Skin Necrosis of the Nose After Injection of Ribose Cross-Linked Porcine Atelocollagen.

We report a case of skin necrosis of the nasal tip after an injection of ribose cross-linked porcine atelocollagen (Evolence; Colbar Life Science Ltd, Herzliya, Israel). A 22-year-old woman had a nasal augmentation. From the glabella to the nasal tip, 10 strokes were injected using 0.6 mL of Evolence. On the day of the injection, her nasal tip became cyanotic; a day after it, an erythematous condition developed and a white cheeselike material appeared. On the second day, it became necrotic. Epithelialization was completed for 2 weeks. Despite laser therapy, permanent scarring of the nasal tip was prominent at the 18-month follow-up. It was thought that the skin necrosis is caused by vascular interruption rather than by hypersensitivity because the skin necrosis was confined to the nasal tip. To avoid vascular interruption from a filler injection, aspiration is needed before injection. The least amount of filler should be released in each stroke with low-pressure injection.

Ideal or Young-Looking Brow Height and Arch Shape Preferred by Koreans.

The aim of this study is to see which brow height and arch shape is preferred as ideal or young-looking by Koreans. A survey was conducted between June and Dec 2014 on 186 women who visited the brow bar ("Benefit" of Incheon city). They were asked to choose which they believed ideal and youngest amongst the 3 brow archetypes according to their height and 4 types of modification of Anastasia (rotation of medial and lateral arms), which was illustrated. Approximately half (52.5%) of the respondents answered that their brow matches them very well or well. Most (81.2%) believed there might be a method to yield an ideal brow archetype and almost all (97.3%) would change the brow shape if the expert advised. The most preferred ideal brow height was of a middle height (63.2%, the distance from the lateral canthus to the lateral end of eyebrow, which was 2/3 of the eye width). The most preferred ideal brow arch shape was the arched type (57.6% arches on a line drawn from the center of the nose through the center of the pupil). The most preferred young-looking brow height was of an upper height (46.2%, the distance from the lateral canthus to the lateral end of eyebrow was 3/4 of the eye width) followed by a middle height (39.7%). The most preferred young-looking brow arch shape was the head-up position (53.3%, medial arm of the brow was rotated upward to the horizontal plane). The result of this study might be useful in facial rejuvenation surgeries as well as in brow esthetics or tattooing of the eyebrows.

Where to fix in rejuvenation surgeries?: tensile strength of the periosteum.

The aim of this study is to elucidate the tensile strength of the periosteum relating to facial rejuvenation surgeries.Twelve hemifaces of 6 formalin-fixed Korean adult cadavers were used. Two horizontal incision lines were made 3 cm above the supraorbital rim and 1 cm below the infraorbital rim. Another 2 vertical incisions were on the medial orbital rim and 2 cm lateral to the lateral orbital rim. Elevated flaps were turned over, and the undersurfaces of the periosteum were exposed. A silk string was passed below the periosteum with a 3-mm bite and wound. A 3-cm loop was made, and this was pulled away using the tensiometer. The breaking strength was measured.The breaking strengths of the periosteum were different according to the location (P = 0.000, analysis of variation). The strongest point was 2 cm above the supraorbital rim at the medial one third of the orbit (14.05 [2.50] N) followed by 1 cm above the frontozygomatic suture (13.35 [4.70] N). The weakest point was the infraorbital rim at the lateral one third of the orbit (6.93 [3.76] N) followed by the lateral orbital rim at the level of the lateral canthus (7.60 [3.49] N). Breaking strengths of the periosteum of the medial side (11.44 [3.83] N) were significantly greater (P = 0.021, t-test) than the lateral side (9.32 [3.76] N). In the supraorbital area, the breaking strengths of the periosteum of the upper points (12.91 [3.00] N) were significantly greater (P = 0.000, t-test) than the lower points (9.36 [2.76] N).The results of this study can be of use when choosing a fixation point in rejuvenation surgeries.

Brow archetype preferred by Korean women.

The aim of this study is to see which brow archetype is preferred by Korean women. The archetypes were chosen from a literature search, which contain detailed, replicable methods and have diagrams (Westmore, Lamas, Anastasia, Schreiber, and Hwang). A survey was conducted on 300 subjects (group A, 100 female medical students; group B, 100 women who had visited a plastic surgery clinic for periorbital rejuvenation; and group C, 100 women who visited the brow bar). They were asked whether they think there might be a method that yields an ideal brow archetype. In the cases where they said yes, they were asked to choose 1 of the illustrated 5 brow archetypes that they think is ideal. Among the 300 respondents, 232 (77.3%) thought there might be a method to yield an ideal brow archetype, whereas 68 (22.7%) answered they did not. The preference for the brow archetypes was different among the 5 archetypes (P = 0.0001, χ2). Anastasia was the most preferred (44.8%, brow starts on a perpendicular line drawn from the middle of the nostril, arches on a line drawn from the center of the nose through the center of the pupil, and ends on a line drawn from the edge of the corresponding nasal ala through the outer edge of the eye). Anastasia was followed by Lamas (22.0%). In group A, Anastasia (55.7%) was the most preferred, followed by Lamas (26.2%) and Westmore (13.1%). In group B, Anastasia (34.8%) was the most preferred, followed by Lamas (30.3%) and Westmore and Schreiber (both 13.5%). In group C, Anastasia (47.6%) was the most preferred, followed by Hwang (25.5%) and Westmore (11.0%). There was a significant difference (P < 0.001) among the 3 groups. There was a significant correlation between the preference of brow archetype and occupation (P = 0.0033). However, no significant differences were noted for the preference of brow archetype between the age groups of younger than 30 years and older than 30 years (P = 0.1374), level of education (P = 0.3403), marital status (P = 0.541), or monthly income (P = 0.1696, χ2). The result of this study might be useful in facial rejuvenation surgeries as well as in brow esthetics or tattooing of eyebrows.

Mixed infection of an atypical Mycobacterium and Aspergillus following a cryopreserved fat graft to a face.

We report a chronic infection of a patient who received a cryopreserved fat graft on her face. A 22-year-old female patient presented with multiple abscesses of her face. Four months previously, she received a second fat graft with the fat harvested at a previous surgery which was cryopreserved for 2 months. On examination, she had tender erythematous nodules on both cheeks. A computed tomography of her neck showed multiple peripheral enhancing nodular lesions. In an open pus fungus culture, Aspergillus fumigatus growth was observed. On the Mycobacterium Other Than Tuberculosis identification PCR, Mycobacterium fortuitum was found. She was treated with levofloxacin, clarithromycin, and minocycline for 11 months, and finally the symptoms subsided. To avoid infection after the fat graft, cryopreserved fat should not be used as a possible grafting material. In cases of persistent infection, or in cases of waxes and gains after drainage of pus and short-term antibiotics therapy, atypical Mycobacterium or Aspergillus should be suspected and a PCR for them should be carried out.

Particle size, temperature, and released amount of fat for safe periorbital fat grafts.

The aim of this study was to determine the particle size, temperature, and amount of released fat for safe periorbital fat grafts. From 28 patients, fat was suctioned from the abdomen (large particles [LPs]) and from the inner thigh (small particles [SPs]) using a 2.1-mm harvesting cannula with a diameter 3.2 × 1.4-mm hole and a 1-mm hole, respectively. The 10-mL syringes full of fat were then put into a centrifuge for 3 minutes (LP) and 1 minute (SP) at 3000 revolutions/min. Fat was then transferred to a 1-mL syringe with Luer-Lock adapters and a blunt cannula of 0.9-mm diameter. The force needed to push the fat out of the cannula was measured with a force gauge. The force was measured within the different groups according to particle size of the fat, temperature of the fat, and released amount of fat. The force needed to push the SP fat out of the cannula into the air with minimal amount (MA) (0.01-0.02 mL) injected at room temperature (25 °C) (1.75 ± 0.82 N) was significantly greater (P = 0.000 [t test]) than at body temperature (BT, 33 °C) (1.27 ± 0.38 N). At BT, the force needed to push the SP fat into subcutaneous pig tissue (2.30 ± 1.46 N) was significantly lesser (P = 0.000 [t test]) than LP fat (6.54 ± 2.39 N). At BT, the force needed to push the MA of SP fat into pig subcutaneous tissue (1.38 ± 0.26 N) was significantly lesser (P = 0.000 [t test]) than the force needed to push the usual amount (0.03-0.04 mL) of SP fat (3.83 ± 1.78 N). The force needed to push the fat into human lower eyelids at room temperature (4.06 ± 2.26 N) was significantly greater (P = 0.000 [t test]) than at BT (2.11 ± 0.96 N). At BT, the force needed to inject an MA of SP fat into human lower eyelids (1.55 ± 0.83 N) was significantly lesser (P = 0.000 [t test]) than the force needed to inject a usual amount of fat (2.78 ± 1.03 N). We suggest injections of the SP (1-mm hole diameter harvesting cannula) fat with MAs (0.01-0.02 mL) by means of fragmented incremental injections stored at BT (33°C) to reduce the injection pressure.

A surgeon's legal liability of compensation for blindness after periorbital fat grafts.

We introduce a case of blindness after a periorbital fat graft and its resulting court ruling in regard to a surgeon's liability of compensation. A 19-year-old woman received an injection of preserved autologous fat to her nasal dorsum. During the injections, she complained of pain and lost vision of her right eye. The pupil responded to light but showed a blepharoptosis and a limitation of the extraocular muscle of her right eye. Upon a fundoscopy, a cherry red spot was observed. Brain magnetic resonance imaging and angiography showed an acute infarction of the ophthalmic nerve. Upon an angio-computed tomography, the ophthalmic artery branch was not visualized. Her right eye remained blind 3 weeks after admission. She claimed compensation for damage from the surgeon. The court determined a ruling in favor of the plaintiff (patient); however, the responsibility was limited to 70%. As a result, the defendant has to pay 84,750 US$ to the patient and 6450 US$ to her parents. Roe (the presiding judge) stated that in this case, the injected autologous fat seems to have been put into the ophthalmic artery and the central retinal artery along the vascular countercurrent because of excessive applied pressure. The court also said that because the plaintiff had a history of rhinoplasty, the defendant should have injected the fat more slowly at low pressure to avoid the vascular injury. We think there is a question about "how slowly and how low the pressure should be" for the fat injection. A further study of injection pressure, particle size, temperature, and release in the amount of fat for safe, periorbital, fat grafts should follow this study.

The early UL31 gene of equine herpesvirus 1 encodes a single-stranded DNA-binding protein that has a nuclear localization signal sequence at the C-terminus.

The amino acid sequence of the UL31 protein (UL31P) of equine herpesvirus 1 (EHV-1) has homology to that of the ICP8 of herpes simplex virus type 1 (HSV-1). Here we show that the UL31 gene is synergistically trans-activated by the IEP and the UL5P (EICP27). Detection of the UL31 RNA transcript and the UL31P in EHV-1-infected cells at 6h post-infection (hpi) as well as metabolic inhibition assays indicated that UL31 is an early gene. The UL31P preferentially bound to single-stranded DNA over double-stranded DNA in gel shift assays. Subcellular localization of the green fluorescent protein (GFP)-UL31 fusion proteins revealed that the C-terminal 32 amino acid residues of the UL31P are responsible for the nuclear localization. These findings may contribute to defining the role of the UL31P single-stranded DNA-binding protein in EHV-1 DNA replication.

Characterization of cis-acting elements required for autorepression of the equine herpesvirus 1 IE gene.

The immediate-early protein (IEP), the major regulatory protein encoded by the IE gene of equine herpesvirus 1 (EHV-1), plays a crucial role as both transcription activator and repressor during a productive lytic infection. To investigate the mechanism by which the EHV-1 IEP inhibits its own promoter, IE promoter-luciferase reporter plasmids containing wild-type and mutant IEP-binding site (IEBS) were constructed and used for luciferase reporter assays. The IEP inhibited transcription from its own promoter in the presence of a consensus IEBS (5'-ATCGT-3') located near the transcription initiation site but did not inhibit when the consensus sequence was deleted. To determine whether the distance between the TATA box and the IEBS affects transcriptional repression, the IEBS was displaced from the original site by the insertion of synthetic DNA sequences. Luciferase reporter assays revealed that the IEP is able to repress its own promoter when the IEBS is located within 26-bp from the TATA box. We also found that the proper orientation and position of the IEBS were required for the repression by the IEP. Interestingly, the level of repression was significantly reduced when a consensus TATA sequence was deleted from the promoter region, indicating that the IEP efficiently inhibits its own promoter in a TATA box-dependent manner. Taken together, these results suggest that the EHV-1 IEP delicately modulates autoregulation of its gene through the consensus IEBS that is near the transcription initiation site and the TATA box.

Does the upper eyelid skin become thinner with age?

The aim of this study was to elucidate whether the thickness of the upper eyelid skin is affected by aging. The upper eyelid skins of 61 Korean women were subject to the study. Fusiform pieces of the skin, 3-mm wide, were obtained at the midpupillary line, 7 mm above the eyelashes, during blepharoplasty. The specimens were stained with hematoxylin and eosin. Thickness of the skin was measured by a micrometer under a microscope. It was substantially the same in all of the age groups. The thickness varied from 818 +/- 85 microm in subjects 60 years or older to 884 +/- 112 microm in subjects between 21-and 30-years old; the mean was 860 +/- 305 microm. Thickness of the epidermis varied from 46 +/- 6 microm in subjects between 41- and 50-years old to 52 +/- 10 microm in subjects between 31- and 40-years old; the mean was 49 +/- 9 microm. There were no significant differences among the age groups (P = 0.440). Thickness of the dermis varied from 771 +/- 78 microm in subjects older than 61 years to 834 +/- 112 microm in subjects between 21-and 30-years old; the mean was 811 +/- 117 microm. There were no significant differences between the age groups (P = 0.553). It is noticeable that upper eyelid skin thickness is not affected remarkably by aging.