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Hi, I'm Dr. John Martin. In this segment, I'm going to show you how I do a ptosis repair through an internal approach. There are two main muscles for elevating the eyelid; one is the levator, which is on the outside, and the other is the Müller's muscle, which is on the inside.

So, in this surgery, I evert the lid so that I have access to the Müller's muscle. Then, I'll take a little piece of that Müller's muscle plus the overlying conjunctiva, I will shorten the Müller's muscle, and this will help to elevate the lid.

Okay, so this is for a Müller's muscle-conjunctival resection, and what we'll do is do a supraorbital block. So, feel for the notch, the supraorbital notch, just go to the side of that. Just scoot down right along the orbital rim, which you can feel. Put in about 1.5 to 2 cc for your local. What we're going to do is evert the lid over a Desmarres retractor.
Sometimes it's very, very tight. Just hold it there for a minute. What we'll do is mark the upper border of the tarsus, and I'll take an [inaudible 00:01:36], and what I'm going to do is just pull on the conjunctiva-Müller's muscle to separate it from the underlying levator.

Then I set my caliper at nine for this side. What we'll do is hold this near the border of the tarsus. Make a mark down here at nine millimeters, because this is how much I want to take off my hood with my müllerectomy clamp. Some people will put a suture through here to help tent up this area. Put a clamp on our lower marks, grab our upper marks. Lock the clamp, and we now have our nine millimeters of conjunctiva-Müller's muscle enclosed in the clamp. Then I'm going to take a double-armed 6-0 plain suture and run it along down and through here. You can either start going through the skin, I actually just start under here and will bury my knot. So I start temporally. Let me get the suture. And just run it a little bit, maybe about a millimeter underneath your clamp. [inaudible 00:04:14] little sleep apnea. [inaudible 00:04:17] good.

Okay, so we've come all the way across the clamp, now we'll take a 15 blade. Run it right along the underside of the clamp, which'll excise my tissue. If you have some bleeding, you can cauterize. Just be careful, because the cautery can unfortunately rip your sutures, so you have to be judicious in your use of cautery here.

Now what I'll do is I'll run the suture back along the wound. What I'm going to be doing is hooking conjunctiva to the tarsus. So here's my conj, tarsus. And when we're picking up the conjunctiva, we're also picking up the Müller's muscle, which is directly underneath it. Dry. This one's a [inaudible 00:06:48] right here. What we can do to do is just pull on the two-end of the suture. Now, what I want to do is bury the suture under the conjunctiva. So, come through one side with one needle, and come from the tarsal side with the other needle so that they're both coming out from within the wound. I'll tie this down. This way it will be buried by the conjunctiva. It will be over here temporally and it won't irritate the eye. And dry. And you can just make sure that that suture's buried there underneath the conjunctiva. And that's it for that eye.

Upper Eyelid Ptosis Repair With Mullerectomy

Dr. John Martin performs a technique to lift a drooping upper eyelid (ptosis). In a mullerectomy, the surgery is done on the underside of the eyelid, so there is no visible external scar.

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