Changes in eyebrow position following blepharoptosis surgery

Background@#The position of the eyebrows is critical when planning blepharoptosis surgery. However, insufficient scholarly attention has been paid to the details of postoperative eyebrow height changes at each anatomical landmark. This study investigated the effect of blepharoptosis surgery on brow height and evaluated the change in brow position. @*Methods@#After a retrospective review of 247 patients, this study analyzed 53 patients (106 eyelids) who underwent levator and Müller’s complex advancement between March 2010 and January 2022. Brow heights were measured from the distance between the upper brow margin of each landmark and horizontal line of pupillary center on a digital photograph. @*Results@#The mean change of eyebrow lowering was 1.54 mm (P<0.001) at the medial canthus, 1.29 mm (P<0.001) at the medial limbus, 1.44 mm (P<0.001) at the center of the pupil, 1.40 mm (P<0.001) at the lateral limbus, 1.15 mm (P=0.001) at the lateral canthus, and 0.75 mm (P=0.021) at the lateral eyebrow end. The brow change was most prominent at medial canthus and least prominent at the lateral brow end. The preoperative brow position was only statistically significant factor predicting brow height descent after surgery according to multiple linear regression analysis (R2=0.305, B=–0.375, P<0.001). @*Conclusions@#The eyebrows lowered in most patients after blepharoptosis surgery. The preoperative brow position is the most important factor in predicting the change in brow height after blepharoptosis surgery.

A novel technique for nipple reduction surgery: the tripod wedge resection method

Nipple size varies from person to person, but having a large nipple, or macrothelia, can be a concern for some women; therefore, some surgical methods have been developed for the reduction of nipple size. Conventional surgical methods for nipple reduction are classified into two types according to their purpose: reduction of length and reduction of diameter. For reduction of length, soft tissue is resected (except the central supplying vessel) and shortened by circumferential repair. The disadvantage of this method is possible necrosis of the nipple and impairment of the lactiferous duct. For reduction of diameter, a wedge-shaped resection is done from side to center and the defect is covered by a local advancement flap. The disadvantage of this method is the locally focused tension line, which is associated with unfavorable aesthetic outcomes. In this article, we present a case involving a novel method of nipple reduction surgery, referred to as the tripod wedge resection technique, which has three benefits compared to conventional nipple reduction surgery: simultaneous reduction of both length and diameter, relative safety for the vasculature and lactiferous duct, and an evenly tensioned incision line.

A novel technique for nipple reduction surgery: the tripod wedge resection method

Nipple size varies from person to person, but having a large nipple, or macrothelia, can be a concern for some women; therefore, some surgical methods have been developed for the reduction of nipple size. Conventional surgical methods for nipple reduction are classified into two types according to their purpose: reduction of length and reduction of diameter. For reduction of length, soft tissue is resected (except the central supplying vessel) and shortened by circumferential repair. The disadvantage of this method is possible necrosis of the nipple and impairment of the lactiferous duct. For reduction of diameter, a wedge-shaped resection is done from side to center and the defect is covered by a local advancement flap. The disadvantage of this method is the locally focused tension line, which is associated with unfavorable aesthetic outcomes. In this article, we present a case involving a novel method of nipple reduction surgery, referred to as the tripod wedge resection technique, which has three benefits compared to conventional nipple reduction surgery: simultaneous reduction of both length and diameter, relative safety for the vasculature and lactiferous duct, and an evenly tensioned incision line.

Cartilage tissue engineering for craniofacial reconstruction

Severe cartilage defects and congenital anomalies affect millions of people and involve considerable medical expenses. Tissue engineering offers many advantages over conventional treatments, as therapy can be tailored to specific defects using abundant bioengineered resources. This article introduces the basic concepts of cartilage tissue engineering and reviews recent progress in the field, with a focus on craniofacial reconstruction and facial aesthetics. The basic concepts of tissue engineering consist of cells, scaffolds, and stimuli. Generally, the cartilage tissue engineering process includes the following steps: harvesting autologous chondrogenic cells, cell expansion, redifferentiation, in vitro incubation with a scaffold, and transfer to patients. Despite the promising prospects of cartilage tissue engineering, problems and challenges still exist due to certain limitations. The limited proliferation of chondrocytes and their tendency to dedifferentiate necessitate further developments in stem cell technology and chondrocyte molecular biology. Progress should be made in designing fully biocompatible scaffolds with a minimal immune response to regenerate tissue effectively.

Dual vascular free transverse rectus abdominis myocutaneous flap for hemifacial reconstruction in a vessel-depleted neck

Cutaneous squamous cell carcinoma (SCC) is the second most common skin malignancy. This report describes the case of an unusual extensive SCC involving the whole hemiface, which required reconstruction with a combination of a dual vascular free transverse rectus abdominis muscle (TRAM) flap and a skin graft. A 79-year-old woman visited our hospital with multiple large ulcerated erythematous patches on her right hemiface, including the parieto-temporal scalp, bulbar and palpebral conjunctiva, cheek, and lip. A preliminary multifocal biopsy was performed in order to determine the resection margin, and the lesion was resected en bloc. Orbital exenteration was also performed. A free TRAM flap was harvested with preserved bilateral pedicles and was anastomosed with a single superior thyroidal vessel. The entire TRAM flap survived. The final pathological examination of the resected specimen confirmed that there was no regional nodal metastasis, perineural invasion, or lymphovascular involvement. The patient was observed for 6 months, and there was no evidence of local recurrence. Usage of a TRAM flap is appropriate for hemifacial reconstruction because the skin of the abdomen matches the color and pliability of the face. Furthermore, we found that the independent attachment of two extra-flap anastomoses to a single recipient vessel can safely result in survival of the flap.

De-epithelialized dermal flap for nipple reconstruction: A modified star flap

BACKGROUND: Multiple approaches for nipple reconstruction exist, and none is considered superior to all others. The star flap is one of the most popular methods for nipple reconstruction, but gradual height loss is a major concern. We present a new modification of the star flap that incorporates a de-epithelialized dermal flap, along with the associated surgical results. METHODS: We reviewed the medical records of patients who underwent nipple reconstruction using the modified star flap method. The design was different from the conventional star flap in that the lateral wings were changed into a trapezoidal shape and de-epithelialized dermal flaps were added. The patients were followed up at 2, 4, 6, and 12 months postoperatively, and nipple height was measured. The postoperative nipple height achieved using the modified method was compared with that obtained using the traditional method. RESULTS: From February 2013 to June 2017, 32 patients received surgery using the modified star flap, and 18 patients who underwent nipple reconstruction before 2013 comprised the conventional method group. All patients had undergone breast reconstruction with an abdominal tissue-based flap. The mean follow-up period was 14.4 months in the modified method group and 17.3 months in the conventional method group. The mean maintenance of projection at 12 months postoperatively was 56.28%±18.58% in the modified method group, and 44.23%±14.15% in the conventional method group. This difference was statistically significant (P<0.05). CONCLUSIONS: The modified method using a de-epithelialized dermal flap provides reliable maintenance of projection in patients who have undergone abdominal tissue-based breast reconstruction.

Mandibular reconstruction using customized three-dimensional titanium implant

Mandibular defects lead to severe deformation and functional deficiency. Vascularized osteocutaneous tissue has been widely used to reconstruct the mandible. However, it is technically challenging to shape this type of grafts in such a manner that they resemble the configuration of the mandible. A 48-year-old female patient who underwent anterolateral thigh (ALT) flap coverage after a tongue cancer excision was diagnosed with a tumor recurrence during the follow-up. A wide excision mandibulectomy and mandibular reconstruction with an ALT flap and a titanium implant were performed. The prefabricated titanium implant was fixed to the condyle. Then, an ALT flap was harvested from the ipsilateral thigh and anastomosed. After confirming that the circulation of the flap was intact, the implant was fixed to the parasymphysis. On the radiograph taken after the surgery, the prosthesis was well positioned and overall facial shape was acceptable. There was no postoperative complication during the follow-up period, 1 year and 2 months. The prefabricated implant allows the restoration of facial symmetry without harvesting autologous bone and it is a safe and effective surgical option for mandibular reconstruction.

Lymphatic vessel mapping in the upper extremities of a healthy Korean population

BACKGROUND: Intraoperative indocyanine green (ICG) lymphography can effectively detect functioning lymph vessels in edematous limbs. However, it is sometimes difficult to clearly identify their course in later-stage edematous limbs. For this reason, many surgeons rely on experience when they decide where to make the skin incision to locate the lymphatic vessels. The purpose of this study was to elucidate lymphatic vessel flow patterns in healthy upper extremities in a Korean population and to use these findings as a reference for lymphedema treatment. METHODS: ICG fluorescence lymphography was performed by injecting 1 mL of ICG into the second web space of the hand. After 4 hours, fluorescence images of lymphatic vessels were obtained with a near-infrared camera, and the lymphatic vessels were marked. Three landmarks were designated: the radial styloid process, the mid-portion of the cubital fossa, and the lower border of the deltopectoral groove. A straight line connecting the points was drawn, and the distance between the connected lines and the marked lymphatic vessels was measured at 8 points. RESULTS: There were 30 healthy upper extremities (15 right and 15 left). The average course of the main lymph vessels passed 26.0±11.6 mm dorsal to the styloid process, 5.7±40.7 mm medial to the mid-cubital fossa, and 31.3±26.1 mm medial to the three-quarters point of the upper landmark line. CONCLUSIONS: The main functioning lymphatic vessel follows the course of the cephalic vein at the forearm level, crosses the mid-cubital point, and travels medially toward the mid-axilla.

Prognostic Factors of Orbital Fractures with Muscle Incarceration

BACKGROUND: Among the various signs and symptoms of orbital fractures, certain clinical findings warrant immediate surgical exploration, including gaze restriction, computed tomographic (CT) evidence of entrapment, and prolonged oculocardiac reflex. Despite proper surgical reconstruction, prolonged complications such as diplopia and gaze restriction can occur. This article evaluated the prognostic factors associated with prolonged complications of orbital fractures with muscle incarceration. METHODS: The medical records of 37 patients (37 orbits) with an orbital fracture with muscle incarceration from January 2001 to January 2015 were reviewed. The presence of Incarcerated muscle was confirmed via CT, as well as by intraoperative findings. Various factors potentially contributing to complications lasting for over 1 year after the injury were categorized and analyzed, including age, cause of injury, injury-to-operation time, operative time, fracture type, nausea, vomiting and other concomitant symptoms and injuries. RESULTS: All patients who presented with extraocular muscle limitations, positive CT findings, and/or a positive forced duction test underwent surgery. Of the 37 patients, 9 (24%) exhibited lasting complications, such as diplopia and gaze restriction. The mean follow-up period was 18.4 months (range, 1–108 months), while that of patients who experienced prolonged complications was 30.1 months (range, 13–36 months). Two factors were significantly associated with prolonged complications: injury-to-operation time and nausea/vomiting. Loss of vision, worsening of motility, and implant complication did not occur. CONCLUSIONS: Patients who present with gaze limitations, with or without other signs of a blow-out fracture, require a thorough evaluation and emergent surgery. A better prognosis is expected with a shorter injury-to-operation time and lack of nausea and vomiting at the initial presentation.

Prognostic Factors of Orbital Fractures with Muscle Incarceration

BACKGROUND: Among the various signs and symptoms of orbital fractures, certain clinical findings warrant immediate surgical exploration, including gaze restriction, computed tomographic (CT) evidence of entrapment, and prolonged oculocardiac reflex. Despite proper surgical reconstruction, prolonged complications such as diplopia and gaze restriction can occur. This article evaluated the prognostic factors associated with prolonged complications of orbital fractures with muscle incarceration. METHODS: The medical records of 37 patients (37 orbits) with an orbital fracture with muscle incarceration from January 2001 to January 2015 were reviewed. The presence of Incarcerated muscle was confirmed via CT, as well as by intraoperative findings. Various factors potentially contributing to complications lasting for over 1 year after the injury were categorized and analyzed, including age, cause of injury, injury-to-operation time, operative time, fracture type, nausea, vomiting and other concomitant symptoms and injuries. RESULTS: All patients who presented with extraocular muscle limitations, positive CT findings, and/or a positive forced duction test underwent surgery. Of the 37 patients, 9 (24%) exhibited lasting complications, such as diplopia and gaze restriction. The mean follow-up period was 18.4 months (range, 1–108 months), while that of patients who experienced prolonged complications was 30.1 months (range, 13–36 months). Two factors were significantly associated with prolonged complications: injury-to-operation time and nausea/vomiting. Loss of vision, worsening of motility, and implant complication did not occur. CONCLUSIONS: Patients who present with gaze limitations, with or without other signs of a blow-out fracture, require a thorough evaluation and emergent surgery. A better prognosis is expected with a shorter injury-to-operation time and lack of nausea and vomiting at the initial presentation.

Fulminant course in a case of malignant phyllodes tumor

We present the case of a 31-year-old woman with an inflammatory and ulcerative malignant phyllodes tumor in her right breast. A right modified radical mastectomy and transverse rectus abdominis myocutaneous (TRAM) flap were performed. A month after the initial operation, several masses recurred at the superior margin and deep margin of the TRAM flap. Wide excision was performed, but masses recurred at the inferior margin and in both lung fields 2 weeks after the second operation. Six weeks after the second operation, the patient died due to progression of dyspnea and respiratory failure.

Closure of Myelomeningocele Defects Using a Limberg Flap or Direct Repair

BACKGROUND: The global prevalence of myelomeningocele has been reported to be 0.8-1 per 1,000 live births. Early closure of the defect is considered to be the standard of care. Various surgical methods have been reported, such as primary skin closure, local skin flaps, musculocutaneous flaps, and skin grafts. The aim of this study was to describe the clinical characteristics of myelomeningocele defects and present the surgical outcomes of recent cases of myelomeningocele at our institution. METHODS: Patients who underwent surgical closure of myelomeningocele at our institution from January 2004 to December 2013 were included in this study. A retrospective chart review of their medical records was performed, and comorbidities, defect size, location, surgical procedures, complications, and the final results were analyzed. RESULTS: A total of 14 patients underwent surgical closure for myelomeningocele defects. Twelve cases were closed with direct skin repair, while two cases required local skin flaps to cover the skin defects. Three cases of infection occurred, requiring incision and either drainage or removal of allogenic materials. One case of partial flap necrosis occurred, requiring secondary revision using a rotational flap and a full-thickness skin graft. Despite these complications, all wounds eventually healed completely. CONCLUSIONS: Most myelomeningocele defects can be managed by direct skin repair alone. In cases of large defects, in which direct repair is not possible, local flaps may be used to cover the defect. Complications such as wound dehiscence and partial flap necrosis occurred in this study; however, all such complications were successfully managed with simple ancillary procedures.

Transconjuctival Incision with Lateral Paracanthal Extension for Corrective Osteotomy of Malunioned Zygoma

BACKGROUND: Conventional correction of malunioned zygoma requires complete regional exposure through a bicoronal flap combined with a lower eyelid incision and an upper buccal sulcus incision. However, there are many potential complications following bicoronal incisions, such as infection, hematoma, alopecia, scarring and nerve injury. We have adopted a zygomaticofrontal suture osteotomy technique using transconjunctival incision with lateral paracanthal extension. We performed a retrospective review of clinical cases underwent correction of malunioned zygoma with the approach to evaluate outcomes following this method. METHODS: Between June 2009 and September 2015, corrective osteotomies were performed in 14 patients with malunioned zygoma by a single surgeon. All 14 patients received both upper gingivobuccal and transconjunctival incisions with lateral paracanthal extension. The mean interval from injury to operation was 16 months (range, 12 months to 4 years), and the mean follow-up was 1 year (range, 4 months to 3 years). RESULTS: Our surgical approach technique allowed excellent access to the infraorbital rim, orbital floor, zygomaticofrontal suture and anterior surface of the maxilla. Of the 14 patients, only 1 patient suffered a complication—oral wound dehiscence. Among the 6 patients who received infraorbital nerve decompression, numbness was gradually relieved in 4 patients. Two patients continued to experience persistent numbness. CONCLUSION: Transconjunctival incision with lateral paracanthal extension combined with upper gingivobuccal sulcus incision offers excellent exposure of the zygoma-orbit complex, and could be a valid alternative to the bicoronal approach for osteotomy of malunioned zygoma.

Comparison of the Effectiveness of Ablative and Non-Ablative Fractional Laser Treatments for Early Stage Thyroidectomy Scars

BACKGROUND: Open thyroidectomy is conventionally performed at the anterior side of neck, which is a body part with a comparatively great degree of open exposure; due to this, postoperative scarring may cause distress in patients. We aimed to compare the effects of ablative and nonablative fractional laser treatments on thyroidectomy scars. We examined medical records in a retrospective manner and analyzed scars based on their digital images by using the modified Manchester Scar Scale (mMSS). METHODS: Between February 2012 and May 2013, 55 patients with thyroidectomy scars were treated with ablative (34 patients) or nonablative (21 patients) fractional laser. Each patient underwent 4 laser treatment sessions in 3–4 week intervals, 1–2 months postoperatively. Scar improvement was assessed using patient images and the mMSS scale. RESULTS: The mean decrease in scar score was 3.91 and 3.47 in the ablative and nonablative groups, respectively; the reduction between 2 groups did not exhibit any significant difference (P=0.16). We used the scale once again to individually evaluate scar attributes. The nonablative group accounted for a considerably higher color score value (P=0.03); the ablative group accounted for a considerably higher contour score value (P<0.01). Patient satisfaction was high and no complications occurred. CONCLUSIONS: Both types of fractional laser treatments can be used successfully for thyroidectomy scar treatment with minimal complications; however, results indicate that higher effectiveness may be obtained from the use of ablative and nonablative lasers for hypertrophic scars and early erythematous scars, respectively. Therefore, the appropriate laser for scar treatment should be selected according to its specific characteristics.

Soft Tissue Reconstruction for Basaloid Squamous Cell Carcinoma on the Hemiface

No abstract available.

Radiation ulcers and other chronic wounds

Radiation ulcers are wounds caused by acute or chronic effects of ionizing radiation. The injury may involve the skin, underlying soft tissue, and even deeper into bones. Radiation is used alone or in combination with surgery and chemotherapy. Although it is useful to affect tumor death, it also exerts a deleterious effect on surrounding normal tissues. These effects are either acute or can manifest months or years after the treatment. The chronic wounds are a result of impaired wound healing. This impairment leads to fibrosis, nonhealing ulcers, lymphedema and radionecrosis amongst others.

Effects of Platelet-Rich Plasma, Adipose-Derived Stem Cells, and Stromal Vascular Fraction on the Survival of Human Transplanted Adipose Tissue

Traditional adipose tissue transplantation has unpredictable viability and poor absorption rates. Recent studies have reported that treatment with platelet-rich plasma (PRP), adipose-derived stem cells (ASCs), and stromal vascular fraction (SVF) are related to increased survival of grafted adipose tissue. This study was the first simultaneous comparison of graft survival in combination with PRP, ASCs, and SVF. Adipose tissues were mixed with each other, injected subcutaneously into the back of nude mice, and evaluated at 4, 8, and 12 weeks. Human adipocytes were grossly maintained in the ASCs and SVF mixtures. Survival of the adipose tissues with PRP was observed at 4 weeks and with SVF at 8 and 12 weeks. At 12 weeks, volume reduction in the ASCs and SVF mixtures were 36.9% and 32.1%, respectively, which were significantly different from that of the control group without adjuvant treatment, 51.0%. Neovascular structures were rarely observed in any of the groups. Our results suggest that the technique of adding ASCs or SVF to transplanted adipose tissue might be more effective than the conventional grafting method. An autologous adipose tissue graft in combination with ASCs or SVF may potentially contribute to stabilization of engraftment.

Empirical Treatment of Highly Suspected Nontuberculous Mycobacteria Infections Following Aesthetic Procedures

BACKGROUND: Infection caused by nontuberculous mycobacteria (NTM) has been increasing. Awareness of this infection is crucial yet problematic. Delayed management may lead to destructive results. We empirically treated a series of patients with clinical suspicion of NTM infection prior to the identification of the pathogen. METHODS: A total of 12 patients who developed surgical site infections between January 2011 and February 2014 were reviewed. Patients with a skin and subcutaneous infection resistant to standard management over two weeks, and previous history of aesthetic procedures within three months were regarded as highly suspected of having an NTM infection. A variety of diagnostic modalities were examined simultaneously, along with starting empirical treatment including a combination of clarithromycin and moxifloxacin, and surgical debridement. RESULTS: All wounds healed completely within 4 weeks. The mean follow-up duration was 7.2 months, and none of the patients developed relapse. Specific NTM pathogens were identified in six patients. Eight patients showed caseating granuloma implying an NTM infection. One patient showed an uncommon Stenotrophomonas infection, which was successfully treated. Three patients had no evidence of a pathogen despite repeated microbial tests. Complications such as scarring, pigmentation, and disfigurement were common in all the patients. CONCLUSIONS: NTM should be considered in the differential diagnosis of an unusual skin and soft-tissue infection. We propose an empirical regimen of clarithromycin and moxifloxacin as an efficient treatment option for an NTM infection.

A Clinical Anatomic Study of Internal Mammary Perforators as Recipient Vessels for Breast Reconstruction

BACKGROUND: Partially resecting ribs of the recipient site to facilitate easy anastomosis of the internal mammary vessels to free flaps during breast reconstruction can cause chest wall pain or deformities. To avoid this, the intercostal perforating branches of the internal mammary vessels can be used for anastomosis. The purpose of this study was to investigate the location and size of the internal mammary perforator vessels based on clinical intraoperative findings and to determine their reliability as recipient vessels for breast reconstruction with microsurgical free tissue transfer. METHODS: Twelve patients were preoperatively screened for the presence of internal mammary perforators using Doppler tracing. After modified radical mastectomy was performed by a general surgeon, the location and size of the internal mammary perforator vessels were microscopically investigated. The external diameter was examined using a vessel-measuring gauge from a mechanical coupling device, and the distance from the mid-sternal line to the perforator was also measured. RESULTS: The largest arterial perforator averaged 1.5 mm, and the largest venous perforator averaged 2.2 mm. Perforators emerging from the second intercostal space had the largest average external diameter; the second intercostal space also had the largest number of perforators arising from it. The average distance from the mid-sternal line to the perforator was 20.2 mm. CONCLUSIONS: Internal mammary perforators presented consistent and reliable anatomy in this study. Based on these results, the internal mammary perforators appear to have a suitable diameter for microvascular anastomosis and should be considered as an alternative recipient vessel to the internal mammary vessel.

Anterograde Intra-Arterial Urokinase Injection for Salvaging Fibular Free Flap

We present a case of a 57-year-old male patient who presented with squamous cell carcinoma on his mouth floor with cervical and mandibular metastases. Wide glossectomy with intergonial mandibular ostectomy, and sequential reconstruction using fibular osteomyocutaneous free flap were planned. When the anastomosis between the peroneal artery of the fibular free flap and the right lingual artery was performed, no venous flow was observed at the vena comitans. Then re-anastomosis followed by topical application of papaverine and lidocaine was attempted. However, the blood supply was not recovered. Warm saline irrigation over 30 minutes was also useless. Microvascular thromboses of donor vessels were clinically suspected, so a solution of 100,000 units of urokinase was infused once through a 26-gauge angiocatheter inserted into the recipient artery just at the arterial anastomotic site, until the solution gushed out through the flap vena comitans. Immediately after the application of urokinase, arterial flow and venous return were restored. There were no complications during the follow-up period of 11 months. We believe that vibrating injuries from the reciprocating saw during osteotomies and flap insetting might be the cause of microvascular thromboses. The use of urokinase may provide a viable option for the treatment of suspicious intraoperative arterial thrombosis.