Followup versus Follow up - Medical Transcription Tips Part 4

FOLLOW UP / FOLLOWUP / FOLLOW-UP - HOW TO USE THEM!


follow-up  - the hyphenated word "follow-up" is not used any longer. It should be either one word (followup) or two words (follow up) depending on the usage!!


For noun and adjectival form, use followup (one word)


For verb form, use follow up (two words)


Example 1:  The patient came in for a followup visit.   (adjective form)


Example 2:  A followup visit will be scheduled in 2 weeks.   (adjective form)


Example 1:  The patient did not return for followup.    (noun form)


Example 2:  The patient will be seen in followup next week.    (noun form)


Example 1:  The patient is to follow up in 2 weeks.     (verb form)


Example 2:  The patient will follow up with his primary care physician.     (verb form)




A SIMPLE WAY TO REMEMBER:


For those who are not good at identifying nouns/adjectives/verbs - there is an easier way. Do note that this is something I've noticed and so it may not work in all situations. It certainly does not follow the usual rules governing the use of the one-word or two-word followup.   Basically, these informal rules are as follows:


If you notice that "followup" is preceded by "is to"  or  "will" - then use the two-word followup  (i.e. follow up)


Eg:  .....is to follow up..   OR   will follow up......


If you notice that "followup" is preceded by "in"  OR  "a"  OR  "for"  - then use the one-word followup (i.e. followup)


Eg:.....presents in followup   OR   .....for a followup appointment....


For those perennially confused about the followup versus follow up conundrum - the above explanation should help!!

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How to Transcribe Specific Gravity in Urinalysis?

Specific gravity may be dictated as "10-10" or "10-15" for example. The correct way to transcribe specific gravity values are as 1.010 or 1.015 in the above examples. Specific gravity values range from 1.001 to 1.030 in adult humans, so just make sure you place the decimal in the correct place, even though the decimal is most often not dictated by the dictator.

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Is it neuroforamina or neural foramina / neuroforamina versus neural foramina - the correct term is?

The correct term is neural foramina. Neuroforamina is a non-word and cannot be verified in reputable reference sources. So, the correct usage would be either,

neural foramen / neural foramina / neural foraminal  

Sounds Like:  neuroforamen    ;   Transcribe As:  neural foramen

Sounds Like:  neuroforamina   ;   Transcribe As: neural foramina

Sounds Like: neuroforaminal   ;   Transcribe As:  neural foraminal


Reference:  Stedman’s Neurology & Neurosurgery Words, Third Edition & Stedman’s Radiology Words, Fourth Edition

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HOW IS "PEN VEE KAY" TRANSCRIBED?


The correct way to transcribe this is as  penicillin V potassium.  Some MTs often transcribe this as "pen VK" which is at best a slang form, as no such drug exists. Then, there are other MTs who often transcribe this as "Pen-Vee K" which has been discontinued. According to Saunders Pharmaceutical Word Book and Ask Dr. Stedman's - penicillin V potassium is the preferred and correct way of transcribing "pen vee kay" 




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C. diff   or   C diff  or  C. difficile  -  how should it be transcribed?

"C diff" is considered slang and should not be transcribed as such in transcribed reports, except for STRICTLY verbatim accounts. Per Ask Dr. Stedman, the preferred and correct way to transcribe "C diff" is to transcribe it as "C. difficile." 

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"URINE ANALYSIS" OR "URINALYSIS?" – SHOULD YOU EVER TRANSCRIBE "URINE ANALYSIS"

The term "urine analysis" is no longer used. If dictated as "urine analysis," it should be edited to "urinalysis."

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WHAT IS IT -    "SHOTTY"     OR    "SHODDY"   ADENOPATHY / LYMPHADENOPATHY?

The correct term is  "shotty" lymphadenopathy   -   the term "shotty" referring to small clusters of nodes

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IS IT  "DORSOLITHOTOMY"   OR   "DORSAL LITHOTOMY?"

The correct term is dorsal lithotomy.

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Link of the Day:  Custom Google Search for MTs - MT Word Seeker - Search Engine just for MTs

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Medical Transcription Word Help

Medical Transcription Tips - Commonly Misused MT Words - Part 3

WOULD YOU TRANSCRIBE GUIDE WIRE OR GUIDEWIRE? WHICH IS CORRECT?

So, would this be transcribed as one word or two words? The correct answer would be one word, i.e. guidewire. This word started out as two words but has now transitioned to being commonly used as one word. If dictated, transcribe this as one word, not two words!!

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THE MUCUS VERSUS MUCOUS USAGE CONFUSION:

Some MTs are often confused about which of the two words to use when dictated - mucus or mucous? Well, to know which one to use, you need to know what the difference between the two is? Let us learn what they mean,

mucus (is the noun form)  –  means the free slimy substance of the mucous membranes

mucous (is the adjective form) – pertaining to or resembling mucus

So, if dictated as a noun - use "mucus." If dictated as an adjective, use "mucous."

Example:  The patient coughed up mucus.   (noun form)

Example:  The patient's mucous membranes were moist.    (adjectival form)


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Sounds like "Kanessa" suppository - however, I am unable to verify! What could the doc mean here?


The med the doc seems to be referring to here most likely is "Canasa." You may check it out in Quick Look or credible online sources.


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PermaCath or PermCath - Which is correct?


The correct term is PermCath and can be verified through Stedman’s Equipment Words. While it is true that other dictionaries and Google search results show Permacath or Perma-Cath, the correct term is PermCath without the "a." 

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DORSOLITHOTOMY OR DORSAL LITHOTOMY?  WHICH IS CORRECT? 

This term often occurs in operative reports and many MTs are unsure of which form to type - dorsolithotomy or dorsal lithotomy? In such cases, always find out which term occurs more commonly in reputed printed references. In this specific instance, "dorsal lithotomy" is the word most reputed publishers use and hence should be correct word.

REFERENCE:  General Surgery / GI Words and Phrases ---- Health Professions Institute --- page 178 


Medical Transcription Word Help

Medical Transcription Tips and Hints and Commonly Misused Words Part 2

THE DIFFERENCE BETWEEN BNP AND BMP:

These two are commonly dictated in the lab data section of a medical report, When dictated, it is hard to discern whether it should be BNP or BMP. Most MTs would transcribe this as BMP regardless of what is dictated, primarily because they are more familiar with BMP as opposed to BNP. So, what is the difference between the two?

BNP (brain natriuretic peptide): This is a single test and has just a single value. This test measures the amount of BNP hormone in your blood. Normal levels of BNP are low, but if the patient has a heart condition such as heart failure, levels of BNP would be elevated.

BMP (basic metabolic panel):  This consists of multiple tests and you would never have a single value dictated against BMP.

Example:  The patient's BNP level was 900. (It cannot be BMP since a single value is dictated)

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Sounds like "rhonchorous." Doc dictates "rhonchorous cough" and later on "rhonchorous" breath sounds. However, I cannot seem to reference "rhonchorous" in any reference source? Is there such a word?


Well, this is essentially a word made up by doctors and can be heard quite often in dictations. The meaning intended is quite clear and so it is fine to transcribe it as such. You can also find references to this word in Stedman’s Cardiovascular and Pulmonary Words, 4th Edition, as well as Stedman’s OB-GYN and Pediatric Words, 4th Edition.


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HYPHENATE COMPOUNDS FORMED WITH THE PREFIX "SELF"

Some examples would be,

self-employed, self-administered, self-assured, self-inflicted, etc.

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Sounds like "cataberic" or "catabaric" kidney transplant - would this be correct? 

The correct word in this context is "cadaveric" - which relates to a dead body. In this instance, it just means a donor kidney derived from a dead person.

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Sounds like - stool was "hemocculted" - Is this acceptable to transcribe?


What the doctor refers to here is the stool test "Hemoccult" with the "H" being capitalized as it is a brand name. However, in this instance, the doc had made up a word, which doesn't exist and cannot be referenced in reference sources. However, the meaning intended is clear and hence the word can be transcribed pending further clarification from the client or doctor, as to how they want it handled. If they want the sentence to be rephrased so that the word transcribed is "Hemoccult," then you can transcribe it like that in the future.


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Should it be "disk" or "disc" when this is transcribed in orthopedic reports? Which one is correct?


The correct spelling/usage of this term has been the subject of much debate over the years. You'd find different answers depending on who you ask. So, what is the correct way to transcribe this term? Well, the general trend now is to use the spelling "disk" with regard to orthopedic use. For example, "lumbar disk." When this term occurs in an ophthalmological context, the preference is to use the word "disc." For example, "optic disc." However, there is also a school of thought that advocates using the spelling "disk" across orthopedic and ophthalmologic contexts. Ultimately, unless the doctor/client/account specifics specifically state a preference, it is safe to transcribe "disk" in an orthopedic context and "disc" in an ophthalmological context.


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TRANSCRIBING CONGESTIVE HEART FAILURE CLASSES:

While transcribing congestive heart failure classes, use Roman numerals.

Dictated:  The patient was diagnosed with class 4 congestive heart failure.

Transcribed:  The patient was diagnosed with class IV congestive heart failure.


Medical Transcription Word Help

Medical Transcription Tips - Answers to Common MT Questions - Part 1

TRANSCRIBING CONTRACTIONS IN A MEDICAL REPORT:

Contractions are not to be used in medical reports. If dictated as a contraction, here is how you'd transcribe,

Dictated:  The patient can't take penicillin as he is allergic to it.

Transcribed:  The patient cannot take penicillin as he is allergic to it.

EXCEPTION:

The only exception to this rule is if a contraction occurs in a direct quote, as in the example below.

Dictated:  CHIEF COMPLAINT:  "I don't feel too good."

Transcribed:  CHIEF COMPLAINT:  "I don't feel too good."

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I HEAR A MED THAT SOUNDS LIKE "ENALOPRAM" - IS THERE SUCH A MED?


If you hear this s/l - the med being referred to most likely is Analpram or Analpram-HC. If this fits the context, then you have your answer!!


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HOW TO TRANSCRIBE DUPLEX ULTRASOUND?

Many newbie as well as experienced MTs are unsure of how to transcribe "duplex ultrasound." So, is the "D" in duplex capitalized?

Well, the answer is "duplex ultrasound" is correct. The "D" is not capitalized. Much of the confusion in this stems from the fact that the "D" in Doppler ultrasound is ALWAYS capitalized. So, the expectation is that the "D" in duplex should also be capitalized. Well, it should not be!

CORRECT:  duplex ultrasound.

CORRECT:  Doppler ultrasound. 

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IS "MELANOTIC STOOL" CORRECT?

Many doctors do dictate "melanotic stool" when in fact they should be dictating it as "melenic stool." 

Melanotic actually refers to the presence of melanin, which is a pigment of the hair/skin, etc. Melanin does not occur in stools.

Melenic is used to refer to melena, which is defined as dark, tarry tools.

NOTE:  Most doctors dictate this wrongly as "melanotic," however it should ALWAYS be typed correctly as 'melenic.' An exception could be if you are on a STRICLY VERBATIM account - in which case you need to ask for guidance from QA or client in regards to how they'd prefer having this term transcribed.


Medical Transcription Word Help

LeFort I Maxillary Osteotomy Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

OPERATIONS PERFORMED:
1.  LeFort I maxillary osteotomy.
2.  Bilateral sagittal split mandibular ramus osteotomy advancement.
3.  Anterior horizontal mandibular osteotomy advancement.

OPERATION IN DETAIL:  Following proper identification in the preoperative holding area, the patient was brought into the operating room with an intravenous line in place.  The patient was transferred to the operating room table and appropriate monitors were placed.  After adequate preoxygenation, the patient was induced to an adequate level of general anesthesia.  The eyes were protected and nasal intubation carried out via the right naris without complication.  A head wrap was placed, which protected the patient's forehead from the nasal tube connector and which secured the nasal tube in place for the remainder of the procedure.  A Betadine scrub pad was used to disinfect the skin overlying the nasofrontal junction, and approximately 1 mL of 2% lidocaine with 1:100,000 epinephrine was infiltrated in the subcutaneous tissues in this area.  To reference the vertical position of the maxilla, a 0.45 K-wire was placed into the nasofrontal junction.  The Perkins vertical reference indicator was used to measure the preoperative vertical position of the maxilla.  Eight mL of 2% lidocaine with 1:100,000 epinephrine was infiltrated into the maxillary vestibule in the areas of the proposed incisions for maxillary osteotomy.  The patient was then prepped and draped in a standard fashion for an orthognathic surgical procedure.

The patient's oropharynx was thoroughly irrigated and suctioned free of debris, and an oropharyngeal throat pack was placed.  Attention was directed to the maxillary vestibule where a full-thickness incision was made utilizing a #15 blade in the mucosa 5 mm superior to the mucogingival junction, from approximately the area superior tooth #3 to that of tooth #14.  Adequate superior and inferior reflection of the tissues was carried out to expose the lateral and maxillary walls from the piriform regions to the buttress regions bilaterally.  The infraorbital foramina were identified at their inferior extent and the infraorbital nerves were protected bilaterally throughout the remainder of the procedure.  The subperiosteal reflection was continued from the buttress regions to the pterygomaxillary junction bilaterally and a toe-out retractor was placed into both sites.

Next, dissection of the nasal mucosa was carried out from the piriform rim region posteriorly along the nasal floor and lateral nasal walls.  The preseptal ligament was sharply dissected from the anterior nasal spine.  Utilizing a reciprocating saw, with thorough irrigation, osteotomies of the lateral maxillary walls were carried out from the pterygomaxillary junction to the piriform rim regions bilaterally.  During this part of the procedure, a ribbon retractor was placed in the piriform rim on both sides to protect the nasal mucosa.

A double safe-sided nasal osteotome was used to separate the nasal septum from the nasal crest of the maxilla, and a single safe-sided osteotome was used to separate the lateral nasal walls.  A pterygomaxillary osteotome was used to separate the maxillary tuberosities from the pterygoid plates bilaterally.  Using firm digital pressure, the maxilla was gently down-fractured at the LeFort I level.  Using the Rowe disimpaction forceps, the maxilla was completely mobilized.  Potential bony interferences were removed from the lateral nasal and posterior maxillary walls.  The greater palatine arteries were identified and protected, and sharp bony projections arising from the palatine bones were removed.  Small tears in the nasal mucosa were repaired using multiple interrupted 4-0 chromic gut sutures.  

Approximately 5 mm of the inferoanterior portion of the nasal septum was removed, and a groove was placed along the nasal crest of the maxilla so that the septum could sit passively in its preoperative position.  The patient was then placed into the intermediate prefabricated interocclusal splint and into maxillomandibular fixation.  Selective bone removal was carried out until the maxilla could be placed into the desired vertical position without interference.  A total of four 2.0 mm rigid internal fixation plates were placed bilaterally along the piriform rim and buttress regions.  The patient was released from maxillomandibular fixation and it was noted that the occlusion was stable and reproducible into the splint.  All surgical sites were irrigated and suctioned free of debris.  A 2-0 Prolene alar cinch suture was placed and a 1.0 cm V-to-Y closure of the upper lip midline was carried out utilizing 3-0 chromic gut suture.  The midline tissues were carefully reapproximated, and the remainder of the surgical sites in the maxilla were closed utilizing 3-0 chromic gut suture in a continuous horizontal mattress fashion.

Then, 8 mL of 2% lidocaine with 1:100,000 epinephrine was next infiltrated into the mandibular vestibules bilaterally in the areas of the proposed osteotomies.  Attention was directed first to the left mandibular vestibule where a #15 blade was used to make an incision in the mucosa beginning at the mid ramus region to a location 5 mm inferior to the mucogingival junction adjacent to tooth #19.  The incision was carried down to bone along the left mandibular body in the area of the external oblique ridge.  Subperiosteal reflection along the lateral mandibular body was carried out to the inferior mandibular border, and a J-stripper was used to relieve the pterygomandibular sling from the mandibular body and angle regions.  An anterior ramus stripper was used along the ascending ramus and the fibers of the temporalis tendon were reflected inferiorly.

Subperiosteal dissection along the medial aspect of the mandibular ramus was accomplished, and a retractor placed to retract the soft tissue superiorly.  A nerve hook was used to identify the location of the lingula so that the medial osteotomy could be located accurately.  A Seldin retractor was placed along the medial ramus to protect the inferior alveolar nerve.  Using a Lindemann bur and a high-speed surgical drill, the medial osteotomy of the mandible was carried out above the lingula and through the medial cortex.

Next, using a #702 bur, an osteotomy of the superior mandibular border was made from the anterior extent of the medial osteotomy along the external oblique ridge, extending anteriorly to the thickest portion of the lateral mandibular body adjacent to tooth #19.  This was then connected to a vertical osteotomy that extended to and included the inferior mandibular border.  Next, using a series of straight and curved osteotomes, the osteotomies were verified and a Smith inferior border separator was placed into the vertical osteotomy at its inferior extent, and worked gently from anterior to posterior.  In this fashion, the sagittal ramus osteotomy was completed on the left side without complications.  It was noted that the left inferior alveolar neurovascular bundle was completely encased in the distal segment.

Furthermore, there was no visible trauma to the nerve and it was protected carefully throughout the remainder of the procedure.  Potential bony interferences were removed from the osteotomy site and a notch was placed into the proximal segment at its anterior extent to aid in positioning later in the procedure.  A moist Ray-Tec was then placed within the osteotomy and attention was directed to the right side where an identical approach to mandibular ramus and body was made.  On the right side, it was also noted that the inferior alveolar neurovascular bundle was completely encased within distal segment without visible trauma.  Potential bony interferences were removed from the right osteotomy site as well as and a notch was placed for positioning in an identical fashion to the left.

Complete and free movement of the distal segment from the proximal segments was verified and the patient was placed into the final acrylic prefabricated interocclusal splint.  Next, she was placed in the maxillomandibular fixation.  An incision, approximately 0.4 cm in length, was made just through skin on the right cheek along the lines of relaxed skin tension lateral to the osteotomy site.  A trocar assembly was placed via this incision and the proximal segment was positioned so that the condyle was seated in the fossa passively.  Three transbuccal 2 mm screws were placed at the superior mandibular border measuring 14 mm and two times 12 mm in length.  Attention was then directed to the left side where an identical skin incision was made, and again three 2 mm superior border screws were placed.  The patient was released from maxillomandibular fixation, and it was noted that she freely rotated in the splint without occlusal interference.

Attention was then directed to the anterior mandibular vestibule where a #15 blade was used to make a curvilinear incision in the mucosa from the area adjacent to tooth #22 to that of tooth #27.  This incision was connected to the anterior extents of pre-existing ramus osteotomy incisions bilaterally.  Both the right and left sides, the mental nerves were identified and protected throughout the remainder of the procedure.  The mentalis muscle was transected down to the level of the bony anterior mandible and subperiosteal dissection was carried out in the area of the symphysis and continued posteriorly along the inferior mandibular border to a point inferior to and proximal to the mental foramina bilaterally.  Care was taken to preserve the attachment of the mentalis muscle to the most distal portion of the symphysis to ensure adequate blood supply to that area following the osteotomy.  The chin midline was marked and the inferior extent of the mandibular canine was marked bilaterally.

Next, an anterior horizontal mandibular osteotomy was carried out from left to right utilizing a reciprocating saw without complication.  This osteotomy was completed 5 mm inferior to both of the mental foramina and the root apices of the mandibular canine teeth.  An 8 mm OsteoMed chin plate was used to achieve advancement of the distal anterior mandibular segment and the plate was secured with a total of four 2.0 x 6 mm screws.  Next, using a total of three 3-0 Vicryl sutures, the mentalis muscle fibers were carefully approximated to the original position.

The remaining surgical sites were thoroughly irrigated and suctioned free of debris.  The mandibular surgical sites were reapproximated using 3-0 chromic gut suture in a continuous interlocking fashion.  The patient's oropharynx was suctioned, irrigated, and oropharyngeal throat pack was removed.  Multiple white dental elastics were placed to guide the patient into the splint and the K-wire was removed from the area of the nasofrontal junction.  The extraoral incisions were closed with 6-0 Prolene suture and each was covered with an elastic bandage.  A chin dressing was placed consisting of two strips of 1 inch foam tape and a head wrap was placed with pressure gauze placed extraorally over the surgical areas.  Care of the patient was then turned back to the anesthesia team.  The patient was extubated in the operating room without difficulty and transported to the postanesthesia recovery area in stable condition with spontaneous respirations, having tolerated the procedure well without known surgical or anesthetic complications.  The patient's estimated blood loss was 200 mL and urine output level 1100 mL.

More Maxillofacial Surgical Samples             More Dental Surgery Sample Reports 

Laparoscopic Lysis of Adhesions Operative Sample Report

OPERATION PERFORMED:  Laparoscopic lysis of adhesions.

DETAILS OF OPERATION:  The patient was placed supine on the operating table, and after administration of general anesthesia, the abdomen was prepped with Betadine and draped sterilely. Saline drop test was performed to verify intraperitoneal position of the Veress needle and then CO2 insufflation was undertaken to achieve adequate pneumoperitoneum. A bladeless trocar was then used for direct entry. After 15 mmHg, pneumoperitoneum was achieved. This bladeless trocar was used under direct vision entering the peritoneal cavity. There was a minimal amount of adhesions in the mid abdomen except for adhesions of the omentum to the midline. This allowed the other five ports to be placed in a standard fashion.

Dissection was undertaken with Harmonic scalpel taking down the omental adhesion to the midline up to the falciform ligament and completely freeing the viscera from the falciform ligament. There was additionally significant adhesions causing the splenic flexure of the colon to be up around the spleen and diaphragm. These were mobilized allowing the splenic flexure of the colon to come down inferiorly and exposing the stomach. 

The right side of the abdomen was inspected first and there was no obvious evidence of the adhesions in this area except for some minor omental adhesions to the gallbladder fossa after prior cholecystectomy. These were mobilized to look for other etiologies hidden behind these adhesions, none was identified. There was, however, noted a significant dilation of the duodenum. This was unexpected, as due to the bypass there is no food going through the duodenum, only bile and pancreas juice. This was followed to the ligament of Treitz and just immediately beyond the ligament of Treitz was a series of adhesions of the proximal biliopancreatic limb causing potentially a relative obstruction of that bile and pancreas juice flow from the biliopancreatic limb. It is postulated that the etiology of her right upper quadrant abdominal pain is transient, severe dilation of the duodenum which would necessitate a competent pylorus. Otherwise, bile and pancreas juices would back up into the excluded stomach. There was no evidence of dilatation of the excluded stomach.

Attention was turned to the bypass where the retrocolic-antegastric Roux limb was identified going up to a gastric pouch. Exposure of this area necessitated mobilization of the left lateral segment of the liver from the stomach. This was done up to a point. However, when it became apparent that the gastrojejunostomy was adherent very high on the lesser curvature of the gastric pouch, it was felt that if a revision were performed, we would end up with a micropouch scenario. The patient had requested us to consider making a lesser curve-based pouch with silastic ring. This did not appear to have been an option which would be tolerated well. It was felt that she may end up with essentially no gastric pouch and the dietary consequences of this.

Consequently, at the conclusion of the operation, the only thing that had been performed was a lysis of adhesions and identifying the potential relative obstruction of the duodenum, we felt we could identify the etiology for the abdominal pain and with the lysis of adhesions it was felt that we may have resolved. It is unclear, at the conclusion of the procedure, whether her abdominal pain would recur. Secondly, I felt that the gastric pouch revision was fraught with potential life style changes and potential complications which the patient may not have desired and because there was no structural defect of the pouch or gastrojejunostomy it was left intact.

Surgical findings were discussed with her husband at the completion of the procedure. All operative gasses and instrumentation were removed. Skin wounds closed with 4-0 Vicryl and Dermabond.

Repair of Mechanical Ptosis via Blepharoplasty Using CO2 Laser Operative Sample

PREOPERATIVE DIAGNOSIS:  Mechanical ptosis, both upper lids.

POSTOPERATIVE DIAGNOSIS:  Mechanical ptosis, both upper lids.

OPERATION PERFORMED:  Repair of mechanical ptosis, both upper lids via an upper lid blepharoplasty using the CO2 laser.

SURGEON:  XXX XXX, MD

ANESTHESIA:  A 50/50 mix of 2% Xylocaine with 1:100,000 epinephrine and 0.75% Marcaine with 1:100,000 epinephrine.  A total of 1 to 2 mL infiltrated in each upper lid and an additional 1 mL underneath the lateral brow on each side.

OPERATION IN DETAIL:  The patient was met in the holding area where the upper lid creases were marked.  Then, using a pinch technique, a moderate amount of excess skin was delineated in both upper lids.  Also noted to have fairly significant lateral brow ptosis and thus I also planned to do an internal browpexy to at least suspend his brow and keep it from falling down on his eye lids further.  IV sedation was administered and the above-mentioned anesthetics were injected.  He was taken to the major OR where tetracaine was placed in both eyes.  He was prepped and draped in the usual manner for sterile facial surgery.  Metal shields were placed in both eyes.  A CO2 laser to superpulse setting of  5 watts was then used to incise the skin, first to the right upper lid and then the left upper lid, along the previous markings.  Burow triangles were excised nasally, and then the laser was used to dissect through the subbrow fat pad over the lateral half of the brow, care being taken to stay lateral to the supraorbital nerve, creating a pocket superiorly, centered over the lateral canthal angle.  This was done first on the right side, then the left side, 5-0 silk sutures were then used to grasp the subbrow tissue along the inferior edge of the brow, and it was attached to the periosteum approximately 3 to 4 mm higher.  These were bow-tied and he was asked to open his eyes and tilt his head forward and good contour of the upper lids were obtained.  These were then tied permanently, and the wounds were then closed with running and interrupted 5-0 plain collagen.  Metal shields were removed.  Polysporin ointment was placed in both eyes and along the wounds.  He tolerated the procedure well without complications.  Estimated blood loss was less than 1 to 2 mL.  There were no complications.