Transconjunctival Subperiosteal Septal Reset for the Correction of Orbital Fat Bulging and Tear Trough

Transconjunctival lower blepharoplasty has gained interest because of less-invasiveness and fast recovery. This is a study about operative skill, strength, and weakness of transconjunctival lower blepharoplasty and a trial for suggesting the guidelines for patient selection. The authors reviewed the medical records and photographs of 530 patients(M:F=470:60) who underwent transconjunctival lower blepharoplasty with orbital fat reposition and subperiosteal septal reset, retrospectively. Most of the patients were satisfied with results for correction of orbital fat bulging and tear trough deformity. Eighteen patients(3.4%) developed relapse of fat bulging requiring revision with subsequent fat removal(seventeen patients) or fat reposition(one patient). Two patient(0.4%) developed entropion. One case was corrected with revisional surgery and the other case was recovered after an injection of triamcinolone. Delayed hematoma was developed in five patients. Surgical evacuation was required in 3 cases. Minor problems included postoperative swelling, bruise, and transient paresthesia that resolved spontaneously. Transconjunctival lower blepharoplasty is an excellent surgical choice for correction of orbital fat bulging and tear trough in the patients who have proper tension of soft tissue. Invisible scar, fast recovery, and low complication rate are merits of this method.

Strategy for the Treatment of Infraorbital Dark Circles

Infraorbital dark circles refer to the darkness of lower eyelids and can be a significant cosmetic problem for the people of any age and sex. Although the general concern for dark circles is increasing, little has been published about the treatment of dark circles in the scientific literature. Dark circles are not a single disease but combination of causative symptoms. We classified patients to five groups according to patients' symptoms; bulging of infraorbital fat(Ia), sunken lower eyelids(Ib), depression or groove on midface(Ic), thin translucent skin(IIa), and excessive pigmentation(IIb). We reviewed medical records and photographs of patients retrospectively. The classification of patients and the treatment of the groups were evaluated. Problems of shape, especially bulging of infraorbital fat was the main cause of dark circles in most patients(65.2%). The treatment of each group included transconjunctival fat reposition or removal(Ia), single fat cell graft(Ib,IIa), microfat graft(Ic), and various dermatologic therapies(IIb). We obtained better results when we did combination of the treatments according to symptomatic groups.

Corneal Abrasion Occurred during Transconjunctival Blepharoplasty in a Patient with History of LASIK Operation

PURPOSE: LASIK, one of the currently popular ophthalmic procedures, can sometimes result in dry eye symptoms. In the patient who had underwent LASIK operation, the periorbital surgery may be more likely to lead to such a complication as dry eye symptom. We would like to report a case of corneal abrasion occurred after transconjunctival blepharoplasty in post-LASIK state and suggest the method about preventing the complication. METHODS: A 30-year-old female patient underwent transconjunctival blepharoplasty and microfat graft into the face. She had history of LASIK operation 2 years ago. Corneal protector was applied to both eye during transconjunctival operation. After the surgery, she complained of visual blurring at left side. Ophthalmic examination revealed corneal abrasion of left eye. RESULTS: Cornea protecting lens was applied to left eye for 2 weeks. Steroid and antibiotic eye drops were applied for relieving the symptoms and the prevention from progressing of complication. After 1 week, visual power and acuity was recovered to preoperative state. No other specific complications happened. CONCLUSION: Post-LASIK patient may have possibility of decreased corneal sensation and tear production. Preoperative ophthalmic examination is recommended for the prevention of complication. When corneal protector is applied, we suggest Optagel(R) as a useful lubricant.

Removal of Microfat Graft in Lower Eyelid with Transconjunctival Approach

PURPOSE: Microfat graft is a common procedure for correcting tear trough deformity and dark circle. Because the tissue in this area is very thin, the grafted fat, sometimes, induces palpable lumps and uneven skin contour. When it happens, the surgical removal of the grafted fat is often needed. The authors made attempt of transconjunctival approach for removal, and this made infraorbital fat repositioning possible at the same time. METHODS: 15 female patients with history of microfat graft on lower eyelid, got operation for the grafted fat removal with transconjunctival approach from April of 2009 to July of 2010. The dissection was performed in accordance with infraorbital fat repositioning surgery. Through the transconjunctival incision, knotted fat on orbital septum and orbicularis oculi muscle was removed without damage on skin. After grafted fat removal, subperiosteal space was made 1~2mm below the inferior orbital rim by elevating periosteum. With preserving orbital septum, infraorbital fat was repositioned and anchored to subperiosteal space. Finally, transconjunctival incision was closed with absorbable suture material. RESULTS: 14 patients in the study showed satisfactory results. The problems like uneven skin contour and knotted fat mass, were all solved. In only one patient, incomplete correction was observed, as bulging on her right lower eyelid still remained. One patient complained of transient numbness on lower eyelid, but there was no specific complication other than this. CONCLUSION: The authors attempted the method of transconjunctival approach to remove former grafted fat in lower eyelid and reposition infraorbital fat simultaneously. Since the study brought great results, the method would be helpful to patients and surgeons.

Experience of Hemophilic Pseudotumor Developed at the Fracture Site of the Proximal Phalanx of the Hand

PURPOSE: Hemophilia is one of the most common bleeding disorder, and circulating levels of factor VIII or IX are closely related to the severity and frequency of the bleeding. The severity of hemophilia is classified to be severe, moderate, and mild when the factor level is less than 1%, between 1% and 5%, and between 5% and 25%, respectively. Hemophilic pseudotumor is a rare complication occurring in 1-2% of patients with factor VIII or IX deficiency. If the treatment is delayed, it would cause disabling and life threatening results. METHODS: We experienced hemophilic pseudotumor developed at the fracture site of the proximal phalanx of the hand in a hemophilic B patient. Hemophilic pseudotumor was successfully treated with perioperative factor replacement and surgical intervention included excision and autologous bone graft. RESULTS: Hemophilic pseudotumor was healed with complete regression, and no specific complication was developed. CONCLUSION: When we accounter hematoma like lesion after surgery unpredictably, we must consider hemophilic pseudotumor and make a accurate diagnosis with preoperative hematologic screening and various imaging study. Subsequently, adequate perioperative supplement of concentrate and surgical intervention brings to the satisfactory result without recurrence.

Correction of the Dorsal Contour Deformity Caused by Scoliosis with Silicone Implant

PURPOSE: Scoliosis is a multifactorial disorder caused by genetic, biochemical, developmental, neuromuscular factors and causes complex deformities which include skeletal deformity, pain, cardiovascular dysfunction, motor function disorder. Until now, the treatment of scoliosis have been focused on orthopedic correction, preservation of cardiopulmonary and neurologic function. But recently, as aesthetic demands increases, the needs for the correction or improvement of the trunk and extremity contour does. So, the correction of soft tissue contour deformity can be a new concept for the treatment of scoliosis. METHODS: We corrected a deformed contour with prefabricated silicone implant in a scoliosis patient who had been operated for orthopedic correction previously. Submuscular pocket was made under trapezius and latissimus dorsi muscle. Silicone implant was placed in the pocket and fixed to thoracolumbar fascia with sutures. RESULTS: We had a satisfactory results for the correction of contour deformity. There was no significant complication. CONCLUSION: Silicone implant is a new trial for the correction of scoliosis contour deformity. This method is simple, safe and brings on satisfactory results.

Treatment of Brachycephaly: Traditional Cranioplasty vs. Distraction Osteogenesis

Craniosynostosis refers to the premature fusion of single or multiple sutures of the cranial base or vault. It causes restriction of cranium and brain growth and variable morphologic deformity. Inadequate intracranial volume for rapid brain growth brings about increased intracranial pressure and functional impairment. To solve this problem, the key is the surgical decompression and insurance of adequate intracranial volume. Traditional surgical approach is frontal advancement with cranial vault remodeling, but has drawbacks such as invasiveness, long operation time, large amount of hemorrhage, difficult postoperative care, and frequent complications. Recently, distraction osteogenesis is used for the treatment of craniosynostosis. So, we compared cranial distraction osteogenesis with traditional cranioplasty about merits and drawbacks and present the effectiveness of cranial distraction osteogenesis. In a comparative study of cranioplasty and distraction osteogenesis, clinical documents and pre/ postoperative X-ray and CT scans of 12 brachycephaly patients were reviewed. From April, 1994 to October, 2001, 8 patients were treated with traditional cranioplasty and 4 patients were treated with distraction osteogenesis. We achieved not only an increase in intracranial volume but also merits such as a reduction in operation time and bleeding, easy postoperative care and low complication rate with distraction osteogenesis.

Clinical Study of Cleft Lip and Cleft Palate

Incidence of congenital anomalies decreased due to decrease in birth rate and popularization of prenatal examination. But there has been relatively high incidence of congenital cleft lip and cleft palate among congenital anomalies. In spite of many studies, the cause of clefting has not been clarified yet. Purpose of this study is to investigate clinical status and etiologic factors of cleft lip and cleft palate. We reviewed clinical records of 1111 cases of cleft lip and palate patient who were treated with primary cheiloplasty and palatoplasty at Hanyang University Hospital from January, 1990 to December, 2002. Clinical analysis of these 1111 cases of cleft lip and palate patients were carried out and summarized as follows. The rate among cleft lip, cleft lip & palate, and cleft palate were 1.5:1.4:1. The rate among left side, right side, and bilateral were 2.5:1.5:1. Male versus Female was 1.3:1. In cleft palate group, the ratio was 0.7:1, conversely. 1st baby was most common in patient group. 5.9 % of patients had congenital anomalies. Medication was the most possible factor with cleft lip and palate in pregnancy. 6.4 % of patients had history of cleft lip or palate in their family trees. For the closure of cleft lip, Millard's rotation advancement method was most commonly used at about 3months of age. In cleft palate group, pushback palatoplasty was most popular method and the timing of surgery was at about 12-18 months of age. Based on the above data, it may be concluded that outbreaks of cleft are affected by multiple factors and that there is no significant difference of clinical status and treatment modalities between this and other investigations. To investigate the correlation between proposed factors and effects, prospective study method is more suitable than retrospective study like this. Good study design for data collection and appropriate control group are also required. For this purpose, I propose construction of new data collecting system and multi-center study for birth monitoring system.

Nasal Reconstruction for Nasal Deformity or Defects: Based on Aesthetical Nasal Subunits

The nose, salient part in the face, is more vulnerable to injury and its minor defect or deformity is highly perceptible. It is thus essential to establish the certain rules for reconstruction. Gonzalles Ulloa mentioned 5 aesthetic nasal subunits, which are nasal dorsum, nasal tip, lateral portion, alar portion and soft triangle. However, the authors insist on the importance of the columella and nasal floor as well as other nasal subunits, considering the nasal reconstruction in structural and functional aspects. Authors' study was based on the aesthetical nasal subunits considering the in-depth knowledge of anatomical and functional aspects of each unit as an individual. Reconstruction of the proximal 2/3 portion of the nose having thin, soft and mobile skin over the osteochondral framework with sparse distribution of the sebaceous glands can be done with skin graft, nasolabial flap, and median forehead flap and lateral wall defect can be repaired by nasolabial flap or glabellar flap. Reconstruction of the distal 1/3 portion of the nose is rather difficult due to its thick, sebaceous skin that is characterized by firm and dense cartilaginous attachment, which makes it more harder to handle especially when it comes to the alar portion. Therefore, composite graft for the small defect and nasolabial flap or median forehead flap for on the larger defect can be used. However, when defect is located on the nasal tip, it results in tremendous spoiling of the whole facial harmony even with a tiny defect so that replantation, composite graft or median forehead flap has been used for the reconstruction. Reconstruction of the columellar defect is considered more complicated and V - Y advancement flap, bilateral nasolabial flap, and composite graft have been utilized.Nasal deformity or defect was reconstructed based on 7 aesthetical nasal subunits; by further dividing the nasal units, in terms of adding 2 more subunits, columella and nasal base, aesthetically and functionally acceptable and advantageous results were deduced with less contractures and scars. Current trends of nasal reconstruction are based on the concepts of aesthetic nasal subnunits or units in which modification was added in some extent. The most important factors that contribute to the later results are evaluation of the depth and color of the deformed or defected area according to the aesthetic nasal subunits whether it is congenital or acquired. Various reconstruction methods of the nose can be utilized based on the size, depth and location of the defects where it can be reconstructed as a unit. Columella and nasal base were newly added in concepts of subdivision from the previously established nasal subunits to produce more detailed, precise and favorable result. Also, nasal reconstruction should be carefully carried out considering the importance of the psychological, social and functional influences of the nasal deformity.

A Case of Thigh Augmentation with Silicone Prosthesis in a Poliomyelitis Patient

Until now, aesthetic concerns have been focused on the face, especially on the eyes, nose and facial contour. But recently, many people have interest in the aesthetics of the trunk and extremities. There is an increasing demands for the correction or improvement of the trunk and extremity contour, especially in cases of poliomyelitis and posttraumatic deformity. Authors did the thigh augmentation with silicone prosthesis in a poliomyelitis patient. Subfascial pocket was made and prefabricated silicone implants were placed in the pocket. Circumferential differences between affected thigh and unaffected thigh were reduced from 11 cm(15 cm above knee), 9 cm(25 cm above knee) to 2.5 cm, 3 cm. No definitive complication was present. So, authors conclude that this technique is useful to obtain the good results in the aesthetic correction of asymmetric thigh.

A Case of Thigh Augmentation with Silicone Prosthesis in a Poliomyelitis Patient

Until now, aesthetic concerns have been focused on the face, especially on the eyes, nose and facial contour. But recently, many people have interest in the aesthetics of the trunk and extremities. There is an increasing demands for the correction or improvement of the trunk and extremity contour, especially in cases of poliomyelitis and posttraumatic deformity. Authors did the thigh augmentation with silicone prosthesis in a poliomyelitis patient. Subfascial pocket was made and prefabricated silicone implants were placed in the pocket. Circumferential differences between affected thigh and unaffected thigh were reduced from 11 cm(15 cm above knee), 9 cm(25 cm above knee) to 2.5 cm, 3 cm. No definitive complication was present. So, authors conclude that this technique is useful to obtain the good results in the aesthetic correction of asymmetric thigh.

A New Method to Conceal Cleft Lip Scar: Follicular Unit Hair Graft

In cleft lip surgery, the scar on lip is minimized with trials but visible in some cases. The causes of visible scar after cheiloplasty include; (1) Mature scar is whitish, so the scar is more visible in Orientals with dark skin color than in Caucasians. (2) Mature scar on lip is conspicuous because it is whitish, so distinguished from hairy skin especially in mustached men. To solve this problem, authors used hair transplantation techniques. Hair transplantation techniques have been used for the treatment of alopecia in the main. The techniques include scalp composite graft technique such as strip graft, square graft and punch graft, but this may have a shortcoming such as unnatural, cobble-stone appearance. Moreover, this is not appropriate to use for the correction of long, slender scar of post-cheiloplasty state. So, authors used another hair transplantation technique, individual hair graft. A donor ellipse of scalp was harvested from the occipital area. The scalp was splitted into many single hair grafts carefully not to hurt hair follicles with No. 11 blade. The grafts were transplanted to the scar using Choi hair transplanter. Between February, 1996 to June, 2001, 8 cleft lip patients underwent individual hair graft and satisfactory results were obtained to conceal cleft lip scar. Hair grafts were well taken. When we splitted a scalp ellipse into many single hair grafts, we removed dermis from hair follicles delicately. So we obtained natural appearance and avoided unnatural, cobble-stone appearance. We didn't observe transient hair loss. So, authors conclude that individual hair graft technique is a new method to conceal cleft lip scar.