Mullerectomy for Upper Eyelid Retraction in Graves' Orbitopathy

Conclusions: Muller’s muscle is a sympathetically innervated muscle that inserts upon the upper border of the superior tarsal plate and provides 2 mm of lift. Eyelid retraction is the most common eyelid abnormality in GO. Upper eyelid surgery involves lengthening or weakening of Muller’s muscle and/or the levator aponeurosis. The mullerectomy procedure has received little attention in the otolaryngology literature. Mullerectomy is a safe and effective procedure that has been shown to improve upper eyelid position, lagophthalmos, exposure keratopathy, and patient comfort. The failure rate is low and is most often due to undercorrection. Otolaryngologists should consider mullerectomy as an option for addressing upper eyelid retraction in GO. Mullerectomy was performed via a posterior conjunctival approach. Operative steps include: •Evert the upper eyelid to expose the superior palpebral conjunctiva (Figure 2). •Incise the conjunctiva at the superior tarsal border. •Dissect the conjunctiva from Muller’s muscle by raising a conjunctival flap (Figure 3). •Incise Muller’s muscle above the superior tarsal border. •Dissect Muller’s muscle from the levator aponeurosis (Figure 4). •Excise Muller’s muscle. •Close the conjunctival incision with absorbing sutures.