threadingneedle during threading on the tarsal surface, the suture wasA

B

Figure 7: A 71-year-old woman with aquired bilateral blepharoptosis with phenylephrine testing positive. A) Preoperative and;B) Postoperative three months after surgery.
Ogasawara. J Ophthalmic Surg 2019, 2(1):7-12

firmly embedded in the tarsus during threading (Figure 8A),
and there were no complications. It may also be favorable
to slightly widen the point of insertion of the thread needle
using the tip of the 27-gauge hypodermic needle (Figure 8B)
to prevent thread exposure.
The benefits of transconjunctival ptosis correction surgery
include a short surgery time, minimal invasiveness, reduced
postoperative pain, fewer postoperative complications, andearly social reintegration in elderly patients. Furthermore,
simultaneous bilateral surgery of both the eyes is possible.
Moreover, the method is advantageous in terms of little
impact on the double eyelid fold and no complications suchas incomplete eyelid closure due to overcorrection.
The Fasanella-Servat method [3] and the Putterman-Urist
method [4] are the most popular transconjunctival methods;
however, in both the procedures, the greater degree of surgicalinvasiveness is a disadvantage. Methods of remedying thesedrawbacks have also been attempted [5,6] and Shimizu, etal. [6] have reported an excellent method to simultaneously
create a double eyelid fold after transconjunctivally burying
the nylon thread in the eyelid and performing fixation of thelevator aponeurosis to the tarsus. However, this procedure isslightly complex and involves limitations regarding the degreeof ptosis and age-related indications. The surgical procedurereported in the present study may be comparable to levator
palpebrae superioris muscle shortening in terms of the tucking

A

B

Figure 8: A) The finding showing the thread was firmly
embedded in the tarsus one month after surgery; B) Showing
widen the insertion point of the threading needle by the tip ofthe 27-guage hypodermic needle.
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Citation: Ogasawara K (2019) Ptosis Surgery with an Improved Method of Shortening the Müller’s Muscle and the Levator Aponeurosis withTransconjunctival Threading. J Ophthalmic Surg 2(1):7-12

AB

this method. Basic physiological [7] and clinical [8] studies
have demonstrated that the Müller’s muscle functions as astretch receptor and is the primary inclusion that transmits
the contraction of the levator palpebrae superioris muscle
to the tarsal plate. Furthermore, contraction of the Müller’smuscle transmits afferent input to the mesencephalic nucleusof the trigeminal nerve [7]. Therefore, it is suggested thatin the present method, due to the traction of the levator
aponeurosis, the levator palpebrae superioris muscle itself
may be rotated anteriorly to obtain elevation of the upper
eyelid, and the tension of the Müller’s muscle causes a
proprioception effect on the levator palpebrae superioris
muscle. Several studies [9,10] have demonstrated that thesurgical effect of shortening the Müller’s muscle can beachieved in phenylephrine test-negative patients as wellsimilar to that observed in phenylephrine test-positive
patients. These findings are supported by the efficacy ofthe surgical method observed in the present study and its
mechanism of success.

Disclosure
The author reports no conflicts of interest in this work.

References
1. Anthony Tyers, JRO Collin (2008) Color atlas of ophthalmic
plastic surgery. Elsevier, Japan, 170-213.
Figure 9: A 87-year-old woman with aquired bilateral blepharoptosis and coexistent blepharochalasis. A) Preoperative and; B)
postoperative six months after surgery in which skin resectionof the upper eyelid was additionally performed simultaneously.

effect of the Müller’s muscle and levator aponeurosis; further,
it is possible to control the extent of its effects by changing
the threading site after conjunctival incision. Although followup observation is necessary for the long-term postoperative
course of this method, it is considered superior in termsof its short operative duration; less patient burden such as
postoperative pain; and no observations of intraoperative
hemorrhage and postoperative overcorrection, entropion,and ectropion. Moreover, in case of patients with coexistent
blepharochalasis, skin resection of the upper eyelid can beadditionally performed simultaneously (Figure 9), and if thecorrection effect is insufficient, the method can be converted
to another surgical procedure.
The above results suggest that the present procedure
may be a favorable method for initial surgery in age-related
and adult ptosis. Regarding the mechanism of success of
this surgical procedure, in the conventional percutaneous
levator palpebrae superioris tucking method, the tarsal
muscle is shortened in a folding form, whereas in the present
method, the force performing traction from the tendon partof the tarsal muscle works more strongly, thus, enhancing
the function of the levator palpebrae superioris muscle; thisappears to be the most important factor in the success of

Ogasawara. J Ophthalmic Surg 2019, 2(1):7-12

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