• Correction of acquired ptosis may be performed in a number of different ways.
• It is sometimes helpful to divide the surgical approaches into either an

1. internal approach (underneath/inside the eyelid)
2. external approach (via a skin incision)

• Both techniques have their advantages and disadvantages.
  

Internal Approach:

• The Müller's muscle-conjunctival resection procedure, first described in 1975 by Putterman and Urist (1) is a technique in which Müller's muscle in the upper eyelid is partially resected and advanced.
• It is used to treat upper eyelid ptosis and may be combined with an excision of upper eyelid excess skin, orbicularis oculi muscle, and herniated orbital fat with reconstruction of the upper eyelid crease (1,2).
• The Müller's muscle-conjunctival resection procedure is used in the treatment of blepharoptosis in patients whose upper eyelid elevates to a normal level when 10% phenylephrine drops are applied to their upper ocular fornix (the phenylephrine test).
• Candidates for this procedure usually have minimal congenital ptosis and varying degrees of acquired ptosis.
• If the eyelid elevates to a normal level with the phenylephrine test, 8.25 mm of Müller's muscle and conjunctiva are resected.
• If the upper eyelid elevates slightly higher, less Müller's muscle is resection is performed (6.25-8.00 mm), and if the upper eyelid rises slightly less, additional Müller's muscle (8.50-9.75 mm) resection is performed.
• The correlation between the phenylephrine test results and the amount of Müller's muscle resection was reported by Fett and Putterman (3)

External Approach:

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