Andrea A. Tooley, M.D. , an oculoplastic and orbital surgeon at Mayo Clinic in Rochester, Minnesota, performs a bilateral upper lid blepharoplasty with sulcus reformation with brassiere suture.
Alright so we're gonna start our bilateral upper eyelid. Blepharoplasty. Well in size on our marks here. She's got a really nice defined crease on one side but kind of an ill defined sulcus. And not really great to find kind of parcel platform on either side. And so we're going to reform that with a breezy suture to support the lateral brow tissue and define the sulcus and then also some lid crease forming sutures just internally. Alright so now we're just gonna take out the skin and a little bit of articular Aris. And I like to use a Wescott suit scissor for this. She has relatively full lids. And so I am going to excise some or big salaries here if someone has pretty hollow lids and I'll tend to leave orbit calories and just do skin only. I like to use monopoly Kateri or bipolar Kateri here. So what we see here is our incision with articular surface on the underside the lower side as well as ridiculous on the upper side of the incision and then articulate. This is mostly gone here centrally and you can see the underlying septum and the pre open arctic fat pad just under the septum right here, that yellow fat sticking through. So now we're going to do the brassiere suture portion and for that I'm gonna tack the edge of orbit calories along the superior incision to the artist marginalized which is right on the superior orbital rim here just along the bone and by tacking it there, we support the lateral brow tissue. You can see that here if I support the tissue here. And it also defines the soul cas by kind of tacking that orbit down to the superior orbital rim there. So we're going to do that just with a 70. Vicryl. I'm going to do this as a mattress so I'm going to take a piece of my articulate various here. A little bite. Then I'm going to do a horizontal pass along the rim. So I kind of see the rim here. You can feel the rim and I'm just going to get a little bit of that curiosity. Um deep along the rim. And then I'm gonna come back up through that articulate various. Again I want to just softly reform her crease here. So I'm going to do it all internally where I basically just take a bite internally of the sorbet calories, A little bit of this elevator kind of right where I want her lid crease to be and then a little bit more of or bigger. Larry's right inside the skin. So this is all internal. These are deep sutures that are buried and so I don't have to worry about this being a very harsh crease. Alright, so now I'm just going to decide if I want one more immediately or if I think we're good. I am. I think I'm going to put one more immediately just to define that crease and give her a nice parcel platform immediately. So we go through the edge of our vocabularies. You want this to be in the periodic system and a nice strong stitch, well just come out of our vocabulary the same way we went in and I don't do this on everybody, but I do feel like this is a great adjunct to an upper lid blepharoplasty that you can add if somebody needs a more defined sulcus or more supported lateral brow tissue. And then I'm going to do those internal lid crease formation futures. So I'm going to go through our vehicular areas just inside the skin Through a little bit of what elevator would be haven't completely isolated elevator just because it's not necessary. So I like to close with a 60 plane just in a running fashion. Um I find that gives a really nice closure. The other time I could recommend doing a breezy suture I found is if you have patients who have a symmetry every now and then, I feel like I'll see a patient who has one lid with a pretty hollow or defined sulcus and then the other lid has extra skin that's overhanging and obscuring the sol cas. And if you're worried that just doing a bluff is going to lead to some asymmetry because of the difference in the appearance of the sulcus. That's a great patient to do a brazil because it'll just define the sulcus a little on that side if you're worried about it. So that's a great time to try a brassiere and that's it, bilateral upper blepharoplasty with sulcus re formation with the brazil suture.
