Re: "Outcomes of Orbital Blow-Out Fracture Repair Performed Beyond 6 Weeks After Injury".

Ophthal Plast Reconstr Surg, Vol. 32, No. 3, 2016 237 To the Editor: Szamocki and Shah-Desai described a Mullerectomy procedure with skin crease preservation, which they advocated because of their good results and faster healing time, compared with a Mullerectomy with skin resection. When I first described the Muller muscle conjunctival resection ptosis procedure, it was also done without any skin excision or crease reconstruction. However, it became apparent that in most of my patients, this led to a lower crease and a greater skinfold that they found unacceptable, as it made one part of them look better by raising their upper eyelids and another part worse by increasing their skinfolds. (This was due to patients no longer having to raise their brows to compensate for their ptosis, as well as the advancement of the levator aponeurosis by the procedure that brought the levator orbicularis skin attachments lower.) Therefore, in selected patients, I began advocating removal of upper eyelid skin and reconstruction of the eyelid creases in addition to the Muller muscle conjunctival resection ptosis procedure. I found that I was able to determine candidates for this skin crease procedure by doing a preoperative phenylephrine test. By instilling several drops of 10% phenylephrine into the upper fornix, the patients were able to look at themselves in a mirror several minutes later and see what they would look like with a higher upper eyelid and the effect it had on increasing their skinfold. If they found this skinfold increase to be unacceptable, I would recommend a skin excision and crease reconstruction in addition to the Muller muscle conjunctival resection. I hope this additional information is helpful for surgeons considering the technique described by Dr. Szamocki.