Internal Ptosis Repair by Muller's Muscle Resection
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Internal ptosis, characterized by an abnormal drooping of the upper eyelid, represents a significant functional and aesthetic concern that affects both visual field and facial appearance. This condition occurs when there is dysfunction or weakening of the eyelid elevator muscles, particularly the Müller's muscle, a sympathetically innervated smooth muscle that normally lifts the upper eyelid by about 2 mm.1,2 Ptosis may be congenital or acquired, with the latter resulting from age-related changes, trauma, neurological disorders, or mechanical factors.2
Correction of internal ptosis is warranted when the condition impairs the superior visual field or causes frontal muscle strain from compensatory brow elevation, which may lead to headaches. Additionally, the cosmetic impact of ptosis can significantly affect patients' quality of life and self-perception.3
Various surgical approaches have been developed for ptosis correction, including external levator advancement, frontalis sling procedures, and internal ptosis repairs.4,5 Among these, the Müller's muscle-conjunctival resection (MMCR) has gained popularity due to its several advantages. First described by Putterman and Urist in 1975, this technique has been improved over the years to become a reliable procedure for mild to moderate ptosis with good Müller's muscle function.6
The MMCR procedure offers several advantages, including a predictable outcome, preservation of the natural lid contour, absence of external scarring, and a relatively quick recovery period.7–10 The procedure is particularly effective in patients who demonstrate a positive response to phenylephrine testing, indicating good Müller's muscle function. One study has reported success rates of 90–97% with the MMCR technique, with most patients achieving satisfactory cosmetic and functional outcomes.11
Furthermore, the complication rate is relatively low compared to external approaches, with temporary dry eye symptoms being the most common postoperative complaint.12
This video describes the surgical technique of internal ptosis repair through Müller's muscle resection, emphasizing the key steps and considerations for successful outcomes.
The initial step involves identifying and marking the mid-pupillary line when the patient's gaze is straight ahead. This anatomical landmark serves as the reference point for optimal centration of the repair. A silk suture is then passed through the gray line of the eyelid at this marked point to create a traction suture. This suture is secured and used to evert the eyelid with the assistance of a lid retractor. The eversion exposes the palpebral conjunctiva overlying the tarsus, which must be navigated to access the underlying Müller's muscle.
The traction suture technique is essential for maintaining proper exposure throughout the procedure. The careful placement of the suture at the mid-pupillary line ensures symmetrical correction, which is critical for aesthetic outcomes.
Once the eyelid is everted, the palpebral conjunctiva is visualized, beneath which lies the Müller's muscle. The muscle layer is carefully teased away, and a plane of dissection is created between the Müller's muscle and the underlying levator aponeurosis.
After successful isolation, a Putterman clamp is used to secure approximately 8.5 millimeters of conjunctiva and Muller's muscle. This measurement is critical as it determines the degree of lid elevation that will be achieved. An alternative is to use a silk traction suture passed through the conjunctiva and Muller’s muscle, at a location superior to the tarsal border half way through the desired amount of isolation, to elevate these tissues to allow isolation in the Putterman clamp.
The resection is accomplished using a double-armed suture that is passed through the clamped tissue multiple times, effectively isolating the section to be removed. The redundant tissue within the clamp is then excised using a 15 blade, with careful attention to maintaining the integrity of the underlying structures.
After the clamped tissue is excised, cut edges of conjunctiva are observed both inferiorly and superiorly. Closure of this defect is essential for maintaining conjunctival surface integrity and preventing postoperative complications, including foreign body sensation and exposure keratopathy.
The closure is achieved using the previously placed sutures, bringing the edges together with minimal tension. A key technical point demonstrated in the video is the passage of the suture laterally through the conjunctiva to exit within the wound. This maneuver allows the knot to be buried beneath the conjunctiva when the suture ends are tied together, thereby preventing corneal abrasion that might occur if the knot were exposed on the conjunctival surface.
The traction suture is then released, allowing the eyelid to return to its normal position. The careful closure technique minimizes postoperative discomfort and speeds healing, with most patients experiencing minimal to moderate conjunctival injection and edema that resolves within 1–2 weeks.
This instructional video on internal ptosis repair through Müller's muscle resection demonstrates a refined surgical technique for correcting mild to moderate ptosis in patients with good Müller's muscle function. It is particularly valuable for ophthalmology residents, oculoplastic surgery fellows, and practicing surgeons. By clearly illustrating the key steps—eyelid eversion with a precisely placed traction suture, careful isolation of the Müller's muscle, precise shortening of the muscle by a measured amount, and closure of the conjunctival defect—the video provides a comprehensive educational resource.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- Beard C. Muller’s superior tarsal muscle: anatomy, physiology, and clinical significance. Ann Plast Surg. 1985;14(4). doi:10.1097/00000637-198504000-00005.
- Finsterer J. Ptosis: causes, presentation, and management. Aesthetic Plast Surg. 2003;27(3). doi:10.1007/s00266-003-0127-5.
- Richards HS, Jenkinson E, White P, Harrad RA. Patient reported psychosocial functioning following successful ptosis surgery. Eye (Basingstoke). 2022;36(8). doi:10.1038/s41433-021-01685-w.
- Bacharach J, Lee WW, Harrison AR, Freddo TF. A review of acquired blepharoptosis: prevalence, diagnosis, and current treatment options. Eye (Basingstoke). 2021;35(9). doi:10.1038/s41433-021-01547-5.
- Hanif F, Tahir H, Beg MSA. Ptosis correction: our modification and experience. Cureus. Published online 2022. doi:10.7759/cureus.26823.
- Putterman AM, Urist MJ. Müller muscle-conjunctiva resection: technique for treatment of blepharoptosis. Arch Ophthalmol. 1975;93(8). doi:10.1001/archopht.1975.01010020595007.
- Sajja K, Putterman AM. Müller’s muscle conjunctival resection ptosis repair in the aesthetic patient. Saudi J Ophthalmol. 2011;25(1). doi:10.1016/j.sjopt.2010.10.011.
- Chen HJ, Wang CY, Huang YF, Wu YC, Wei LC. Effect of Muller’s muscle-conjunctival resection on the upper eyelid crease position in Asian eyelids: a retrospective cohort study. BMC Ophthalmol. 2022;22(1). doi:10.1186/s12886-022-02605-6.
- Danesh J, Ugradar S, Goldberg R, Rootman DB. A novel technique for the measurement of eyelid contour to compare outcomes following Muller’s muscle-conjunctival resection and external levator resection surgery. Eye (Basingstoke). 2018;32(9). doi:10.1038/s41433-018-0105-4.
- Karam M, Alsaif A, Abul A, et al. Muller’s muscle conjunctival resection versus external levator advancement for ptosis repair: systematic review and meta-analysis. Int Ophthalmol. 2023;43(7). doi:10.1007/s10792-023-02633-1.
- Sweeney AR, Dermarkarian CR, Williams KJ, Allen RC, Yen MT. Outcomes after Müller muscle conjunctival resection versus external levator advancement in severe involutional blepharoptosis. Am J Ophthalmol. 2020;217. doi:10.1016/j.ajo.2020.04.039.
- The results of Muller muscle conjunctival resection versus levator advancement for mild to moderate ptosis. Rom J Ophthalmol. 2023;67(2). doi:10.22336/rjo.2023.23.
Cite this article
Lee J. Internal ptosis repair by Muller's muscle resection. J Med Insight. 2025;2025(514). doi:10.24296/jomi/514.
Procedure Outline
Table of Contents
Transcription
CHAPTER 1
Hi, my name is John Lee. I'm the oculoplastic surgeon at Boston Vision. And you're gonna see me perform an internal ptosis repair, or otherwise known as a Muller's muscle resection. We will evert the lid, isolate the Muller's muscle, shorten it, and close the resultant conjunctival defect.
CHAPTER 2
Do you feel me pinching you at all? Yeah. Does it hurt? Doesn't hurt. Do you feel anything sharp? No. Good. Start with the silk. So I wanna start the internal ptosis repair. We've marked the surgical marker where his mid-pupillary line is when his gaze is straight ahead. We use a silk suture as traction here. We go through the gray line centered right around that mid-pupillary line mark. Needle off. Right here. Mm-hmm. We'll secure that, and we'll take a Desmarres vein retractor, and evert the lid using that traction suture. This exposes the palpebral conjunctiva overlying the tarsus, and the palpebral conjunctiva.
CHAPTER 3
And just below that is the Muller's muscle, which is what we want, so we're gonna tease away that Muller's muscle. The next structure next to it is the levator aponeurosis and levator muscle. So now, we have some space there. We'll take a Putterman clamp. And we're gonna isolate approximately eight and a half millimeters of this conjunctiva and Muller's muscle. Which we have now, you can see isolated within that clamp.
CHAPTER 4
Can you give me some traction inferiorly? I'll hold that first. Can you get me the plain gut double-armed, or single-armed? And we're gonna use this suture to isolate the clamped tissue, and then bring the inferior edge of that Muller's muscle, and attach it to an area eight and a half millimeters superiorly. So in essence, we're gonna shorten that Muller's muscle by eight and a half millimeters, the amount that's within that clamp. So we're gonna pass the suture back and forth. To isolate the clamp material and shorten the Muller's muscle by about eight and a half millimeters. Set that aside, make sure we don't have any slack, 15 blade. Now we're gonna excise the clamped tissue by running a blade just underneath the clamp. Clamped tissue is discarded.
CHAPTER 5
And we're gonna use the Desmarres retractor again to give us better access, better view, to those cut edges. Gauze to you. Mm-hmm. So you can see the cut edges inferiorly, and superiorly of the conjunctiva. I'll lead my head out to the left a bit here. So now, we have a mostly-closed conjunctiva wound. And to finish off that suture, we will pass very far laterally through the conjunctiva to exit in the wound. That way, when we tie these two loose ends together, the knot will end up buried within the wound under the conjunctiva so it does - not to abrade the cornea. Scissors to me. And cut one of these to release the traction suture, and come on out. And we're all done.
CHAPTER 6
In this case, the patient had quite a mobile and flexible upper eyelid, which was easily everted. This allowed us to isolate a significant amount of Muller's muscle. In the preoperative evaluation, we had to determine if the Muller's muscle was active enough, so we put him through a phenylephrine eye drop test to which he responded quite briskly. If he had not responded to the phenylephrine, we would've proceeded with an external or levator advancement surgery. In that case, we would've gone through the skin, isolated the levator muscle to give him a better eyelid position.