Internal Ptosis Repair by Muller's Muscle Resection

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.