ANDREA A. TOOLEY: All right, so we're going to start our bilateral upper eyelid blepharoplasty. We'll incise on our marks here. She's got a really nice defined crease on one side but an ill-defined sulcus and not really great defined tarsal platform on either side, and so we're going to reform that with a brassiere suture to support the lateral brow tissue and define the sulcus and then also some lid crease forming sutures just internally.

All right, so now we're just going to take out the skin and a little bit of orbicularis. And I like to use a Westcott scissor for this. She has relatively full lids and so I am going to excise some orbicularis here. If someone has pretty hollow lids and I'll tend to leave orbicularis and just do skin only.

I like to use monopolar cautery or bipolar cautery here. So what we see here is our incision with orbicularis on the underside, the lower side, as well as orbicularis on the upper side of the incision. And then orbicularis is mostly gone here centrally and you can see the underlying septum and the preaponeurotic 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 going to tack the edge of orbicularis along the superior incision to the arcus marginalis, 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 sulcus by tacking that orbic back down to the superior orbital rim there.

So we're going to do that just with a [INAUDIBLE]. I'm going to do this as a mattress. So I'm going to take a piece of my orbicularis here, a little bite, then I'm going to do a horizontal pass along the rim. So I see the rim here, you can feel the rim, and I'm just going to get a little bit of that periosteum deep along the rims. And then I'm going to come back up through that orbicularis 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 this orbicularis a little bit of this [INAUDIBLE] right where I want her lid crease to be and then a little bit more of orbicularis 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.

All right, so now I'm just going to decide if I want one more medially or if I think we're good. I am. I think I'm going to put one more medially, just to define that crease and give her a nice tarsal platform medially. So we go through the edge of orbicularis. You want this to be in the periosteum and a nice strong stitch. We'll just come out of orbicularis the same way we went in. I don't do this on everybody, but I do feel like this is a great adjunct to an upper lip 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 suture. So I'm going to go through orbicularis, just inside the skin, through a little bit of what levator would be. I haven't completely isolated levator just because it's not necessary.

So I like to close with the [INAUDIBLE] plane just in a running fashion. I find that gives a really nice closure. The other time I could recommend doing a brassiere suture I found is If you have patients who have asymmetry. 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 sulcus.

And if you're worried that just doing a bleph 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 brassiere 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 lid blepharoplasty with sulcus reformation with the brassiere suture.

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