This video demonstrates a pretrichial browplasty with upper eyelid blepharoplasty.
The blepharoplasty markings are incised with the monopolar cautery.
This could also be performed with a 15 blade or laser.
A flap of skin and orbicularis is removed. If desired, a skin only blepharoplasty could be performed with conservation of the orbicularis muscle.
The orbital septum is opened medially and the medial fat pad is conservatively excised.
This is performed in a symmetrical manner on both sides.
This patient is a candidate for a pretrichial browplasty because she has a relatively high forehead and wears bangs.
A saw tooth incision is made along the pretrichial marking with the 15 blade.
A dissection plane is then developed medial to the temporal fusion line with the monopolar cautery along the surface of the periosteum.
This is performed inferior to a level 2 cm above the superior orbital rim.
Lateral to the temporal fusion line, dissection is carried out along the surface of the deep temporalis fascia. The same is done on the other side.
This is performed in a plane that is deep to the facial nerve.
The periosteum is then incised approximately 2 cm above the superior orbital rim medial to the temporal fusion line. Dissection is then carried out in a subperiosteal plane to the superior orbital rim.
This dissection plane is chosen so that the supraorbital neurovascular bundle can be visualized.
This dissection is carried out so that the deep attachments of the brow to the superior orbital rim can be released.
The temporal fusion line is then identified and lysed with Metzenbaum scissors.
This results in the forehead to be completely mobile. The same transection of the temporal fusion line is performed on the other side.
The amount of lift needed is determined and marked with a marking pen.
In general the vertical height of the tissue to be excised will be between 10 and 15 mm, depending on the amount of lift needed.
The 15 blade is again used to make a saw-tooth incision.
The saw-tooth incision is made to not give the patient a perfectly linear scar which is more noticeable.
The excess tissue is excised with the monopolar cautery.
This incision results in transection of some of the sensory nerves and will give the patient some numbness above the incision.
The defect is then closed with interrupted deep 4-0 Vicryl sutures.
The purpose of the deep closure is to have minimal tension on the wound edges.
Superficial sutures are then placed with interrupted 5-0 prolene sutures placed in a vertical mattress fashion.
This is somewhat labor intensive, however, it does give the patient an excellent scar.
The blepharoplasty incisions are then closed with running 6-0 prolene sutures.
At the end of the case, the hair is washed and the head is wrapped with a dressing of Kerlex and Coban.
The bandage is removed in 2 days and the patient returns in approximately one week for suture removal.