An overview of minimal incisional ptosis correction: A surgeon’s perspective

People increasingly prefer fast and convenient methods for aesthetic procedures in busy modern society. Therefore, physicians and patients increasingly desire to improve cases of mild ptosis of the eyes in a simpler way. The purpose of this review is to organize the surgical methods of minimal incisional ptosis correction that the author has developed to satisfy this need and to examine the indications of each method and its advantages and disadvantages. The basic technique is a triangular single-knot stitch method using five points. Additionally, the method of applying a special loop (tucking the Müller muscle by pulling the conjoint fascial sheath) and the method of combining a non-incisional method with making a loop will be explained herein.

Management of Lacrimal Fistula during Epicanthoplasty: A Case Report

Lacrimal fistula (LF) is a rare abnormality of the lacrimal system. Patients with LF are usually asymptomatic, and thus, treatment is unnecessary. During surgery on a patient with LF, the fistula may fall into the range of dissection. In such cases, fistula management becomes important. A 19-year-old woman visited our department to receive incisional blepharoplasty and medial epicanthoplasty, and a preoperative physical examination revealed LF. During surgery, we found the fistula tract to be within the dissection field, and thus, the LF was cut and cauterized. One year after the surgery, inflammation and hypertrophy of the remnant lacrimal duct occurred. The wound was stabilized by creating an opening that reconnected the stump and the overlying skin. Through this case, we hope to establish the appropriate strategy for managing LF detected during medial epicanthoplasty. As seen in our case, cauterization should be avoided because of the high recurrence rate of LF. Instead, as definitive treatment, fistulectomy should be performed, or the fistula should be moved along with the skin flap when a small skin flap is transferred.

Management of Lacrimal Fistula during Epicanthoplasty: A Case Report

Lacrimal fistula (LF) is a rare abnormality of the lacrimal system. Patients with LF are usually asymptomatic, and thus, treatment is unnecessary. During surgery on a patient with LF, the fistula may fall into the range of dissection. In such cases, fistula management becomes important. A 19-year-old woman visited our department to receive incisional blepharoplasty and medial epicanthoplasty, and a preoperative physical examination revealed LF. During surgery, we found the fistula tract to be within the dissection field, and thus, the LF was cut and cauterized. One year after the surgery, inflammation and hypertrophy of the remnant lacrimal duct occurred. The wound was stabilized by creating an opening that reconnected the stump and the overlying skin. Through this case, we hope to establish the appropriate strategy for managing LF detected during medial epicanthoplasty. As seen in our case, cauterization should be avoided because of the high recurrence rate of LF. Instead, as definitive treatment, fistulectomy should be performed, or the fistula should be moved along with the skin flap when a small skin flap is transferred.

Botulinum Toxin Type A for Treatment of Masseter Hypertrophy: Volumetric Analysis of Masseter Muscle Reduction over Time

BACKGROUND: There has been increasing interest in facial contouring procedures throughout Asian countries. As such, botulinum toxin A injections for masseteric hypertrophy have become a common procedure provided to patients who desire non-surgical correction of a square-angled mandible. We published a retrospective review of our initial results and our technique and treatment protocol in 2005. We also completed a long-term follow-up of the results (average follow-up period of 4.28 years) and the efficacy of repeated injections in 2010. The purpose of the current study is to systematically evaluate the changes to the masseter muscle at weekly intervals to determine the physiologic effects of botulinum toxin A injection. METHODS: Eight patients were prospectively followed on a weekly basis after botulinum toxin A injection for masseteric hypertrophy. Eight patients were followed for 15 weeks and four patients were followed for 25 weeks. Changes in the thickness of the muscle were recorded and analyzed. RESULTS: A reduction in the muscle thickness was found during the clenching phase of the muscle in the first week followed by a reduction in thickness during the resting phase in the second week. The reduction in muscle thickness continued until the eleventh week after which there was a gradual, but incomplete, return of muscle thickness over the study period. CONCLUSIONS: There is a predictable, phasic reduction in muscle thickness after botulinum toxin A injection for masseteric hypertrophy. This reduction first occurs during the clenching phase followed by a concomitant reduction during the resting phase. Maximal size reduction occurs at 11 weeks followed by gradual muscle size recovery.

Mild Ptosis Correction with the Stitch Method During Incisional Double Fold Formation

BACKGROUND: Numerous methods exist for simultaneous correction of mild blepharoptosis during double eyelid surgery. These methods are generally categorized into either incisional (open) or non-incisional (suture) methods. The incisional method is commonly used for the creation of the double eyelid crease in patients with excessive or thick skin. However, concurrent open ptosis correction is often marred by the lengthy period of intraoperative adjustment, causing more swelling, a longer recovery time, and an increased risk of postoperative complications. METHODS: The authors have devised a new, minimally invasive technique to alleviate mild ptosis during incisional double eyelid surgery. The anterior lamella is approached through the incisional technique for the creation of a double eyelid while the posterior lamella, including Muller's and levator muscles, is approached with the suture method for Muller's plication and ptosis correction. RESULTS: The procedure described was utilized in 28 patients from June 2012 to August 2012. Postoperative asymmetry was noted in one patient who had severe preoperative conjunctival scarring. Otherwise, ptosis was corrected as planned in the rest of the cases and all of the patients were satisfied with their postoperative appearance and experienced no complications. CONCLUSIONS: Our hybrid technique combines the benefits of both the incisional and suture methods, allowing for a predictable and easily reproducible correction of blepharoptosis with an aesthetically pleasing double eyelid.

Comprehensive Review of Asian Cosmetic Upper Eyelid Oculoplastic Surgery: Asian Blepharoplasty and the Like

BACKGROUND: Asian Aesthetic Oculoplastic Surgery is a fast-growing field, both within the United States and abroad. With growing interest, there have also been multiple terminologies used for the same concepts. This has created redundant and confusing language - prone to errors in patient-physician communication. In addition, there has been an upsurge of various techniques or variations to existing techniques that has created unnecessary confusion among plastic surgeons. The objective of this article is to provide organization and simplification to the terminology and to the techniques used in what some broadly refer to as "Asian Blepharoplasty" or perhaps more correctly termed Asian Aesthetic Oculoplastic Surgery. METHODS: Unified terminology, aesthetic goal and detailed operative technique of commonly conducted Asian blepharoplasty were suggested by experienced oculoplastic surgeons. RESULTS: The main procedures of Asian Aesthetic Oculoplastic Surgery including supratarsal crease surgery and medial epicanthoplasty were presented with figure and video in this paper. We also have provided author's preferred selection of the major techniques with evaluation of its advantages and disadvantages. CONCLUSIONS: The most important element in patient satisfaction is clear communication of surgical expectations. Then, proper selection of the most suitable pre-operative design, type of surgery performed, and specific crease configuration based on the individual's anatomic and physiological characteristics can be achieved.

Combined, Minimally Invasive, Thread-based Facelift

BACKGROUND: As society changes, patients have high expectations of plastic surgery and rapid recovery after surgery. A thread-based facelift meets these requirements and is growing in popularity. METHODS: Former thread lifts were either floating or fixed types. The authors used both types. Using a vertical line from the lateral orbital rim as the center, the anterior face was lifted with floating-type threads and the lateral face was lifted with fixed-type threads. The Blue RoseTM thread was used for the combined-type facelift, as it is stronger than other threads. Improvements were measured using the Global Aesthetic Improvement Scale (GAIS). RESULTS: Eighteen patients out of 28 were followed over 3 months. Five patients (28%) reported a GAIS score of 2, 10 patients (55%) had a GAIS score of 3, 2 patients (11%) had a GAIS score of 4, and one patient was unsatisfied with the surgical results. Results showed improvements in 83% of the patients. CONCLUSIONS: The combined, minimally invasive, thread-based facelift has some benefits. First, the functional anatomy of the face is considered. Second, the pulling force of the threads is stronger than formerly used threads. Third, especially in Asian patients, the postoperative broadening of the malar area can be minimized. Thus, a combined thread lift using Blue Rose threads can provide a natural-looking and strong facelift.

The Relationship Between Eyebrow Elevation and Height of the Palpebral Fissure: Should Postoperative Brow Descent be Taken into Consideration When Determining the Amount of Blepharoptosis Correction?

BACKGROUND: Combining blepharoptosis correction with double eyelid blepharoplasty is common in East Asian countries where larger eyes are viewed as attractive. This trend has made understanding the relationship between brow position and height of the palpebral fissure all the more important in understanding post-operative results. In this study, authors attempt to quantify this relationship in order to assess whether the expected postoperative brow descent should be taken into consideration when determining the amount of ptosis to correct. METHODS: Photographs of ten healthy female study participants were taken with brow at rest, with light elevation and with forceful elevation. These photographs were then viewed at 2 x magnification on a computer monitor and caliper was used to measure the amount of pull on the eyebrow in relation to the actual increase in vertical fissure of the eye. RESULTS: There was a positive, linear correlation between amount of eyebrow elevation and height of the palpebral fissure, which was statistically significant. Brow elevation increased vertical fissure, and thereby aperture of the eye, by 18%. CONCLUSIONS: Although the eye-opening strength as well as height of the palpebral fissure is improved with ptosis repair, the true effectiveness of ptosis surgery is diminished by the associated descent of the brow from relief of the involuntary frontalis muscle action and this should be taken into account prior to surgical intervention. Regardless, the combination of frontalis muscle relaxation and the increased eye-opening strength from ptosis repair gives the eye and the periorbital region a more natural look.

Cases of Mild Ptosis Correction with Suture-Method

There are many methods to correct mild blepharoptosis and create double eyelid creases. However, all prior methods have the disadvantages of prolonged swelling, increased recovery time, and the need for an incision when the ptosis correction is simultaneously performed with double eyelid surgery. The authors have devised a new minimally invasive technique to correct mild ptosis during double eyelid surgery. Our technique utilizes stronger suture methods to create double eyelid folds and simultaneously perform the ptosis repair. The correction of mild blepharoptosis is achieved through the transconjunctival Muller's muscle tucking technique during a non-incisional suture method of double eyelid surgery.

Surgical Treatment of Contact Point Headache

OBJECTIVES: Contact point headache is caused by contact between the nasal septum and the lateral nasal wall, resulting in referred pain involving the trigeminal nerve. We aimed to assess the benefits of surgical correction in patients with endoscopic and radiographic evidence of a contact point in the nasal cavity. MATERIALS AND METHODS: A prospective study was performed on patients who met the following criteria:) history of chronic headache, 2) lack of acute or chronic inflammatory findings, 3) presence of a contact point upon nasal endoscopy and CT scan, 4) relief of headache within five minutes after applying topical anesthesia to the contact point. The severity of pain was assessed preoperatively and postoperatively using a visual analogue scale (VAS). The duration and frequency of headaches were also assessed using a questionnaire. RESULT: The patients whose headaches were believed to result from an intranasal contact point underwent surgical management. According to the same pain questionnaire given preoperatively and postoperatively, severity, duration, and frequency of headache were significantly reduced. CONCLUSION: A contact point headache must be considered in patients who have no other obvious causes of headache. Significant relief can be obtained by surgery in patients with endoscopic and radiographic evidence of a contact point in the nasal cavity.

The Utility of Galectin-3, MUC1, Epidermal Growth Factor Receptor in Differential Diagnosis of Thyroid Nodule / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The diagnosis of thyroid nodular diseases is critical in clinical management. Fine needle aspiration cytology and ultrasound-guided core needle biopsy are widely considered as diagnostic techniques in assessment of thyroid nodular diseases. Because of the histological similarity of follicular patterned thyroid lesions, the differential diagnosis between some thyroid lesions is often difficult to determine, even with permanent sections. For this reason, we assessed diagnostic usefulness of immunohistochemical staining for the three potential markers of malignant thyroid nodule, Galectin-3, MUC1 and EGFR (Epidermal growth factor receptor) in the tissue obtained by surgery. SUBJECTS AND METHOD: The immunohistochemical expression of galectin-3, MUC1 and EGFR was evaluated in 76 thyroid lesions obtained by surgery to assess their potential as markers in differential diagnosis of thyroid nodule. The following were studied: 20 cases of papillary carcinoma, 16 cases of follicular carcinoma, 20 cases of follicular adenoma and 20 cases of adenomatous goiter. RESULTS: The expression of Galectin-3 was stronger in malignant thyroid nodules, especially in papillary carcinoma, than in benign thyroid nodules. However, there were no significant differences in the expression rates of MUC1 and EGFR between malignant thyroid nodules and benign thyroid nodules. The expression of MUC1 and EGFR was weaker in follicular neoplasm than in other thyroid nodules. CONCLUSION: Galectin-3 was a reliable marker for papillary carcinoma. The expression of MUC1 and EGFR was increased in the papillary carcinoma and goiter, so if we could selectively identify cytoplasm MUC1, we could distinguish papillary carcinoma from the goiter.

A Case of Cochlear Implantation in a Patient with Mutation in the Coagulation Factor C Homology Gene(W117R) / 대한이비인후과학회지

The autosomal dominant deafness disorder at the DFNA9 locus has been described and the clinical aspects extensively characterized, showing adult-onset, progressive sensorineural hearing loss and vestibular dysfunction. DFNA9 is caused by mutations of the human Coagulation factor C homology (COCH)gene. COCH encodes cochlin, a highly abundant secreted protein of unknown function in the inner ear. Several mutations have been identified so far: P51S, V66G, G87W, G88E, V104del, I109T, I109N, W117R, A119T, M512T, C542F, C542T. We hereby report a case of cochlear implantation in a 55-year-old man with bilateral sensorineural hearing loss, which is caused by a mutation in COCH gene (W117R).

The Relationship between Harm Avoidance Temperament and Right Frontal and Left Parietal Lobes in Young Adults: A Cortical Thickness Analysis

OBJECTIVES: Increasing evidence suggests the presence of neurobiological bases for temperamental characteristics in humans. Brain correlates of harm avoidance(HA) have been most extensively studied using functional and structural brain imaging methods due to its potential link with anxiety and depressive disorders. To date, however, we are not aware of any reports that have examined the potential relationship between HA levels and regional cortical thickness. The aim of the current study is to examine the cortical thickness which is associated with HA temperament in healthy young subjects. METHODS: Twenty-eight young, healthy individuals(13 men and 15 women, mean age, 29.4 +/- 6.3 years) were screened for eligibility and administered the Korean version of the Cloninger's Temperament and Character Inventory and underwent high-resolution structural magnetic resonance imaging scanning. RESULTS: HA was associated with cortical thickness in the right superior frontal cortex and in the left parietal cortex, adjusted for age and sex and corrected for multiple comparisons using the permutation testing method. CONCLUSION: Individual temperamental differences in HA are associated with structural variations in specific areas of the brain. The fact that these brain regions are involved in top-down modulations of subcortical fear reactions adds functional significance to current findings.

Blepharoptosis Correction with Stitch Method

There are various methods to correct mild ptosis and to make a double fold. However, all pre-existing methods have similar disadvantages, such as long-lasting swelling and down time. Recently, many patients prefer more convenient and minimal invasive methods with faster recovery. So we have devised a new technique to correct mild ptosis. Our technique is very similar to other non-incisional stitch methods. We try to correct ptosis through Muller's muscle tucking using the non-incisional stitch method. We think this method could be applied to mild degree ptosis. We hope to report the long-term follow up data of our cases and analysis with more efficient technique in the near future.

Solitary Fibrous Tumor in Nasal Cavity: Surgical Treatment after Angiographic Embolization / 대한이비인후과학회지

The solitary fibrous tumor (SFT) is made of potential malignant spindle cells, a neoplasm of mesenchymal origin that is normally described as a thoracic lesion originating from pleural tissues. Recently, numerous extrapleural sites of the origins such as the following have been described: the liver, parapharyngeal space, sublingual gland, tongue, vulva, parotid gland, thyroid, larynx, nasal cavity and paranasal sinuses. The treatment of choice for SFTs is a complete surgical excision of the tumor. But, the possibility of profuse bleeding must be considered during resection and even during initial biopsies. This case report presents a case of an SFT in the nasal cavity of a 20-year-old male patient who was treated with surgical treatment after angiographic embolization.

Otologic Manifestations in Patients with Systemic Lupus Erythematosus / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Systemic lupus erythematosus (SLE) is considered a prototype of the autoimmune disease because of its multi-organ involvement. Pathologic immune complexes and autoantibodies are the main causes of organ damage. Patients with SLE appear to be at increased risk of inner ear injury. The aim of this study was to evaluate the audiovestibular manifestations in patients with SLE. SUBJECTS AND METHOD: We investigated the audiovestibular manifestations of 22 patients with SLE. Pure tone audiometry and electronystagmography were performed for baseline evaluation. ESR, complement count and dsDNA were evaluated to investigate relationships between audiovestibular manifestations and disease activity of SLE. RESULTS: Ten (45.5%) patients complained of hearing loss. Four of 10 patients were diagnosed as sensorineural hearing loss (SNHL) and 3 patients as sudden SNHL. 9 (40.9%) patients complained of vertigo. Five of 9 patients were diagnosed as peripheral vestibulopathy, 2 as central vestibulopathy and 2 showed nonspecific findings. Audiovestibular symptoms were not related with disease activity of SLE (p>0.05). CONCLUSION: Audiovestibular symptoms are rare but various among patients with SLE. The mechanism of ear damage remains unknown. Thus, additional prospective studies are needed to elucidate its pathogenesis.

Culture of Chondrocytes on Scaffolds with Different Pore Network of PLGA and PLLA

This study was performed to investigate the in vitro proliferation and migration of rabbit auricular chondrocytes into the various sized pore of PLLA and PLGA scaffolds. The chondrocytes were harvested, expanded, and seeded onto PLGA(50 : 50, 75 : 25, 85 : 15) and PLLA scaffold having either small(50 - 100 micrometer) or large(300 - 350 micrometer) pores. On the 4th and 8th week after culture, histologic observation and quantitative DNA assay were done. We noted that the largest amount of DNA was found in the 85 : 15 PLGA sponges than others, and in the 4th and 8th week, some amount of DNA was detected in the lower portion of 85 : 15 PLGA sponge only, and DNA amounts were increased during the culture period in the 85 : 15 PLGA, significantly. We also found that the numbers of cells were low in middle portion of scaffolds, and in large pore-sized group of 85 : 15 PLGA, there were many cells in the lower portion of the scaffolds more than that of small pore group. In conclusion, the pore size of the scaffold for chondrocyte culture is important for cell migration and proliferation, and PLGA, especially 85 : 15 PLGA with 300- 350 micrometer sized pore is the more suitable biomatrix for proliferation and migration of the chondrocytes.

A Case of Melkersson-Rosenthal Syndrome

Melkersson-Rosenthal syndrome is a rare condition and clinical diagnosis was established on the basis of the triad: facial or lip edema, peripheral facial palsy and scrotal or plicated tongue. Labial swelling(Cheilitis granulomatosa) is the most common feature of this syndrome complex. The lips may enlarge up to three times their normal size, resulting in aesthetic deformity and functional disability. The condition appears to be a granulomatous disorder causing edema and inflammation of the soft tissues of the face, lips, oral cavity and particularly, the facial nerve. Traditional medical interventions are only marginally successful in treating this syndrome. We report the case of a young man with cheilitis granulomatosa as a manifestation of Melkersson-Rosenthal syndrome successfully treated by transverse and vertical star-shaped resection with a transmodiolar labial suspension suture at mouth angle. Our result shows symmetry of the lip, a normalized anterior projection, dimensional harmony between upper and lower lip and no disfiguring cicatrices.