The Extended, Quantitated Internal Suture Browpexy

I have played around a lot with browpexies.  When I first started doing them, my main problem was that I was unhappy with the placement of the sutures.  I then started quantitating my suture placement, which made sense to me.  Realistically, browpexies are weak.  You might get 1 mm of elevation.  This video is a modification of the quantitated internal suture browpexy in that it adds a subperiosteal dissection.  I believe that I get about an additional 1-2 mm of brow elevation with this procedure. 

This is Richard Allen at oculosurg.com.  This video demonstrates an extended, quantitated browpexy.  This is a modification of my previously posted quantitated internal suture browpexy.  The needle tip cautery is used to make an incision along the blepharoplasty marking and a flap of skin and orbicularis are removed on each side.  I am almost always going to perform a blepharoplasty with this procedure.  Dissection is then carried out superiorly along the anterior surface of the orbital septum to the superior orbital rim.  Care is taken to keep the brow fat anterior to your dissection.  Once the superior orbital rim is exposed, the freer periosteal elevator is used to dissect along the surface of the periosteum superiorly.  This is performed for approximately 2 cm superior to the superior orbital rim.  The needle tip cautery is then used to make an incision through the periosteum, starting medial at the level of the superior orbital rim and extending superiorly to the conjoint tendon laterally.  This will leave a patch of periosteum superior laterally that will be used for suture fixation.  The freer periosteal elevator is then used to perform a subperiosteal dissection superiorly.  This is the extended portion of the browpexy – adding a subperiosteal dissection superiorly to attain greater brow elevation.  Medially, the supraorbital neurovascular bundle can be exposed.  It is important not to transect the supraorbital nerve.  This dissection is carried out 2-3 cm superiorly.  The quantitated portion of the browpexy is then performed as described in previous videos.  A 5-0 Monocryl suture is placed approximately 12 mm above the superior orbital rim.  The suture is then placed through the subcutaneous tissue 12 mm superior to the skin edge.  Tying the suture places the skin edge at the superior orbital rim.  An additional suture is placed medial to the previously placed suture in the exact same manner.  The procedure is then performed on the contralateral side in the exact same manner.  Dissection is carried out along the surface of the orbital septum to the superior orbital rim.  The freer periosteal elevator is then used to perform a preperiosteal dissection superior to the superior orbital rim.  The needle tip cautery is then used to make an incision the is about 2 cm superior to the superior orbital rim temporally and then is directed to the superior orbital rim lateral to the level of the supraorbital neurovascular bundle.  The freer periosteal elevator is the used to perform a subperiosteal dissection superiorly.  I think that the higher you go with this dissection, the more mobilization of the brow and, thus, lift of the brow you attain.  Be careful of the supraorbital nerve medially.  Laterally, the conjoint tendon can be lysed.  The sutures are placed in a quantitated fashion as on the other side.  The upper blepharoplasty can then be closed.  Antibiotic ointment is placed over the incision and the patient will follow up in approximately one week.