Sir,

We thank Madhusudhan et al for their interest in our paper entitled ‘Isolated Muller resection’ and would like to take the opportunity to respond to the comments raised.

Although the Muller muscle is the tissue of interest in both techniques, there is a fundamental difference to account for advantages, described in our paper.

Like Putterman's, Chandra's technique, a minor modification of Dortzbach's paper published in 1979,1 does not allow perioperative adjustment and depends on the use of a nomograms. In our experience with more than 300 Muller muscle resection performed over the last 5 years, in different degree of eyelid ptosis severity, one does not always find correlation between the degree of eyelid ptosis and the amount of Muller muscle resected to achieve the desired effect. Moreover, the result of phenylephrine test does not always correlates with the outcome of Muller resection.2 Intraoperative adjustment therefore opens the opportunity to be able to use the technique in more severe degree of eyelid ptosis.

Similarly, in their technique, there is no opportunity for postoperative adjustment as the sutures do not exit through the skin. We feel that the timed removal of skin sutures offer great advantage over anterior levator resection as well as Putterman's and Chandra's techniques. Another advantage of external suture is the precise placement and augmentation of skin crease as well as pleasing lash eversion often desired in correction of lash ptosis, when present.

In our experience, resecting the whole width of Muller muscle has never led to damage of the lacrimal gland ductules as we do not extend our incision too far laterally into lacrimal gland ductules. We, therefore, do not see any advantage in using only the central part of the muscle, which might deny us the correction of severe medial droop seen in some advanced cases, as well as adding another surgical step.

Like minimal incision anterior approach, we have tried to perform Muller resection using only one central suture.

The lack of opportunity to correct the medial droop has let us to abandon this in favour of resection of whole width using three sutures as described in our technique.