Internal Ptosis Repair by Muller's Muscle Resection

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.