Re: "The Sutureless Mullerectomy".

Abstract

To the Editor: We are grateful to Drs. Homer, Huggins, and Nakra for their letter discussing our paper on Sutureless Mullerectomy. Dr. Homer et al. point out several criticisms which we would like to address. We agree that the efficacy of the sutureless Müller's muscleconjunctival resection would be better demonstrated in a series of ptosis patients without concurrent blepharoplasty. However, the reality is that most patients undergoing ptosis repair can also benefit from blepharoplasty, if for no other reason than to address the redundant skin created by the ptosis repair. Dr. Homer cites their own study that blepharoplasty alone is responsible for a 0.7 mm improvement in upper lid height. This may be an important finding. However, the sample size was small (19 patients), had a relatively short follow-up, and had its own confounder that about half the patients underwent concurrent lower blepharoplasty. A more recent study demonstrated only 0.19 mm improvement in lid height after blepharoplasty in a much larger cohort. And this improvement in lid height is generous when compared to results of other studies found in the literature. Homer et al. themselves cite such articles that demonstrate minimal or no improvement in lid height after blepharoplasty. Thus, their own study can hardly be considered a gold standard. Dr. Homer presumes that our technique was based on the report of sutureless Fasanella. While we acknowledged the potential corroboration of our technique with that of the sutureless Fasanella, we emphasize that the inspiration for our study came from our observation of the exuberant re-adherence of the tissues after recession for overcorrected Müller's muscleconjunctival resection as well as from the success of Müller's muscleconjunctival resection with fibrin glue. To the Editor: The authors read with interest Gildener-Leapman et al.’s article on sutureless mullerectomy. Gildener-Leapman et al. describe a modification to the traditional Putterman clampassisted mullerectomy, in which the isolated Müllers muscleconjunctival tissue is clamped, excised, and cauterized, without use of sutures. They report an average 1.4 mm improvement in MRD1 in 19 patients who underwent this procedure. The authors are enthusiastic about the practical evolution of oculoplastic procedures; however, the authors have several critiques of Gildener-Leapman et al.’s research methodology and surgical technique. First, the authors question the validity of the reported upper eyelid height improvement in the study. Previous reports have found an average margin reflex distance 1 (MRD1) improvement of 1.3–3.26 mm with the traditional mullerectomy. The authors have previously reported an average 0.7 mm MRD1 improvement with upper blepharoplasty alone. The authors noted that 15 of Gildener-Leapman et al.’s 19 patients in the current study underwent concurrent upper blepharoplasty. The lessons of the authors’ study suggest that a majority of GildenerLeapman et al.’s patients may have had <1 mm correction of blepharoptosis resulting directly from this modified procedure. The efficacy of this sutureless blepharoptosis procedure would be better evaluated by controlling for this substantial confounding simultaneous surgery by studying only patients undergoing isolated posterior ptosis repair. Second, the authors are concerned by Gildener-Leapman et al.’s hemostat application to the superior edge of the tarsus. While a hemostat is often similarly utilized during the Fasanella-Servat procedure to promote hemostasis, the compromised tarsus in these cases is subsequently excised. In GildenerLeapman et al.’s procedure, the Putterman clamp is placed at the superior tarsal border and then the hemostat clamps the underlying superior tarsal tissues, which is retained following conjunctiva-muellers muscle resection. The crush injury to the tarsus may affect tarsal structural integrity and meibomian gland functioning. Interestingly, the crush injury might lead to ischemic healing that would contract and perhaps contribute to ptosis correction. Simple histologic animal studies would demonstrate this possible alternative mechanism of ptosis correction using Gildener-Leapman et al.’s technique. Finally, to rationalize a modification of a well-proven technique, Gildener-Leapman et al. should demonstrate a clinically relevant benefit. Reports of the sutureless Fasanella-Servat procedure, which inspired this study, proved this technique to reduce the suture-related keratitis rates to 0 among GildenerLeapman et al.’s 50 patients. In contrast, Gildener-Leapman et al.’s patient cohort had a 5.3% rate of corneal abrasion, higher than that reported in the traditional mullerectomy procedure, ranging from 0% to 2.9%. The authors have found their own large private Oculoplastic surgery practice’s rate of corneal abrasions after traditional conjunctivo-muellerectomy to be far below Gildener-Leapman et al.’s cohort, further questioning the relevance of their technique. The authors could alternatively argue and demonstrate a decreased surgical time or cost to justify their modification. It may be possible that study design and patient cohort limitations may be masking the benefits of Gildener-Leapman et al.’s technique. Additional study is warranted to investigate the technique further. The authors offer Gildener-Leapman et Re: “The Sutureless Mullerectomy” al. the benefit of the doubt, and kindly welcome the response to their critique.