Scientific review of the aesthetic uses of botulinum toxin type A

Botulinum toxin type A (BoNT-A), onabotulinumtoxinA (Botox) was approved by the United States Food and Drug Administration for temporary improvement of glabellar lines in patients 65 years and younger in 2002, and has also been used widely for aesthetic purposes such as hyperhidrosis, body shape contouring, and other noninvasive facial procedures. BoNT-A inhibits presynaptic exocytosis of acetylcholine (ACh)-containing vesicles into the neuromuscular junction at cholinergic nerve endings of the peripheral nervous system, thereby paralyzing skeletal muscles. ACh is the most broadly used neurotransmitter in the somatic nervous system, preganglionic and postganglionic fibers of parasympathetic nerves, and preganglionic fibers or postganglionic sudomotor nerves of sympathetic nerves. The scientific basis for using BoNT-A in various cosmetic procedures is that its function goes beyond the dual role of muscle paralysis and neuromodulation by inhibiting the secretion of ACh. Although the major target organs for aesthetic procedures are facial expression muscles, skeletal body muscles, salivary glands, and sweat glands, which are innervated by the somatic or autonomic nerves of the peripheral cholinergic nerve system, few studies have attempted to directly explain the anatomy of the areas targeted for injection by addressing the neural physiology and rationale for specific aesthetic applications of BoNT-A therapy. In this article, we classify the various cosmetic uses of BoNT-A according to the relevant component of the peripheral nervous system, and describe scientific theories regarding the anatomy and physiology of the cholinergic nervous system. We also review critical physiological factors and conditions influencing the efficacy of BoNT-A for the rational aesthetic use of BoNT-A. We hope that this comprehensive review helps promote management policies to support long-term, safe, successful practice. Furthermore, based on this, we look forward to developing and expanding new advanced indications for the aesthetic use of BoNT-A in the future.

Breast Reconstruction Using Implant: Long Term Follow-up Complications & Patient's Satisfaction

BACKGROUND: The breast reconstruction using implant has been conducted widely. Many studies were presented to analyze the complications, but most of these studies were conducted with patients relatively short term period follow up. The authors studied with patients who were followed up at least five years. METHODS: Among the patients who were underwent breast reconstruction with implant from 1998 to 2007, 37 patients who met were followed up more than 5 years were selected in the study. Relationships between factors such as the operation methods, volume, type of surfaces of the implants, etc. and the complication rate or reoperation rate were analyzed. The level of satisfactory scoring was measured by patients' and 5 plastic surgeons. RESULTS: Complications were developed in 21 patients (65.6%) and 9 of them underwent reoperations. Infection was most common cause of complication. Implant removal was conducted to 7 patients, and 5 of them due to infection. The percentages of patients who received postoperative chemotherapy or radiotherapy in complication group and implant removal group were higher than the whole group whereas such correlation was not statistically significant. Direct Implant insertion has 50% of complication and 80% in permanent expander insertion and 73.7% of expanderimplant exchange. The average value of subjective score at last follow up was 4.2 points and the average value of objective score was 5.74. CONCLUSIONS: The incidence rate of complications was relatively high, and the final followup satisfaction score was low. This study should be helpful not only to select reconstruction methods, but also further studies to compare with other reconstruction methods.

Effect of the Refrigerator Storage Time on the Potency of Botox for Human Extensor Digitorum Brevis Muscle Paralysis

BACKGROUND AND PURPOSE: It is recommended that Botox be used within 5 hours of reconstitution, which results in substantial quantities being discarded. This is not only uneconomic, but also inconvenient for treating patients. The aim of this study was to determine the potencies of Botox used within 2 hours of reconstitution with unpreserved saline, the same Botox refrigerated (at +4degrees C) 72 hours after reconstitution, and during the next 4 consecutive weeks (weeks 1, 2, 3, and 4). This comparison was used to determine the length of refrigeration time during which reconstituted Botox will maintain the same efficacy as freshly reconstituted toxin. METHODS: Individual paralysis rates in the extensor digitorum brevis (EDB) compound muscle action potential (CMAP) amplitude and area were measured 1 week after injecting fresh reconstituted 2.5 MU of Botox on one side of the foot, and when the same quantity of Botox that had been refrigerated for a designated time (i.e., 72 h, or 1, 2, 3, or 4 weeks) into the other side of the foot. The EDB CMAP amplitude and area at 12 and 16 weeks postinjection were also measured to compare the efficacy durations in all five comparative groups. RESULTS: Ninety-four volunteers were divided into five groups according to the refrigerator storage time of the second Botox injection. The paralysis of the EDBs was significant for each injection of Botox, both fresh and refrigerated, with no statistically significant differences between them, regardless of the refrigeration time. There was a tendency toward increased CMAP amplitude and area at 12 or 16 weeks postinjection (p<0.0001). The duration of effective muscle paralysis did not differ significantly throughout the 16-week follow-up period between all five groups. CONCLUSIONS: The potency of reconstituted Botox is not degraded by subsequent refrigeration for 4 weeks. However, there are definite concerns regarding its sterility, and hence its safety, since multiple withdrawals from the same vial over long periods can introduce bacterial contamination.

The Comparison of Long-term Effect of Botox(R) Injection on Lower Face Contouring after Single Injection and Long-term Repeated Injections by Standardized Photograph Analysis

PURPOSE: A botulinum toxin type A(BoNT-A) injection has been used as a noninvasive management for lower face contouring since 2000. The aim of this study is to compare reduction rate of lower face width for a longtime according to repeated Botox(R) injections on masseter muscles for lower face contouring procedure. METHODS: Forty-five patients were analyzed for single session of Botox(R) injection and 13 patients were evaluated for repeated Botox(R) injections for over two years. Single injection group was tracked regular intervals at 1, 3, 6, 10, 12 months after the injection, and repeated injection group was measured at every injection time. Twenty-five to thirty units of Botox(R) was injected into each masseteric muscle at five to six points at the prominent portions of the mandibular angle. Standardized frontal view of digital photographs were analyzed by Adobe Photoshop(R)(version CS3) to measure an reduction rate of lower face's width. RESULTS: Reduction rate was 3.7%, 6.9%, 6.2%, 4%, 4% at 1, 3, 6, 10, 12 months post injection each other in single injection group. However, more than 8% reduction rate was found in repeated injection group persistently for more than two years. CONCLUSION: This study shows that effective duration of Botox(R) injection for lower face contouring is expected to continue over one year clinically. Moreover, repeated injections maintained lower reduction rate consistently for a long time. Therefore, repeated injections on masseter muscles at regular intervals is the most effective procedure for lower face contouring.

Evaluation of the Effects of Mandibular Angle Sagittal Ostectomy and Botulinum Toxin Type A Treatment using Facial Golden Mask

PURPOSE: A lower facial contouring surgery has become a commonly performed procedure in Asia. Currently, mandibular angle sagittal ostectomy and botulinum toxin type A treatment are main procedures for aesthetic correction of a broad lower face. There are a few data to show the differences in the mandibular contouring changes between mandibular angle splitting ostectomy and botulinum toxin type A treatment. Facial golden mask is easy to apply, inexpensive, and relatively objective in evaluating facial contour analysis. This study was designed specifically to compare the changes in lower face width after two different forms of lower facial contouring procedure using facial golden mask. METHODS: Seventeen patients, with the ages ranged from 18 to 55 years(mean, 28.6 years), 15 women and 2 men, consented to the study and receive a contouring procedure of lower face. The patients were classified into 2 groups. In group A, the sample consisted of 10 patients with a prominent squared mandibular angle and mandibular angle splitting ostectomy was performed. In group B, the sample consisted of 7 patients with masseteric hypertrophy and botulinum toxin type A treatment was performed. Photographs of the face were taken to record the facial change at preoperative and postoperative. The postoperative photographs were taken to considered maximal effect in 2 years after the surgery in group A, and 4.8 months after the treatment in group B. The authors applied the facial golden mask to preoperative and postoperative photographs and horizontal ratio, which compares facial width with golden mask width, were calculated. We made an analysis of the result of horizontal ratio using SPSS. RESULTS: Overall average horizontal ratio of pre- and postoperative photos of group A were 1.24 and 1.11, whereas overall average horizontal ratio of pre- and postoperative photos of group B were 1.19 and 1.12. The horizontal ratio decreased 10.24% in group A and 5.93% in group B. There was a statistically significant changes in before and after treatment, but there was no significant change in comparing the group A and group B. CONCLUSION: The results from this study suggest that mandibular angle sagittal ostectomy and botulinum toxin type A treatment showed relatively satisfactory clinical effects on lower facial contouring treatment. There were no statistical significant differences within two lower facial contouring treatment. Facial golden mask is easy to apply, inexpensive, and relatively objective, so we think that facial golden mask is a good method for evaluation of lower facial contouring treatment.

The Wound Healing Effects of Alginate-crosslinked Collagen Dermal Substitute of Artificial Skin

Alginate, which is isolated from brown seaweed, is a bioabsorbable long chain polysaccharides, beta-D-mannuronic acid and alpha-L-guluronic acid. The authors produced alginates and alginate-colllagen as a disc form. Then, to evaluate the efficacy of alginate and alginate-collagen complex as a wound healing material, three full-thickness skin defects of 2 cm in diameter were made at the back of the New Zealand white rabbits. Three groups of dressing materials-alginate, alginate-collagen complex and vaseline gauze as control group - were applied on the wound and the results were evaluated grossly and histopathologically. The authors compared gross findings of sizes of healed wound, wound epithelization and wound contraction by tracing the remaining wound area at 5th, 10th, 15th, 20th, 25th day after wound introduction, and wound biopsy was performed at 3rd, 7th, 14th, 21st day, respectively. Alginate and alginate-collagen complex showed statistically higher percentage of wound contraction and wound healing compared to control group(p<0.05). Alginate-collagen complex showed statistically higher percentage of wound contraction, epithelization and wound healing compared to alginate alone. In conclusion, the result suggests that alginate has a good effect of wound healing and that alginate-collagen complex is more effective in wound healing than alginate alone.

The Histological Change of Orbicularis Oculi Muscle according to the Age

This study is to investigate the patients who had blepharoplasty for cosmetic purposes or facial nerve disorders. 21 patients were examined with an age from 17 to 63 years. Sixteen cases were classified as a normal group for investigation of the histopathologic change according to the age. The rest were patients of Bell's palsy(2), Botox(R) injection(2) and blepharospasm (1). We measured a mean diameter of myofiber and dimension's proportion of muscluar tissue per regular visual field. First, we measured a statistical significance according to the age in normal cases by grouping them into younger than 30-year-old, 30's, 40's, 50's and 60's. Second, we divided normal cases(16) into Group A and B by two bases for statistical analysis. In conclusion, although there were several differences as vacuolation, internalization of sarcolemnic nuclei between 35-year-old and 62-year-old patients in simple comparison, there was no uniform decrease according to the age. There were also no significant statistical changes in the value of a diameter of myofibers and dimension's proportion of muscular tissue according to the age in any of the two normal groups. But in Botox(R) injection and Bell's palsy, blepharospasm patients, two values showed remarkable difference compared to the normal group of same age.

A Total Lid Resection Selectively with Levator Aponeurosis Resection for the Treatment of Blepharoptosis

Blepharoptosis refers to drooping of upper eyelid due to weakness of the levator muscle or Mllers muscle. This results in not only a loss of visual field but also aesthetic problems. There has been many procedures in correction of ptosis; A vertical lid-shortening operation such as the Fasanella-Servant tarsomullectomy, advancement of the levator aponeurosis, a external or conjunctival levator muscle resection, and Frontalis suspension or transfer. These methods have many advantage and disadvantages respectively and it is very difficult to have a choice for any ptosis. We modified levator aponeurosis resection to reduce undercorrection and recurrence of the ptosis after operations. The refinement of our procedure consist of the skin approached semilunar resection of total upper eyelid with levator aponeurosis resection according to ptosis amount. From January 1997 to June 2002, 10 congenital and acquired blepharoptosis patients and 10 cases were done. The follow-up period of patients ranged from 9 months to 6 years and 2 months. The preoperative average amount of ptosis is 3.3 mm and the postoperative one is 1.6 mm. Satisfactory result has been achived in 8 cases. Undercorrection and temporary severe lagophthalomos were done 2 cases and 3 cases respectively, but we did not have any expirences of severe complication such as exposure keratitis and symblepharon. Although our method has some disadvantages such as somewhat difficult procedure and longer operation times, better results and less recurrence of ptosis were done after long term follow-up.

The Cognition Study of the Freshman in College About Aesthetic Plastic Surgery

Recently, as standard of living has been improving and awareness of well-being has been generalized, people's desire pursuing beauty has been spreading across the world. We made a survey with 184 graduating high school girls in December 2003. According to the survey. 57.6% of them knew about plastic surgery, 41.8% of them knew well about whole field of plastic surgery, and 60.3% of them wanted to have an aesthetic surgery. 44.6% got an information about an aesthetic surgery from general public and 27.6% from TV, respectively. Regarding the use of aesthetic surgery, 59.8% answered that it makes them more confident about themselves rather than just to be beautiful. 78.8% of them have complaints about how they look. Finally, as the personal desire to make themselves look beautiful to others increases, so does the interest in aesthetic plastic surgery. In conclusion, as the society of plastic and reconstructive surgeons, we still need more effort for the correct cognition and awareness of plastic surgery among general public.

The Change of the Maximal Bite-force after Botulinum Toxin A Injection for Lower Face Contouring

The temporary effects of muscle atrophy, followed by chemodenervation due to acetylcholine blockade at the neuromuscular junction by botulinum toxin type A(BTX-A) were mainly used for the treatment of hypertrophied muscle. In the treatment of masseter hypertrophy or cosmetic contouring of the lower face with injection of botulinum toxin type A, these muscle atrophy causes the change of the bite-force inevitably. Although several reports about the histological change of muscle, ultrasound and computerized tomography measurement studies of the change of muscle thickness in the treatment of masseter hypertrophy with injection of BTX-A have become available recently, it is necessary to study further the change of the bite-force and the relationship between the bite-force and clinical effects after the botulinum toxin A injection. The aim of this study was to evaluate the change of maximal bite-forces after botulinum toxin type A injections for treating the contouring of the lower face. Botulinum toxin type A(BTXA(R), Lanzhou, China) of 25U per side was carried out in 7 subjects. The change of maximal bite-forces was evaluated at pre-injection and 2 week, 4 week, 8 week, 12 week post-injections using bite- force measuring machine(MPM-3000, Japan). There were statistically significant differences between pre-injection and 2 week, 4 week, 8 week post-injections(p<0.05). However, there was no significant difference between pre-injection and 12 week post-injection. In conclusion, the change of maximal bite-forces after BTX-A injections according to the period was similar to the histological change of the muscle. The clinical effects last more longer than maximal bite force. Therefore, it is necessary to evaluate further these difference with more larger samples and the relationship between the change of maximal bite force and clinical effects.

The Classification and Clinical Characteristics of the Crow`s Feet in Koreans

Most common signs of human aging often include skin fold and wrinkles in the lateral canthal area. It is called "crow's feet". The accordion-like activity of the orbicularis oculi muscle during movements of facial expression accentuates this phenomenon because the muscle shortens but the skin does not. The purpose of this study is to present the classification of the crow's feet and to look for it's clinical characteristics in Koreans. The pictures of lateral view of the crows feet in 105 patients taken with digital camera are classified by their age, sex, types and degree of direction. Results show that there are three types of crows feet such as upper, lower and bidirectional types. Bidirectional type is the most common type(85%), lower directional type is 15% and upper directional type is 5%. In thirties, bidirectional type is 50% but the rate of this type increases in older groups. So in over sixties, bidirectional type is almost 100%. There are no differences between the two sexes. The degree of the direction of wrinkles increases in thirties and forties, but in fifties or over no difference was seen. In summary, this study could be helpful to decide the procedure in correction of the crow's feet.

Surgical Treatment in Recurred Axillary Osmidrosis

There are several surgical or non-surgical methods for osmidrosis, which have their own merits and drawbacks. Especially, recurrence and scarring of operation site are cumbersome problems. One of the limitations of each method is recurrence of osmidrosis. The authors evaluated surgical treatments of recurrent cases. The authors experienced 14 recurrent osmidrosis cases from January 1998 to December 2003. Previous methods in recurrent cases are as follows; dermal shaving with Inaba dermal shaver(3 cases), liposuction method(10 cases), non-surgical hair removal method(4 cases). The authors managed recurrent cases with radical excision in 4 recurrent cases which had severe scar with large fibrotic tissue due to previous operations, and dermal manual resection in 10 cases. We had no recurrence in our series and no complications like hematoma, seroma, infection, wound disruption or dehiscence and brachial plexus compression. In conclusion, dermal manual resection can be applied to recurrent osmidrosis cases, and radical resection is also applicable to managing recurrent cases with severe scar with large fibrotic tissue.

Treatment of the Medial Blow-out Fracture by Medial Transconjunctival Approach

Blow-out fractures usually occur at the weakest point of orbital wall such as medial wall or orbital floor. The operative treatment of blow-out fracture involve restoration of intra-orbital soft tissue and bony structural integrity. The surgical reduction of medial blow-out fracture are mainly transcutaneous, transnasal and transconjunctival approaches. The conventional methods has several disadvantages, such as external scar, narrow operative field and injury of neurovascular bundle. But medial transconjunctival approach has advantages such as minimal scar, short operative time and relative safety. We experinced 26 cases of medial blow-out fracture using medial transconjunctival approach from June 2001 to May 2003. Preoperatively 21 cases showed diplopia and 14 cases showed enophthalmos. In postoperative complications, diplopia were 2 cases, enophthalmos was 1 case, anterior displacement of implant were 2 cases, conjunctival scar were 2 cases and injury of caruncle was 1 case. We report the medial transconjunctival approach that was effective treatment for medial blow-out fracture without specific complications.

Reconstruction of the Lower Extremity Using the Various Flap Operations

There are some difficulties in the reconstruction according to anatomic regions of the lower extremity such as thigh, knee, anterior tibia, heel and so on. The earlier the normal tissue saved and the necrotic tissue removed, the less the patients had complications and functional disability. There are many kinds of flap surgery in the reconstruction of the lower extremity such as local skin flap, local fasciocutaneous flap, local muscle flap and free flap. We have done 71 cases using the various flap operation excluding direct closure and skin graft among the patient of lower extremity injury from Jul. 1997 to Oct. 2002. Among 71 cases, 46 cases were due to traffic accidents and mechanical damages and 4 cases were burn, 5 cases were diabetic ulcer, 16 cases were cancer and other skin defects. Lower leg and foot were the most common lesion and the next was knee and thigh. And in the flap operations we have done, 32 cases(45%) were local skin flap, 18 cases(25%) were local fasciocutaneous flap, 6 cases(9%) were local muscle flap, 15 cases(21%) were free flap and so on. In early postoperative complications, the total flap necrosis was seen in 1 case, the partial necrosis in 6 cases, the infection in 5 cases and the hematoma or seruma in 3 cases. The bulky flap and ulceration were seen in 3 cases respectively and needed secondary operation after long term follow-up. The area below the knee joint is limited by its low vascularity, low tissue flexibility, high infectiousness and long periods of wound healing, and the reconstruction of the weight bearing heel needs proper skin thickness and durability. The better reconstruction of the lower extremity needs many experiences of various methods to us and we should know about their advantages and disadvantages.

The Dynamic Lip Reconstruction with Variable Free Neuromuscular Transfers in Chronic Facial Palsy

The goals of ideal lip reconstruction in chronic facial palsy include recovery of sphincteric function of the lip and symmetry of mouth during facial expression and the resting state. The lip reconstruction in chronic facial palsy can be mainly divided into dynamic and static method. Recently, the dynamic lip reconstruction tend to be reported more frequently with the development of microsurgery. From December of 1994 to August of 2001, We had 6 dynamic lip reconstruction by one or two staged free neurovascular flap, and followed up from 1 to 4 years and 4 months (mean 36 months). One case was two-staged free rectus abdominis flap after cross-face nerve graft with sural nerve. Another case was one- staged free gracilis muscle flap anastmosised with one of the buccal branch of facial nerve in the affected side, which had relatively good function. The other 4 cases were one-staged free neurovascular latissimus dorsi flaps. We also combined other procedures such as gold implant for lagophthalmos, temporalis muscle transfer on ectropion of the lower eyelid, and the excisional eyebrow lift on the affected side. We got relatively satisfactory results except 1 case.

Experience of Sclerotherapy for Varicose Veins

Sclerotherapy has been demonstrated as an effective and minimally invasive procedure for varicose veins of the lower limbs, which can be performed on an out-patient basis. Between March 2000 and August 2001, we reviewed 138 patients who had been diagnosed as chronic venous disease in our hospital, and treated and evaluated a total of 32 limbs in 21 patients with primary varicose veins. There were 18 women and 3 men whose age was ranging from 31 to 55 years old, with a mean of 41.7 years. Eleven of 21 patients had bilateral involvement of lower extremity. Sclerodex (Sclerosant) was administered for telangiectasia less than 1 mm and reticular vein less than 4 mm, and Thromboject (Sodium Tetradecyl Sulfate) was for reticular vein more than 4 mm. Two types of operations were stripping of saphenous vein (6 cases) and high ligation (18 cases). All patients were cosmetically satisfied with the results. Minor complications after injection such as 7 cases (21.9 %) of erythema, 5 cases(15.6 %)of bullae, 4 cases (12.5 %)of thrombosis were occurred. However, no permanent change such as skin necrosis and pigmentation were appeared. Systemic responses such as dizziness or sweating were not observed in anyone. Sclerotherapy should improve both the safety and efficacy of the treatment of varicose vein. Our study suggests that the careful evaluation before planning the treatment of varicose vein is important for exact choice of patients and proper results.

New Classification of Naso-Ethmoid-Orbital Fracture using Computerized Tomography

Naso-ethmoid-orbital fractures are the most challenging of all craniofacial fractures to treat because of the intricate anatomy of this region and the difficulty in fracture fixation. Inadequate initial treatment will often result in severe deformity that may be extremely difficult or impossible to correct adequately. Naso-ethmoid-orbital injuries have been described in detail by numerous authors, but to date, no adequate classification of these injuries exits. In this study, we reviewed and analyzed the medical records and facial bone CT scans of 66 patients from May 1990 to August 1998 by retrospective analysis method. The pattern of injury in these patients was carefully analyzed in order to formulate a working classification based on clinical features and fracture types. Injuries may be unilateral or bilateral, and three clinical types of fractures have been recognized, each of which may occasionally have a combination of features. The types of fracture were divided into Type I, Type II and Type III. Type I was isolated bony NEO injury (31 cases), Type II was bony NEO injury with maxilla (11 cases) and Type III was extended NEO injury (24 cases). Also, type II was subdivided into 1) Bony NEO injury with central maxillay crush only, 2) with central maxilla and one lateral maxillary crush, and 3) with central and bilateral maxillary crush, and type III was 1) with craniofacial injuries, 2) with Le Fort II and III fractures and 3) with orbital displacement. The recognition and diagnosis of each specific injury pattern by our new classification method will define the correct treatment choice in each case.

The Effectiveness of MRI in Blow Out Fracture

The blowout fracture needs early diagnosis and active treatment if the fracture site, the degree of injury and herniation of orbital soft tissue are identified. It is more important than diagnosis itself that doctors identify the combined injury of orbital structures such as fat herniation and entrapment of the extraocular muscle with radiologic methods. Computed tomography(CT) is the standard method in the diagnosis of blowout fracture today, but with this method herniated orbital fat or extraocular muscle is not well differentiated from hematoma in case of the minimal blowout fracture. MRI(magnetic resonance image) was taken for further evaluation of extraocular muscle and orbital fat in 20 patients(16 males, 4 females) among 58 patients who were suspected or diagnosed as blowout fracture on simple X-ray or CT view. Fractured sites were located on the medial wall in 4 patients, orbital floor in 6 patients. 10 patients suffered from the blowout fracture on more than 2 walls. In 18 of total 20 patients, the herniation of orbital fat or extraocular muscle was identified on MRI view. In 2 patients whose orbital soft tissue was not herniated, the fracture was observed on CT view but not observed on MRI view. In case of suspicious hematoma or herniation of orbital soft tissue within maxillary sinus, CT view could not identify the hematoma or herniation of orbital soft tissue, but oblique sagittal MRI view could identify the herniation of inferior rectus muscle and differentiation of the herniation of orbital soft tissue from hematoma within maxillary sinus on T1 and T2-weighted images. In 7 patients who were difficult to decide the operative indication on CT view, MRI identified herniation and entrapment of extraocular muscle. MRI is especially useful when you differentiate hematoma from herniated orbital fat or extraocular muscle in case of minimal blowout fracture. MRI is useful in deciding the operative method and evaluating the soft tissue involvement in case of blowout fracture.

Epicanthoplasty Using Modified Park's Method

The creation of a supratarsal fold is the most frequently performed cosmetic surgical procedure in Asia. The presence of epicanthal folds in Asian eyelids is one of their unique features, in combination with the lack of supratasrsal folds. While this represents an element of Oriental beauty in a traditional way, many seek cosmetic improvement in the medial canthal area to eliminate the epicanthal fold. Epicanthoplasty enhances the aesthetic result of the double-lid procedure by lengthening the palpebral fissure, thus producing the image of a larger, open eye. In this paper, we present modified Park's epicanthoplasty based on our experience with 36 cases performed during the past 3 years. Double fold operation with modified Park's epicanthoplasty were performed in 25 cases and modified Park's epicanthoplasty without double fold operation were performed in remaining 11 cases. The follow-up period ranged from 6 months to 2 years. The results were satisfactory except 1 case of hypertrophic scar and 3 cases of undercorrection. The advantages of modified Park's epicanthoplasty are simplicity in design and minimal scarring produced in the medial canthal area as compared with complex W-plasty or Z-plasty, which requires multiple incisions and often creates unsightly scarring. Incorporating epicanthoplasty by modified Park's method with or without double-lid procedure gives oriental eyes a balanced and aesthetically pleasing look.

The Treatment of Maxillary Fracture with Malocclusion

Twenty-five Le Fort fractures accompanying palatal fracture or malocculsion had been studied from October 1990 to May 1997. The patients were analyzed on the basis of classification causes, operative procedure treatment of fracture, status of malocclusion and complication. The most common cause of fracture was a traffic accident and diagnosis was performed by history, physical examination, reontgenogram, and computed tomography. The follow-up period ranged from 5 months to 5 years, averaging 17 months. Internal fixations with plates and screws were performed in 22 cases and external fixations with halo apparatus were used in 3 cases. Intermaxillary fixations with arch bar were applied during the preoperative and postoperative period in all cases. In 6 cases of Le Fort fractures, acylic splints were applied. In 3 cases of palatal fractures, transverse wiring of the palatal arch were also used. Overall 19 of 25 patients were satisfied with the results. Six patients complained about depression of the midface because of undercorrection 4 patients had persisting hypoesthesia of the infraorbital nerve for more than 6 months postoperative. In summary, the dental plast and acrylic splint are very helpful in correcting malocclusion in severe maxillary fractures. Also, in cases of palatal fracture, it is important to minimize maloccusion by rigid fixation or transverse wiring of the palatal arch.