Workup
Laboratory Studies
When evidence of thyroid disease is present, referral to an endocrinologist is recommended in order to evaluate the thyroid. Thyroid function tests may be ordered, although clinical symptoms may present before and abnormalities in the laboratory studies.
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Measure the desired height of the fold. Typically, an 8-mm fold yields a medium-sized fold in young patients. If one brow lies lower, then mark the fold 1 mm higher on that side to compensate for the increased overhang of skin.
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Perform the medial epicanthoplasty first. Mark the V-W plasty; each limb measures approximately 2 mm. Mark the W portion on the surface of the epicanthal fold. The tip of the central flap of the W sits at the edge of the epicanthal fold, and the V component lies on the undersurface of the epicanthal fold. The markings represent skin that will be resected.
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Use 6-0 nylon to suture the apex of each flap, as well as one in between them, for a total of 7 sutures.
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Remove thin slivers of tissue, going through orbicularis muscle, retro-orbicularis fat, and septum until reaching prelevator fat. Do not confuse the proper fat layer. Verify prelevator fat by the glistening levator aponeurosis underneath, which moves when the patient opens his or her eyelid.
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Pass 6-0 nylon through the conjunctiva along the upper border of the tarsal plate.
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Pass one arm of the needle through the full thickness of the eyelid.
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Arm the free end of the suture with a free needle, and then pass it through to the other side of the eyelid using the same needle hole as the initial conjunctival bite.
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Tie the suture and sink the knot deeply into the space previously created to accommodate it.
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Close the skin and place a light compression dressing.
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Preoperative (top) and 2-wk postoperative (bottom) photos of a patient who underwent semiopen procedure (without medial epicanthoplasty).
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After the skin markings and incision, a sliver of orbicularis muscle is excised to expose the underlying orbital septum.
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The prelevator fat is identified and used as an anatomical guide to open the entire septoaponeurotic sling.
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After the lateral portion of the fat is excised, the pretarsal soft tissue "bursa" is cleared, exposing the relevant anatomy. The skin flap has been everted; the tarsal plate fully exposed; and the levator aponeurosis lies just cephalad to the tarsal plate, under the forceps.
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Use 6-0 Vicryl to secure the dermis to the tarsal plate and levator aponeurosis.
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The suture has been tied.
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The sutures have been placed in 6 positions along the incision. Closure is with 6-0 Prolene.
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Preoperative (top) and postoperative (bottom) photos of a 22-year-old patient after anchor blepharoplasty and medial epicanthoplasty.
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