A Study of Entropion Occurred after Lower Eyelid Cosmetic Surgery

Purpose@#Cosmetic procedures for lower eyelids are popular in the field of plastic surgery for patients who want to make their eyes look bigger in Korea. We have experienced patients who developed entropion after the lower eyelid cosmetic procedure and treated it surgically, and therefore we would like to report on these cases. @*Methods@#From 2015 to 2021, among all patients diagnosed as having entropion at Woori Yonsei eye clinic, 34 patients with a history of lower eyelid plastic procedure were included in this study. @*Results@#All patients were female and their mean age was 30.6 years. We classified subjects from grade I to grade IV according to the degree of resistance to the lower eyelid retraction and lower eyelid upward movement restriction. The Hotz operation was performed in all patients. Filler removal, lower eyelid retraction recession, or palate mucosal transplantation were additionally performed depending on the severity of entropion. @*Conclusions@#After the cosmetic procedure of lower eyelid, some patients had entropion as a complication and required surgery. To prevent these complications, sufficient pre-examination of eye conditions such as the degree of relaxation of the lower eyelid, size of eyelid fissure, morphological problems, and reevaluation of surgical technique are required before the procedure starts. In addition, it seems the patients need to provide with sufficient explanation about the necessity of the procedure and its side effects.

Reconstruction of a severely gashed auricle using two-stage cartilage preservation surgery following auricular composite graft failure: a case report

After the failure of a composite graft in a patient with complete auricle amputation, we successfully reconstructed the severely gashed auricle using two-stage cartilage preservation surgery. We removed the skin of the amputee and buried the cartilage under the postauricular scalp. The end of the right ear was sutured to the postauricular scalp. A separation surgery was performed on the 14th day after the burying surgery. After removing the suture, the cartilage along with the postauricular scalp was carefully separated from the postauricular donor site under local anesthesia. Using two-stage cartilage preservation surgery, we successfully reconstructed the severely gashed auricle and achieved cosmetically and functionally satisfactory results.

Multiple Pilomatricomas with a Bullous Appearance / 대한피부과학회지

Pilomatricoma or calcifying epithelioma of Malherbe is a benign tumor originating from the matrix of hair follicles. Clinically, these tumors are classified as familial, perforating, multinodular, exophytic, anetodermic, bullous, and giant pilomatricomas. The bullous variety is observed only in 3 to 6% of cases. Furthermore, multiple pilomatricomas are rare and are usually associated with genetic disorders. To date, only 13 cases of bullous pilomatricoma and 8 cases of multiple pilomatricomas have been reported in Korean dermatologic literature. Among these cases, no case of multiple bullous pilomatricomas has been reported. This report describes a 23-year-old healthy man who was diagnosed with multiple pilomatricomas with bullous features, based on clinical and histopathological findings.

Clinical and Demographic Characteristics of Blepharoptosis in Korea: A 24-year Experience including 2,328 Patients

PURPOSE: To describe the demographics, relative incidence of subtypes, and clinical characteristics of blepharoptosis in Korean patients. METHODS: This is a retrospective, observational case series consisting of 2,328 patients who underwent ptosis surgery from 1991 to 2014 at a tertiary referral hospital in Korea. The patients were classified according to the type of ptosis and the evaluation of clinical characteristics including levator muscle function (LF) and degree of ptosis. RESULTS: Of the 2,328 patients, 1,815 (78%) had congenital ptosis and 513 (22%) had acquired ptosis. Simple congenital ptosis is the most common type overall (73.7%), and aponeurotic ptosis is the most common acquired type. More than three-quarters of eyes with congenital ptosis were affected in a moderate (34.4%) to severe degree (41.3%), and most of these eyes had fair (33.7%) to poor LF (60.1%). Among eyes with acquired ptosis, approximately three-quarters were affected in a mild (33.3%) to moderate degree (41.0%), with 63.3% of these eyes having good LF. The most widely used surgical technique was frontalis suspension (55.1%), followed by levator resection (29.0%) and aponeurosis repair (14.8%). At 3 years after the first surgery, 15.7% of patients with congenital ptosis and 10.4% of patients with acquired ptosis underwent reoperation. CONCLUSIONS: Although the prevalence has decreased from previous years, the proportion of cases with congenital ptosis was higher in this study than has been shown in research conducted in the West. The majority of eyes with congenital ptosis was affected to a severe degree and had poor LF, while those with acquired ptosis were affected to a moderate degree and had good LF. More cases with acquired ptosis presented with fair to poor LF, and frontalis suspension surgery was performed more commonly compared to previous studies. The reoperation rate was higher in congenital ptosis compared to acquired ptosis.

Clinical Course of Optic Nerve Sheath Meningioma

PURPOSE: To evaluate the clinical course of optic nerve sheath meningioma (ONSM) in Korean patients. METHODS: A retrospective study of 11 eyes of 11 patients with a diagnosis of ONSM between 2002 and 2015 at Severance Hospital. RESULTS: The mean age at symptom onset was 47.6 years. Ten females and 1 male participated in the study and all tumors were unilateral. Patients typically presented with visual loss and proptosis. Three patients complained of limited extraocular movements and seven patients exhibited visual field defects. Three patients who had a greater growth rate with intracranial involvement and two patients who had decreased vision received treatments. Five patients maintained good vision and visual field during the follow-up period. However, one patient who underwent surgical treatment presented significant visual loss and deterioration of visual field defect. One out of two patients who received three-dimensional conformal radiotherapy (3D-CRT) experienced improvement in visual field, and the other showed no change in visual field defect but remained stable with decreased tumor size. One out of two patients who underwent gamma-knife surgery showed aggravated visual field defect and the other presented with visual loss. CONCLUSIONS: ONSM is typically a slow-growing tumor. Deterioration of visual loss and visual field defect can occur after treatment of ONSM. Therefore, management should be considered carefully and should be limited to cases in which progression of the disease is advanced or tumor growth is fast. 3D-CRT can be considered in patients in need of treatment.

Percutaneous Drainage and Sclerotherapy for Delayed Lumbar Morel-Lavalee Lesion: Two Case Reports

Closed internal degloving is a significant soft-tissue injury associated with a trauma that results in a tear of the subcutaneous tissue away from the underlying fascia. Although the diagnosis of Morel-Lavallee lesion (MLL) is routinely based on clinical and radiological examinations, in one-third of the cases, there is a possibility that clinicians may fail to diagnose MLL due to its inconsistent clinical manifestations. Additionally, it often involves initial skin bruising due to underlying soft-tissue injury. We present two cases of delayed MLL without a fracture treated using percutaneous drainage and sclerotherapy. Our cases demonstrated successful treatment with a minimally invasive percutaneous approach. The potential advantage of using a percutaneous technique is to preserve the subdermal arterial plexus, which is the only remaining blood supply to the skin in the area of the lesion. Maintaining this blood supply may result in healthier skin at the time of any open procedure.

Pilomatricoma: An Unusual Presentation

No abstract available.

Graded Decompression of Orbital Fat and Wall in Patients with Graves' Orbitopathy

PURPOSE: To investigate the results of graded decompression of orbital fat and walls in Graves' orbitopathy (GO) considering the degree of proptosis reduction at surgery and preoperative computed tomography (CT) findings. METHODS: This is a retrospective interventional case series. Graded orbital fat and wall decompression was performed in 90 orbits of 55 patients. In patients with enlarged extraocular muscles and minimal orbital fat proliferation in preoperative CT scans, one- or two-wall decompression of posterior orbit was performed with minimal fat excision. In other cases, the maximal amount of fat tissue was removed from the post-septal area to the apex. If the proptosis was not satisfactorily symmetrically reduced at surgery, one- or two-wall decompression was performed successively. Symmetric reduction of proptosis was consistently confirmed intraoperatively to assure that a desired amount of exophthalmos reduction was achieved. RESULTS: Four types of decompression were performed: fat only (group 1), fat and one-wall (group 2), fat and two-wall (group 3), and two-wall and minimal fat decompression (group 4). The mean preoperative Hertel value (20.6 +/- 2.8 mm) was reduced significantly at six months postoperatively (16.1 +/- 2.3 mm). Proptosis significantly decreased with a mean of 4.3 +/- 1.7 mm, and the reduction was greatest (5.1 +/- 2.1 mm) in group 3. In group 1, a significant correlation between Hertel change and the volume of resected orbital fat was found (r = 0.479). Diplopia was newly developed or aggravated postoperatively in eight patients, and six of these patients were in group 3. With the exception of one patient, visual acuity improved to nearly normal postoperatively in all patients with optic neuropathy. CONCLUSIONS: Graded orbital decompression of orbital fat and bony walls, as assessed by the degree of proptosis reduction during surgery, was effective and predictable with minimal complications in GO patients with vision-threatening or cosmetically disfiguring proptosis.

Graded Decompression of Orbital Fat and Wall in Patients with Graves' Orbitopathy

PURPOSE: To investigate the results of graded decompression of orbital fat and walls in Graves' orbitopathy (GO) considering the degree of proptosis reduction at surgery and preoperative computed tomography (CT) findings. METHODS: This is a retrospective interventional case series. Graded orbital fat and wall decompression was performed in 90 orbits of 55 patients. In patients with enlarged extraocular muscles and minimal orbital fat proliferation in preoperative CT scans, one- or two-wall decompression of posterior orbit was performed with minimal fat excision. In other cases, the maximal amount of fat tissue was removed from the post-septal area to the apex. If the proptosis was not satisfactorily symmetrically reduced at surgery, one- or two-wall decompression was performed successively. Symmetric reduction of proptosis was consistently confirmed intraoperatively to assure that a desired amount of exophthalmos reduction was achieved. RESULTS: Four types of decompression were performed: fat only (group 1), fat and one-wall (group 2), fat and two-wall (group 3), and two-wall and minimal fat decompression (group 4). The mean preoperative Hertel value (20.6 +/- 2.8 mm) was reduced significantly at six months postoperatively (16.1 +/- 2.3 mm). Proptosis significantly decreased with a mean of 4.3 +/- 1.7 mm, and the reduction was greatest (5.1 +/- 2.1 mm) in group 3. In group 1, a significant correlation between Hertel change and the volume of resected orbital fat was found (r = 0.479). Diplopia was newly developed or aggravated postoperatively in eight patients, and six of these patients were in group 3. With the exception of one patient, visual acuity improved to nearly normal postoperatively in all patients with optic neuropathy. CONCLUSIONS: Graded orbital decompression of orbital fat and bony walls, as assessed by the degree of proptosis reduction during surgery, was effective and predictable with minimal complications in GO patients with vision-threatening or cosmetically disfiguring proptosis.

Correlation between TSH Receptor Antibody Assays and Clinical Manifestations of Graves' Orbitopathy

PURPOSE: To investigate an association between the levels of serum thyroid-stimulating hormone (TSH)-receptor autoantibodies (TRAbs) and Graves' orbitopathy (GO) activity/severity scores, and compare the performance of three different TRAb assays in assessing the clinical manifestations of GO. MATERIALS AND METHODS: Cross-sectional study. Medical records of 155 patients diagnosed with GO between January 2008 and December 2010 were reviewed. GO activity was assessed by clinical activity score (CAS) and severity graded with the modified NOSPECS score by a single observer. Serum TRAb was measured by three different methods: 1st generation thyrotropin-binding inhibitor immunoglobulin (TBII) assay (TRAb1st); 3rd generation TBII assay (TRAb3rd); and biological quantitative assay of thyroid-stimulating immunoglobulin (TSI) using Mc4-CHO cells (Mc4-CHO TSI assay). Results were correlated with scores of activity/severity of thyroid eye disease. RESULTS: All three assays (TRAb1st, TRAb3rd, and Mc4-CHO TSI) yielded results that were significantly positively correlated with CAS (beta=0.21, 0.21, and 0.46, respectively; p<0.05) and proptosis (beta=0.38, 0.34, and 0.33, respectively; p<0.05). Mc4-CHO TSI bioassay results were significantly positively correlated with all GO severity indices (soft tissue involvement, proptosis, extraocular muscle involvement, and total eye score; beta=0.31, 0.33, 0.25, and 0.39, respectively; p<0.05). CONCLUSION: Mc4-CHO TSI bioassay was superior over the two TBIIs in assessing active inflammation and muscle restriction due to GO, whereas TBII assay would be sufficient for evaluation of patients with proptosis.

Comparison of Pain-relieving Effects of Fentanyl versus Ketorolac after Eye Amputation Surgery

PURPOSE: To investigate the analgesic effect and incidence of postoperative nausea and vomiting (PONV) between the opioid fentanyl and the non-steroidal anti-inflammatory drug ketorolac in patients who underwent eye amputation surgery. METHODS: Retrospective observational case series. Eighty-two patients underwent evisceration or enucleation surgery by one surgeon over a 2-year period. Fentanyl by intravenous patient-controlled analgesia (IV-PCA) at 20 microg/kg with 12 mg/kg ondansetron or intravenous ketorolac at 2 mg/kg/day was administered to patients at postoperative days 0, 1, and 2. The pain score was measured using an 11-point visual analog scale (VAS). The incidence of severe nausea requiring anti-emetics and the incidence of vomiting were reviewed. RESULTS: The mean postoperative VAS in the fentanyl group was significantly lower than that in the ketorolac group on the day of operation for both types of surgery (p = 0.001 and p = 0.004, respectively). At postoperative days 1 and 2, the mean VAS was not different between the two groups for either surgical type (p > 0.05 for both days). The mean VAS was significantly higher in eviscerated patients than in enucleated patients at postoperative days 0 and 1 in the fentanyl group (p = 0.023 and p = 0.016, respectively). However, this was not observed in the ketorolac group. The incidence of PONV was higher in the fentanyl group than in the ketorolac group, although this was not statistically significant for either surgical type (p > 0.05 for both groups). CONCLUSIONS: Fentanyl was more effective as an analgesic than was ketorolac on the day of operation for both surgical types. There was no difference between the two analgesics on postoperative day 1. The analgesic effect of fentanyl in enucleated patients was significantly higher than in eviscerated patients at postoperative days 0 and 1. The use of fentanyl by IV-PCA was associated with greater PONV despite co-administration with anti-emetics, although this finding was not significant.

Prevalence and Risk Factors for Thyroid Eye Disease among Korean Dysthyroid Patients

PURPOSE: To determine the prevalence of thyroid eye disease among dysthyroid Korean patients and to analyze the relationship between demographic data, lifestyle risk factors, and status of thyroid disease and thyroid eye disease. METHODS: All dysthyroid patients who visited endocrinology clinics in 24 general hospitals in Korea during a chosen one-week period were enrolled in this cross-sectional study. Data were collected during an interviewer-administered questionnaire and chart review. Demographic data, lifestyle risk factors, and status of thyroid disease variables were analyzed as risk factors using multivariable regression models to identify independent associations with thyroid eye disease. RESULTS: A total of 1,632 dysthyroid patients were included (1,301 females [79.7%] and 331 males [20.3%]). Two hundred eighty-three of these patients (17.3%) had thyroid eye disease. Multiple logistic regression analyses revealed that female gender, young age, Graves' disease, dermopathy, anti-thyroid medication treatment, and radioiodine treatment were independent risk factors for thyroid eye disease. CONCLUSIONS: The lower prevalence of thyroid eye disease in dysthyroid Korean patients and the influence of gender on risk factors in this study are novel findings compared to studies performed involving Europeans. Although the risk factors for thyroid eye disease are understood in part, a more in-depth comparative study of gender and ethnic groups is needed to fully understand the biological significance of the demographic factors.

A Beveled Frontal Hairline Incision for Subcutaneous Forehead Lift

Anterior frontal hairline incisions have been used for subcutaneous forehead lifts, reduction foreheadplasty, endoscopic forehead lifts in patients with long foreheads. However, the resulting visible hairline scar has been a major concern. To obtain a more aesthetic scar, different types of incisions have been used. Since 2005, we have been using 30~45degrees anteriorly beveled incisions 4~5 mm behind the anterior frontal hairline when performing subcutaneous forehead lifts. In the present study, 32 patients who underwent subcutaneous forehead lifts and could be followed up for more than 6 months were evaluated for the incisional scars. Using a questionnaire, all the patients were interviewed regarding their postoperative hairstyle changes and reaction to the scars from the subcutaneous forehead lifts. Their responses with respect to the scars were as follows: less than expected, 30 patients; equal as expected, 2 patients; worse than expected, no patients. The surgeon's evaluation of scar visibility was as follows: barely visible (scar and alopecia were not seen or barely seen), 19 patients; minimally visible (a fine scar was seen), 12 patients; markedly visible (a wide scar or alopecia was seen), 1 patient. Except 1 patient, all other patients did not change their hairstyles permanently to camouflage their scars. Therefore, the 30~45degrees anteriorly beveled incision 4~5 mm behind the anterior frontal hairline was demonstrated to result in an aesthetically acceptable scar.

Subcision: An Ancillary Procedure to Face-Lift Operation to Improve Prominent Nasolabial Folds

Face-lift operations have been performed to correct the stigma of aging of the lower face, and its techniques have been modified to obtain more favorable results. However, the lack of significant improvements in the appearance of nasolabial folds has been a problem in face-lift procedures, requiring surgeons to perform ancillary procedures such as fat strip, dermofat, and superficial musculoaponeurotic system (SMAS) grafting to address the issue. In this report, we describe a subcision technique using a wire scalpel or a thread as an ancillary procedure to a face-lift operation to improve the appearance of nasolabial folds. The procedure is simple, safe, easy, and effective with minimal complications.

Subcision Using a Spinal Needle Cannula and a Thread for Prominent Nasolabial Fold Correction

Deepening of the nasolabial crease is an esthetically unpleasing aging phenomenon occurring in the midface. Various treatment modalities have been introduced to improve the appearance of prominent nasolabial folds, all of which have pros and cons. Currently, a minimally invasive technique using synthetic dermal fillers is most commonly used. A simple and easy subcision procedure using a wire scalpel has also been used and reported to be effective for prominent nasolabial fold correction, with minimal complications. As an alternative to the wire scalpel, we used a 20-gauge metal type spinal needle cannula (Hakko Co.) and 4-0 Vicryl suture (Ethicon Inc.) for subcision of nasolabial folds. This technique is less expensive than the use of a wire scalpel and easily available when needed. Therefore, on the basis of favorable results, our modified subcision technique may be considered effective for prominent nasolabial fold correction.

Factors Associated with Diabetic Retinopathy and Nephropathy Screening in Korea: The Third and Fourth Korea National Health and Nutrition Examination Survey (KNHANES III and IV)

This cross-sectional study was done to identify and determine the socio-demographic and health-related factors associated with diabetic retinopathy and nephropathy screening in Korea. Participants included 2,660 adults, aged 40 or older, with diabetes. Of the 2,660 adults, 998 (37%) and 1,226 (46.1%) had received a diabetic retinopathy and a nephropathy screening within one year, respectively. Regarding retinopathy, subjects older than 65, living in urban areas, with high educational levels, and with self-reported "unhealthy" status were likely to receive annual screening. Subjects living in urban areas, with higher educational levels, with self-reported "fair" or "unhealthy" status, and with 1 to 2 co-morbidities were likely to receive annual nephropathy screening. The Korea Composite Stock Price Index (KOSPI) continued to rise until 2007 when it started to decline over the subsequent years, following the same curve as the diabetic retinopathy and nephropathy screening rates during that time. Together with the financial matter, lack of patient education proved to be a hindrance to diabetes-related screening. The relatively low screening rates in Korea compared to the Western countries are likely to be due to the difference in the health system, economic situations and national demographics.

Effects of Nasopore Packing on Dacryocystorhinostomy

PURPOSE: To investigate the effects of placement of the absorbable packing material Nasopore at the anastomosis site of newly formed mucosal flaps on postoperative re-bleeding, discomfort, and on the success rate of dacryocystorhinostomy (DCR). METHODS: A review of the medical records of patients with primary acquired nasolacrimal duct obstruction that underwent external or endonasal DCR by a single surgeon was performed. The degree of re-bleeding, discomfort, and postoperative results, including anatomical success, functional success and postoperative nasal findings such as granulation, synechiae, and membrane formation were compared in patients whose anastomosis site was packed with either Nasopore or Merocel, a non-absorbable packing material. RESULTS: A total of 77 patients (101 eyes) were included. Of the 101 eyes, 30 were packed with Nasopore, while 71 were packed with Merocel. The Nasopore group showed significantly better results than the Merocel group in the degree of re-bleeding and the level of patient discomfort (p = 0.000, 0.039, respectively; Pearson's chi-square test), whereas there were no statistically significant differences between the two groups in postoperative anatomical and functional success (p > 0.05). CONCLUSIONS: Nasopore significantly reduced postoperative nasal re-bleeding and patient discomfort during the early post-surgical period, but failed to show an effect on the postoperative anatomical and functional success of DCR.

Effects of Nasopore Packing on Dacryocystorhinostomy

PURPOSE: To investigate the effects of placement of the absorbable packing material Nasopore at the anastomosis site of newly formed mucosal flaps on postoperative re-bleeding, discomfort, and on the success rate of dacryocystorhinostomy (DCR). METHODS: A review of the medical records of patients with primary acquired nasolacrimal duct obstruction that underwent external or endonasal DCR by a single surgeon was performed. The degree of re-bleeding, discomfort, and postoperative results, including anatomical success, functional success and postoperative nasal findings such as granulation, synechiae, and membrane formation were compared in patients whose anastomosis site was packed with either Nasopore or Merocel, a non-absorbable packing material. RESULTS: A total of 77 patients (101 eyes) were included. Of the 101 eyes, 30 were packed with Nasopore, while 71 were packed with Merocel. The Nasopore group showed significantly better results than the Merocel group in the degree of re-bleeding and the level of patient discomfort (p = 0.000, 0.039, respectively; Pearson's chi-square test), whereas there were no statistically significant differences between the two groups in postoperative anatomical and functional success (p > 0.05). CONCLUSIONS: Nasopore significantly reduced postoperative nasal re-bleeding and patient discomfort during the early post-surgical period, but failed to show an effect on the postoperative anatomical and functional success of DCR.

Treatment of Parotid Fistula with Type A Botulinum Toxin: A Case Report

PURPOSE: The purpose of this report is to present a case of persistent parotid fistula treated successfully with preoperative botulinum toxin type A injection into the parotid parenchyma, followed by fistulectomy. METHODS: A 72-year-old female patient presented to the hospital with a 5-month history of clear, watery discharge from a tiny opening on the left cheek, which increased during food intake. A chemistry test of the fluid revealed an high amylase level. An ultrasonography of left parotid gland showed a 1.13x0.6cm sized fistula. After demarcating the left parotid gland with assistance of ultrasonography, a total 40 units of botulinum toxin type A(Botox, Allergan, Irvine, CA) was injected into 4 subdivisions of the left parotid gland. The clear serous discharge ceased completely on the 5th day after botulinum toxin injection. On the 7th day, a fistulectomy was performed under the local anesthesia. RESULTS: The parotid fistula healed completely without complications. During the 6-month follow up period, there was no discharge from the cheek. CONCLUSION: On the basis of our experience with type A botulinum toxin as a local anticholinergic agent in treating parotid fistula, preoperative botulinum toxin A injection seems to be very useful to prevent recurrence after fistulectomy.

Comparison of Clinical Manifestations between Patients with Ocular Myasthenia Gravis and Generalized Myasthenia Gravis

PURPOSE: To compare the clinical manifestations between patients with ocular myasthenia gravis and those with generalized myasthenia gravis (MG). METHODS: The medical records of 71 patients diagnosed with MG between January 1995 and December 2007 were reviewed. Demographics, sensitivities of diagnostic methods, the presence of systemic autoimmune diseases, ophthalmic complications caused by MG, and treatments were evaluated and compared. RESULTS: Fourteen patients (20%) were diagnosed with ocular MG and 57 patients (80%) with generalized MG. Sensitivities of anti-acetylcholine receptor antibody and repetitive nerve stimulation tests were significantly higher in the generalized MG group (84%, 89%) compared to those in the ocular MG group (50%, 54%) (p = 0.011, p = 0.008). The sensitivity of the neostigmine test was the highest in both groups (98% of generalized MG, 79% of ocular MG), and the difference between the two groups was borderline significant (p = 0.058). The most common symptoms were ptosis and diplopia, and both groups presented with pain, blurred vision, and tearing. Systemic autoimmune disease was more prominent in the generalized MG group (21%) than in the ocular MG group (14%), and steroid therapy was used more frequently in the generalized MG group (82%) than in the ocular MG group (57%). Ophthalmic complications associated with long-term steroid treatment were more profound in the generalized MG (30%) compared to those of the ocular MG (21%). CONCLUSIONS: The generalized MG group was associated with higher sensitivities to diagnostic tests, more systemic steroid use, higher ophthalmic complications caused by systemic autoimmune disease, and long-term steroid treatment compared to those of the ocular MG group.