Elizabeth A. Bradley, M.D., an ophthalmologist at Mayo Clinic in Rochester, Minnesota, performs an external browpexy, blepharoplasty and Muller muscle-conjunctival resection for a patient with temporal brow ptosis and hooding. 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 brought Asus 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 brow pixie 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% federal effort. This is the before final reference photo here and the after photo here. You can see that the eyelid position elevated nicely after the final effort. So that makes her an excellent candidate for a post area approach to tosa surgery. The Mueller's muscle contract table resection. So the surgical plan will be external brow pixie, blepharoplasty and a Mueller's muscle contract table 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 brow pecs e 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 the 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 or blepharoplasty. Give about two CCs. Get in that same line and follow it temporarily. That's a good depth of incision there through the skin but not through the articular various muscle. So I'm just going just deep to the skin or vehicular various 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 bruising to deal with essentially none that completes the blepharoplasty other than the closure. And now we'll move on to the Mueller's muscle content table resection. Just getting just convective and Mueller's muscle with the future. So one nasal lee, there's our central one and then one temporarily 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 where you are truly advancing the elevator from a posterior aspect. So as I close this wound, that elevator is going to get advanced back onto the tarsus release without releasing my future. I just want to release the skin in the articular areas. They're 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 Mueller's muscle ketosis incisions are all closed. That completes this case. We'll go to the other side and do an identical procedure.