A Radiomics-Based Model for Potentially More Accurate Identification of Subtypes of Breast Cancer Brain Metastases

Purpose@#Breast cancer brain metastases (BCBM) may involve subtypes that differ from the primary breast cancer lesion. This study aimed to develop a radiomics-based model that utilizes preoperative brain MRI for multiclass classification of BCBM subtypes and to investigate whether the model offers better prediction accuracy than the assumption that primary lesions and their BCBMs would be of the same subtype (non-conversion model) in an external validation set. @*Materials and Methods@#The training and external validation sets each comprised 51 cases (102 cases total). Four machine learning classifiers combined with three feature selection methods were trained on radiomic features and primary lesion subtypes for prediction of the following four subtypes: 1) hormone receptor (HR)+/human epidermal growth factor receptor 2 (HER2)-, 2) HR+/HER2+, 3) HR-/HER2+, and 4) triple-negative. After training, the performance of the radiomics-based model was compared to that of the non-conversion model in an external validation set using accuracy and F1-macro scores. @*Results@#The rate of discrepant subtypes between primary lesions and their respective BCBMs were 25.5% (n=13 of 51) in the training set and 23.5% (n=12 of 51) in the external validation set. In the external validation set, the accuracy and F1-macro score of the radiomics-based model were significantly higher than those of the non-conversion model (0.902 vs. 0.765, p=0.004; 0.861 vs. 0.699, p=0.002). @*Conclusion@#Our radiomics-based model represents an incremental advance in the classification of BCBM subtypes, thereby facilitating a more appropriate personalized therapy.

Multimodal Imaging Findings of Cerebral Amyloid Angiopathy Related Inflammation With Unusual Clinical Manifestation: A Case Report

Cerebral amyloid angiopathy-related inflammation (CAA-RI) is a rare encephalopathy characterized by the coexistence of a perivascular inflammatory reaction in patients with cerebral amyloid angiopathy. CAA-RI diagnosis is challenging as its final diagnosis requires invasive procedures such as autopsy or brain biopsy. Therefore, multimodal imaging approaches with clinical considerations are essential for the probable diagnosis of CAA-RI. In particular, in the case of CAA-RI presented with uncommon clinical symptoms, the need for imaging in diagnosis is further highlighted by difficulties of clinical approaches. Herein, we report a case of CAA-RI with unusual clinical manifestation diagnosed using multimodal imaging including magnetic resonance imaging (MRI) and amyloid positron emission tomography-computed tomography (PET-CT). Multimodal imaging approaches using adequate MRI sequences and PET-CT scans could facilitate the diagnosis of CAA-RI without requiring invasive pathological confirmation.

Dynamic Contrast-Enhanced MRI and Its Applications in Various Central Nervous System Diseases

Dynamic contrast-enhanced MRI (DCE-MRI) is a noninvasive imaging technique used to evaluate tissue vascularity/permeability features through consecutive imaging acquisitions after gadolinium-based contrast agent administration. Over the past several decades, techniques and protocols for DCE-MRI have evolved, leading to growing applications of DCE-MRI for different neurological disorders. Although most established applications of DCE-MRI are for studying tumors, an increasing number of studies have been evaluating the use of this technique for neurodegenerative and other miscellaneous diseases. The purpose of this article was to provide an overview of DCE-MRI and its clinical applications in various neurological diseases.

Comparison of Contrast-Enhanced T2 FLAIR and 3D T1 Black-Blood Fast Spin-Echo for Detection of Leptomeningeal Metastases

PURPOSE: Imaging plays a significant role in diagnosing leptomeningeal metastases. However, the most appropriate sequence for the detection of leptomeningeal metastases has yet to be determined. This study compares the efficacies of contrast-enhanced T2 fluid attenuated inversion recovery (FLAIR) and contrast-enhanced 3D T1 black-blood fast spin echo (FSE) imaging for the detection of leptomeningeal metastases. MATERIALS AND METHODS: Tube phantoms containing varying concentrations of gadobutrol solution were scanned using T2 FLAIR and 3D T1 black-blood FSE. Additionally, 30 patients with leptomeningeal metastases were retrospectively evaluated to compare conspicuous lesions and the extent of leptomeningeal metastases detected by T2 FLAIR and 3D T1 black-blood FSE. RESULTS: The signal intensities of low-concentration gadobutrol solutions (< 0.5 mmol/L) on T2 FLAIR images were higher than in 3D T1 black-blood FSE. The T2 FLAIR sequences exhibited significantly greater visual conspicuity scores than the 3D T1 black-blood sequence in leptomeningeal metastases of the pial membrane of cistern (P = 0.014). T2 FLAIR images exhibited a greater or equal extent (96.7%) of leptomeningeal metastases than 3D T1 black-blood FSE images. CONCLUSION: Because of its high sensitivity even at low gadolinium concentrations, contrast-enhanced T2 FLAIR images delineated leptomeningeal metastases in a wider territory than 3D T1 black-blood FSE.

Late-Developing Metastatic Malignant Melanoma in the Thoracic Spine Originating from Choroidal Melanoma

A 54-year-old woman visited Gangnam Severance Hospital for left side flank pain. She had a history of total removal of malignant melanoma on the left eye ball 20 years prior. No evaluation had been performed since then. A paravertebral mass at thoracic ninth level (T9) was discovered on spinal magnetic resonance imaging, and pathology confirmed malignant melanoma. Following positron emission tomography-computed tomography, no other metastasis was discovered. After removal of the paravertebral mass, palliative chemotherapy (dacabarzine + tamoxifene) was administered in 3 cycles over 2 months. Radiotherapy with simultaneous integrated boost technique was performed at 4,350 cGy total over 15 days, 290 cGy per delivery, and was administered with the first cycle of palliative chemotherapy. Despite this treatment, multiple metastases developed throughout her body 7 months later, and the patient is continuing chemotherapy.

Clinical Features Indicating Nigrostriatal Dopaminergic Degeneration in Drug-Induced Parkinsonism

OBJECTIVE: Patients with drug-induced parkinsonism (DIP) may have nigrostriatal dopaminergic degeneration. We studied the clinical features that may indicate nigrostriatal dopaminergic degeneration in patients with DIP. METHODS: Forty-one DIP patients were classified into normal and abnormal [¹⁸F] FP-CIT scan groups. Differences in 32 clinical features and drug withdrawal effects were studied. RESULTS: Twenty-eight patients had normal (Group I) and 13 patients had abnormal (Group II) scans. Eight patients of Group I, but none of Group II, had taken calcium channel blockers (p = 0.040). Three patients of Group I and six of Group II had hyposmia (p = 0.018). After drug withdrawal, Group I showed greater improvement in Unified Parkinson's Disease Rating Scale total motor scores and subscores for bradykinesia and tremors than Group II. Only hyposmia was an independent factor associated with abnormal scans, but it had suboptimal sensitivity. CONCLUSION: None of the clinical features were practical indicators of nigrostriatal dopaminergic degeneration in patients with DIP.

Prevalence and Characteristics of Unruptured Cerebral Aneurysms in Ischemic Stroke Patients / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: The prevalence of unruptured cerebral aneurysms (UCAs) in ischemic stroke patients is not clearly defined. This study aimed to measure the prevalence and characteristics of UCAs in patients with acute ischemic stroke (AIS) and to compare our findings with those of the general population. In addition, we investigated the factors associated with cerebral aneurysms in AIS patients. METHODS: We retrospectively reviewed the brain magnetic resonance angiography images of 955 patients with AIS and 2,118 controls who had received a brain magnetic resonance angiography as part of a health check-up. We investigated the prevalence, size, location, and risk factors of the subjects in the context of UCAs. RESULTS: UCAs were found in 74 patients with AIS (7.7%) and in 79 who received a health check-up (3.7%). The prevalence of UCAs was significantly higher in the AIS group than in the health check-up group (odds ratio 2.17, 95% confidence interval 1.56-3.01). The mean aneurysm diameter was larger in the AIS group than in the health check-up group (3.75 mm vs. 3.02 mm, P=0.009). UCAs were primarily located in the internal carotid artery in both groups, and aneurysms in the middle cerebral artery were particularly common in the AIS group. According to multivariate analysis, hypertension alone was associated with an increased prevalence of UCAs in stroke patients. CONCLUSIONS: This study identified a higher prevalence and larger size of UCAs in AIS patients than in the general population. Hypertension was an independent risk factor of UCA in AIS.

Wernicke's Encephalopathy Mainly Involving the Cerebellum

No abstract available.

Ivy Sign on Fluid-Attenuated Inversion Recovery Images in Moyamoya Disease: Correlation with Clinical Severity and Old Brain Lesions

PURPOSE: Leptomeningeal collateral, in moyamoya disease (MMD), appears as an ivy sign on fluid-attenuated inversion-recovery (FLAIR) images. There has been little investigation into the relationship between presentation of ivy signs and old brain lesions. We aimed to evaluate clinical significance of ivy signs and whether they correlate with old brain lesions and the severity of clinical symptoms in patients with MMD. MATERIALS AND METHODS: FLAIR images of 83 patients were reviewed. Each cerebral hemisphere was divided into 4 regions and each region was scored based on the prominence of the ivy sign. Total ivy score (TIS) was defined as the sum of the scores from the eight regions and dominant hemispheric ivy sign (DHI) was determined by comparing the ivy scores from each hemisphere. According to the degree of ischemic symptoms, patients were classified into four subgroups: 1) nonspecific symptoms without motor weakness, 2) single transient ischemic attack (TIA), 3) recurrent TIA, or 4) complete stroke. RESULTS: TIS was significantly different as follows: 4.86+/-2.55 in patients with nonspecific symptoms, 5.89+/-3.10 in patients with single TIA, 9.60+/-3.98 in patients with recurrent TIA and 8.37+/-3.39 in patients with complete stroke (p=0.003). TIS associated with old lesions was significantly higher than those not associated with old lesions (9.35+/-4.22 vs. 7.49+/-3.37, p=0.032). We found a significant correlation between DHI and motor symptoms (p=0.001). CONCLUSION: Because TIS has a strong tendency with severity of ischemic motor symptom and the presence of old lesions, the ivy sign may be useful in predicting severity of disease progression.

High-Resolution Contrast-Enhanced 3D-Spoiled Gradient-Recalled Imaging for Evaluation of Intracranial Vertebral Artery and Posterior Inferior Cerebellar Artery in Lateral Medullary Infarction

PURPOSE: To determine whether high-resolution contrast-enhanced three dimensional imaging with spoiled gradient-recalled sequence (HR-CE 3D-SPGR) plays a meaningful role in the assessment of intracranial vertebral artery (ICVA) and posterior inferior cerebellar artery (PICA) in lateral medullary infarction (LMI). MATERIALS AND METHODS: Twenty-five patients confirmed with LMI were retrospectively enrolled with approval by the IRB of our institute, and 3T MRI with HR-CE 3D-SPGR and contrast-enhanced magnetic resonance angiography (CE-MRA) were performed. Two radiologists who were blinded to clinical information and other brain MR images including diffusion weighted image independently evaluated arterial lesions in ICVA and PICA. The demographic characteristics, the area of LMI and cerebellar involvement were analyzed and compared between patients with arterial lesion in ICVA only and patients with arterial lesions in both ICVA and PICA on HR-CE 3D-SPGR. RESULTS: Twenty-two of twenty-five LMI patients had arterial lesions in ICVA or PICA on HR-CE 3D SPGR. However twelve arterial lesions in PICA were not shown on CE-MRA. Concurrent cerebellar involvement appeared more in LMI patients with arterial lesion in ICVA and PICA than those with arterial lesion in ICVA alone (p = 0.069). CONCLUSION: HR-CE 3D-SPGR can help evaluate arterial lesions in ICVA and PICA for LMI patients.

The Added Value of Double Dose Gadolinium Enhanced 3D T2 Fluid-Attenuated Inversion Recovery for Evaluating Small Brain Metastases

PURPOSE: Single dose gadolinium (Gd) enhanced fluid-attenuated inversion recovery (FLAIR) is helpful for visualizing superficial parenchymal metastases. However, the usefulness of FLAIR with a higher dose of Gd is uncertain. The aim of our study was two-folds: first, to prove that the signal to noise ratio (SNR) of small brain metastases is higher than large brain metastases on double-dose (DD) enhanced FLAIR and, second, to explore the added value of DD Gd enhanced FLAIR in relation to T1 GRE for evaluating small brain metastases. MATERIALS AND METHODS: For the first purpose, 50 pairs of small (2 mm5 mm) were included. The difference in the SNR and contrast ratio (CR) between small and large metastases on DD Gd-enhanced 3D T2 FLAIR was compared by Wilcoxon signed-rank tests. For the second purpose, a total of 404 small metastases were included. The diagnostic sensitivities between 3D T1 gradient echo (GRE) alone and combined results of 3D T1 GRE and 3D T2 FLAIR were compared with McNemar test. RESULTS: The SNR and CR of small brain metastases were significantly higher than those of large brain metastases (p<0.001). In qualitative analysis, the diagnostic sensitivities for small brain metastases were significantly higher for 3D T1 GRE plus 3D T2 FLAIR than 3D T1 GRE alone regardless of scan time (p<0.001). CONCLUSION: Small brain metastases showed higher signal intensity than large brain metastases on the DD Gd enhanced 3D T2 FLAIR images. DD Gd enhanced 3D T2 FLAIR imaging may have a complementary role to 3D T1 GRE for evaluating small brain metastases.

The Effects of Pueraria lobata on Osteoclast Differentiation and Bone Resorption / 체질인류학회지

Previous researches have proved that Pueraria lobata up-regulates bone mineral contents and bone mineral density in bone-loss model, ovariectomized mice and orchidectomized rats. However, the precise effects and mechanisms of Pueraria lobata on osteoclast differentiation and bone resorbing activity of mature osteoclasts still remains unknown. Therefore, we investigated the effect and mechanism of Pueraria lobata on receptor activator of nuclear factor-kappaB ligand (RANKL) and macrophage colony stimulation factor (M-CSF)-induced osteoclast differentiation in bone marrow macro-phages (BMMs). First of all, we treated BMMs derived from mice with various concentrations of Pueraria lobata in order to perform screening by tartrate-resistant acid phosphatase (TRAP) staining. Also, we conducted western blotting and RT-PCR for the purpose of verifying the treatment mechanism of Pueraria lobata and lastly, we used hydroxyapatite-coated plate to evaluate the effects of Pueraria lobata on bone resorbing activity of mature osteoclasts. As a result, Pueraria lobata has inhibitory effect on phosphorylation of p38, Akt, c-Jun N-terminal kinase (JNK), and IkappaB which are essential early signaling pathway of osteoclastogenesis. Also, the inactivation of nuclear factor of activated T cells (NFAT)c1, and c-Fos which is caused by Pueraria lobata is followed by the suppression effects of Pueraria lobata on osteoclast-related various genes, osteoclast-associated receptor (OSCAR), TRAP, Integrin beta3, osteoclast stimulatory transmembrane protein (OC-STAMP), and dendritic cell-specific transmembrane protein (DC-STAMP). Particularly, Pueraria lobata blocks the formation of pit area on hydroxyapatite-coated plate in a dose-dependent manner as well as the mRNA expression of Cathepsin K, which is associated with bone resorbing activity. These results demonstrate the molecular mechanism relating to anti-osteoclastogenesis effect of Pueraria lobata as well as the inhibitory effect of Pueraria lobata on mature osteoclast formation and bone resorbing activity.

Intramedullary Spinal Lesions Involving the Conus Medullaris: MR Imaging Features for Differential Diagnosis

PURPOSE: Intramedullary spinal lesions in the conus medullaris (CM), including tumors and vascular lesion, are rarely reported. We reported various MR features of intramedullary spinal cord lesions involving the CM including ependymoma, hemangioblastomas, dermoid cyst, ventriculus terminalis and spinal AVF and tried to discuss them for differential diagnosis. MATERIALS AND METHODS: Six patients (male: female = 4:2, mean age = 44.3 year old) were enrolled from the clinical database of our institute from 2004 to 2010 and their radiological images and clinical symptoms were reviewed retrospectively. All patients had taken initial and postoperative MRI with contrast enhancement using gadopentate dimeglumine (Gd-DTPA). These images were analyzed by tumor size, location, signal intensity relative to the spinal cord, vascular flow voids, syrinx or cyst, edema and enhancement pattern. RESULTS: Contrast enhancement was seen in all intramedullary masses. An eccentric enhancing nodule was noted in two hemangioblastomas and unusual peripheral rim enhancement with septation was seen in ventriculus terminalis. Patchy enhancement of the CM was observed in spinal arteriovenous fistula (AVF). Extensive cord edema adjacent to the intramedullary lesions was seen in four cases and syrinx was noted in three cases. Vascular signal voids were found in two hemangioblastomas and one spinal AVF. CONCLUSION: In evaluation of intramedullary spinal lesions in the CM, it is necessary to consider these unusual MR findings and discriminate various pathologies with prudence and caution.

Quantitative Assessment of Tumor Responses after Radiation Therapy in a DLD-1 Colon Cancer Mouse Model Using Serial Dynamic Contrast-Enhanced Magnetic Resonance Imaging

PURPOSE: The purpose of this study was to investigate the predictability of pretreatment values including Dynamic Contrast-Enhanced Magnetic Resonance Imaging (DCE-MRI) derived parameters (Ktrans, Kep and Ve), early changes in parameters (Ktrans, tumor volume), and heterogeneity (standard deviation of Ktrans) for radiation therapy responses via a human colorectal cancer xenograft model. MATERIALS AND METHODS: A human colorectal cancer xenograft model with DLD-1 cancer cells was produced in the right hind limbs of five mice. Tumors were irradiated with 3 fractions of 3 Gy each for 3 weeks. Baseline and follow up DCE-MRI were performed. Quantitative parameters (Ktrans, Kep and Ve) were calculated based on the Tofts model. Early changes in Ktrans, standard deviation (SD) of Ktrans, and tumor volume were also calculated. Tumor responses were evaluated based on histology. With a cut-off value of 0.4 for necrotic factor, a comparison between good and poor responses was conducted. RESULTS: The good response group (mice #1 and 2) exhibited higher pretreatment Ktrans than the poor response group (mice #3, 4, and 5). The good response group tended to show lower pretreatment Kep, higher pretreatment Ve, and larger baseline tumor volume than the poor response group. All the mice in the good response group demonstrated marked reductions in Ktrans and SD value after the first radiation. All tumors showed increased volume after the first radiation therapy. CONCLUSION: The good response after radiation therapy group in the DLD-1 colon cancer xenograft nude mouse model exhibited a higher pretreatment Ktrans and showed an early reduction in Ktrans, demonstrating a more homogenous distribution.

Correlations of 3T DCE-MRI Quantitative Parameters with Microvessel Density in a Human-Colorectal-Cancer Xenograft Mouse Model

OBJECTIVE: To investigate the correlation between quantitative dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) parameters and microvascular density (MVD) in a human-colon-cancer xenograft mouse model using 3 Tesla MRI. MATERIALS AND METHODS: A human-colon-cancer xenograft model was produced by subcutaneously inoculating 1 x 106 DLD-1 human-colon-cancer cells into the right hind limbs of 10 mice. The tumors were allowed to grow for two weeks and then assessed using MRI. DCE-MRI was performed by tail vein injection of 0.3 mmol/kg of gadolinium. A region of interest (ROI) was drawn at the midpoints along the z-axes of the tumors, and a Tofts model analysis was performed. The quantitative parameters (Ktrans, Kep and Ve) from the whole transverse ROI and the hotspot ROI of the tumor were calculated. Immunohistochemical microvessel staining was performed and analyzed according to Weidner's criteria at the corresponding MRI sections. Additional Hematoxylin and Eosin staining was performed to evaluate tumor necrosis. The Mann-Whitney test and Spearman's rho correlation analysis were performed to prove the existence of a correlation between the quantitative parameters, necrosis, and MVD. RESULTS: Whole transverse ROI of the tumor showed no significant relationship between the MVD values and quantitative DCE-MRI parameters. In the hotspot ROI, there was a difference in MVD between low and high group of Ktrans and Kep that had marginally statistical significance (ps = 0.06 and 0.07, respectively). Also, Ktrans and Kep were found to have an inverse relationship with MVD (r = -0.61, p = 0.06 in Ktrans; r = -0.60, p = 0.07 in Kep). CONCLUSION: Quantitative analysis of T1-weighted DCE-MRI using hotspot ROI may provide a better histologic match than whole transverse section ROI. Within the hotspots, Ktrans and Kep tend to have a reverse correlation with MVD in this colon cancer mouse model.

Prevalence of Spotted Fever Group Rickettsia from Haemaphysalis Ticks in Chungju Province

A total of 190 ticks collected from the Chungju area of Korea was examined for the presence of Spotted Fever Group(SFG) Rickettsia using a PCR assay. Twenty-five (13.2%) Haemaphysalis ticks were found positive of the groEL gene of SFG Rickettsia. The prevalence rate of R. japonica in these 25 Haemaphysalis ticks was 72% (18 out of 25 SFG Rickettsia). The prevalence rate of R. conorii and new SFG rickettsia in these 25 Haemaphysalis ticks was 4% (1 out of 25 SFG Rickettsia) and 24% (6 out of 25 SFG Rickettsia), respectively. These results suggest that R. japonica was the highest infection frequency among in Haemaphysalis ticks SFG Rickettsia, and that R. conorii and new SFG Rickettsia are also present in the Chungju area.

Limbus Vertebra Demonstrated by Computed Tomography or Magnetic Resonance Image / 대한척추외과학회지

STUDY DESIGN: We studied retrospectively the limbus vertebra by computed tomography or magnetic resonance image. OBJECTIVES: To analyze the clinical and radiologic characteristics of the limbus vertebra and to distinguish it from a fracture, infection or tumor. SUMMARY OF LITERATURE REVIEW: The limbus vertebra is common. However, the clinical manifestations including the level, symptoms and radiologic characteristics of the limbus vertebra are not understood exactly in the literatures. MATERIALS AND METHODS: We presented 25 cases of the limbus vertebra that were confirmed by plain roentgenogram combined with computed tomography (CT) or magnetic resonance imaging (MRI). Of the 25 patients, 18 were males and 7 females. RESULTS: The levels of the limbus vertebra were L3 (2 cases), L4 (13 cases), and L5 (8 cases). There were two cases of 2 level involvement (L3/4 and L4/5). All cases showed the lower lumbar lesion and complained of the lower back pain. The accompanying diseases included 10 cases of herniated intervertebral discs, 2 cases of ankylosing spondylitis, 2 cases of spinal stenosis and one spondylolisthesis. Three patients were first diagnosed as tuberculous spondylitis and 2 patient as spine fracture on plain roentgenograms. But they can be confirmed by demonstrating the herniation of disc material between the anterosuperior bony fragment and the rest of the body in CT or MRI. CONCLUSIONS: The CT or MRI could be great diagnostic modalities. The pathogenesis is thought to be the herniation of disc material into the vertebral body such as Schmorl's node and disc degeneration. Most limbus vertebra was found at the lower lumbar region and accompanied with disc bulging and degeneration. The correlation between the limbus vertebra and lower back pain is not certain.

SUB-ORBICULARIS OCULUS FAT(SOOF) RESECTION IN AESTHETIC BLEPHAROPLASTY

The traditional aesthetic blepharoplasty has limitations in correcting the heaviness and bulkiness of the lateral orbital region. These limitation is due to presence of sub-orbicularis oculus fat(SOOF) which is defined as that layer of fibrofatty soft tissue deep to the orbicularis oculus muscle, superficial to orbital septum and orbital rim, and extending medially from supraorbital nerve and laterally to varying distance over the lateral upper orbit. Therefore authors performed resections of the SOOF in conjunction with aesthetic blepharoplasty in 15 patients, who visited the clinic with complaints of thickness and heaviness over their lateral eyebrow, often accompanied by tired or sad-looking appearance. We believe that in these patients the heaviness. bulkiness and fullness in the lateral upper orbital region were corrected effectively and smoothly in aesthetical aspect. No patients developed postoperative hematoma, dry eye syndrome, lacrimal gland injury and significant paralysis of the orbicularis oculus of corrugator muscle. Our department performed the SOOF resection to those who had bulkiness and heaviness in lateral upper orbital region. From this experience, the SOOF resection would appear to be a useful adjunct to standard blepharoplasty technique in selected patients. Since we achieved a satisfactory result aesthetically through this method on patients who showed proper indications, we are recording the indications, operative techniques and complications in addition to review of reference.

Nasal Tip plasty on the Bulbous Nasal Tip

Management of the bulbous nasal tip with inadequate projection and drooping is challenging aesthetic plastic surgery. The bulbous nasal tip is influenced by several factors; 1) thick, non-elastic oily skin, 2) soft tissue bulkiness due to supratip fibrous fatty tissue, and 3) a wide intercrural angle or increased interdormal distance. Another common factor among caucasians, hypertrophic alar cartilage, is seen less in orientals. These variable factors can be corrected with various surgical maneuvers for proper tip projection and refined alar shape. All these procedures are performed through open rhinoplasty incision. The fibromuscular fatty tissue on the nasal tip is resected with subdermal tangential excision without violating the detmal blood supply. The proximal part of the lateral crus, dome and the part of medial crus which was isolated from the skin and nasal mucosa are replaced and plicated in midline in the role of a new columellar strut and skeletal support. If more skeletal supports are desired, the new columellar is reinforced with a silicone strut and conchal cartilage onlay grafts are applied. And for lengthening of the columella, a V-Y advancement incision on the columellar base with open rhinoplasty is applied. The pressure splint on the upper third of the columella and nasal tip is applied on the 7th postoperative day and maintained for two months. All procedures are focused on the preservation of catilaginous integrity and in providing skeletal support. We performed nasal tip plasty on the bulbous nasal tip and its simple technique and predictability resulted in improved nasal tip projection and contour.