Extended, Quantitated Browpexy with Exposure of the Supraorbital Nerve

In this video, the supraorbital neurovascular bundle is exposed during the extended, quantitated, internal suture browpexy.  In general, I prefer to expose the supraorbital neurovascular bundle rather than dissect in the preperiosteal plan in this area, which I believe places the nerve at risk of compromise.  Currently, this is my preferred browpexy procedure. 

This is Richard Allen at oculosurg.com.  This video demonstrates exposure of the supraorbital neurovascular bundle with the performance of the extended, quantitated, internal suture browpexy.  The blepharoplasty has been performed, and dissection is carried out along the anterior surface of the orbital septum to the superior orbital rim.  The superior orbital rim is exposed and dissection is carried out superior to the superior orbital rim with the freer periosteal elevator along the surface of the periosteum.  The needle tip cautery is the used to make an incision through the periosteum medially, but lateral to the supraorbital neurovascular bundle, which then extends superior and laterally to the conjoint tendon.  The freer periosteal elevator is then used to elevate the periosteum superiorly.  This dissection is carried out about 2 cm superiorly.  I believe that the farther you elevate superiorly, the more mobilization you will get of the brow.  Medially, the supraorbital neurovascular bundle is exposed.   The quantitated browpexy is then performed, measuring approximately 12 mm superior to the superior orbital rim.  A 5-0 Monocryl suture then engages the periosteum at this marking.  The suture then engages the subcutaneous tissue/brow fat 12 mm superior to the edge of the skin.  Tying the suture places the edge of the skin at the superior orbital rim.  An additional suture is placed in the exact same manner medial to the previously placed suture.  The same procedure is then performed on the contralateral side.  Dissection is carried out along the anterior surface of the orbital septum to the superior orbital rim.  The freer periosteal elevator is used to dissect superior to the superior orbital rim approximately 2 cm in a preperiosteal plane.  The needle tip cautery is then used to make an incision from the medial superior orbital rim, lateral to the supraorbital neurovascular bundle, and then directed superior and laterally at a level approximately 15-20 mm superior to the superior orbital rim.  The freer periosteal elevator is then used to elevate the periosteum superiorly.  Medially, the supraorbital neurovascular bundle is exposed.  Dissection can be continued quite high, mobilizing the brow maximally.  The quantitated browpexy is then performed as on the other side, measuring the exact same amount from the superior orbital rim and the edge of the skin for suture placement.  The additional suture is placed.  The blepharoplasty incisions are closed.