ELIZABETH A. BRADLEY: For preoperative planning for this case, it's helpful to look at the photos that we took in clinic. And in that, we were assessing the patient's brow position. She had some temporal brow ptosis and some hooding.

The patient did not want to have a full, direct brow nor an endoscopic brow. And so for that reason, we're choosing an external browpexy, where we make an incision here and are able to bring up that lateral third of the brow and stabilize the brow from further descent. Clearly, she needs to have some skin removed with the blepharoplasty.

And then she had an excellent response to 10% phenylephrine. This is the before phenylephrine photo, here and the after photo, here. You can see that the eyelid position elevated nicely after the phenylephrine. So that makes her an excellent candidate for a posterior approach to ptosis surgery, the Muller's muscle-conjunctival resection. So the surgical plan will be external browpexy, blepharoplasty, and a Muller's muscle-conjunctival resection.

When we do a full brow, I don't mark the blepharoplasty until after we get the brow into a normal position. But with a browpexy, the position of the brow does not fundamentally change how much skin we can safely remove. So I go ahead and mark the blepharoplasty at the beginning of the case.

This patient has very well-defined eyelid creases, and they look symmetric. So we'll just mark, marking her crease there, and then we'll make sure that this side is symmetric. And so that's the lower limit of our incision.

And then use these blunt-tipped forceps, because the patient hasn't had any local anesthetic, to just gently measure how much skin we can take. Mark that as the upper aspect of our crescent-shaped removal here. More important than the amount of skin you remove, is the amount you leave behind. If you take too much, you'll get a foreshortened appearance between the brow and the lashes.

For blepharoplasty, you give about two cc's-- in that same line and follow it. Temporarily, that's a good depth of incision there, through the skin, but not through the orbicularis muscle. So I'm just going, just deep to the skin.

Orbicularis muscle is deep here. And it takes very little energy to separate the tissues. You can see I'm not leaving any char. Resect this last little bit, especially, peek underneath the tissue to make sure I'm where I want to be.

You can see we have very little oozing to deal with, essentially, none. That completes the blepharoplasty, other than the closure. And now we'll move on to the Muller's muscle-conjunctiva resection. Just conjunctiva and Muller's muscle with the suture.

So one nasally, there's our central one, and then one temporally here. Clamp the tissue, advance the device there, and now we can remove these sutures. I can feel the metal on metal as I cut all the way across, releasing the tissue.

We are truly advancing the levator from a posterior aspect. So as I close this wound, that levator is going to get advanced back onto the tarsus. Without releasing my suture, I just want to release the skin and the orbicularis there a little bit.

We're coming to place our final one or two skin sutures into the brow wound. The skin is thicker here. So we can take a slightly wider bite.

So now our brow wound, and our blepharoplasty wound, and our Muller's muscle ptosis incision are all closed. That completes this case. We'll go to the other side and do an identical procedure.

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