Anchor epicanthoplasty combined with out-fold type double eyelidplasty for Asians: do we have to make an additional scar to correct the Asian epicanthal fold?

The epicanthal fold along with a lack of a superior palpebral fold, excessive fat, and laxity of pretarsal skin represent the ethnic characteristics and a traditional sense of beauty in the Asian upper eyelid. But, too prominent an epicanthal fold may ruin an otherwise beautiful eye; furthermore, it becomes a restriction that makes the out-fold type double eyelidplasty, one of the two main types of double eyelidplasty, impossible. If a double eyelid as an out-fold type is desired, a concomitant epicanthoplasty should be performed with the possibility of hypertrophic scarring of the medial canthal area in Asians. To address the Asian epicanthal fold without danger of hypertrophic scarring, the authors developed an anchor epicanthoplasty technique that leaves no additional scar when combined with a double eyelidplasty. This technique is based on the concept of trimming of muscle and soft tissue under the Asian epicanthal fold and downward medial advancement and anchoring of the medial canthal skin to the deep tissue. The technique consists of five procedures based on the assumed causes of the Asian epicanthal fold: (1) augmentation rhinoplasty, (2) downward medial advancement of the medial upper lid skin, (3) removal of the superficial insertion of the medial canthal ligament and selective removal of the orbicularis oculi muscle, (4) subcutaneous contouring of the thick nasal skin, and (5) anchoring of the medial end of the incision to the deep tissue. During the past 12 years (1988 to 1999), 67 anchor epicanthoplasty procedures have been performed. Twenty-eight cases were followed up for more than 3 months, and all of the patients were satisfied with the results. There were only a few minor complications, which could be corrected with minimal revision. As an ancillary procedure to a double eyelidplasty, this anchor epicanthoplasty can reduce the Asian epicanthal fold and make a double fold as an out-fold type without an additional scar. In terms of hypertrophic scarring and compatibility with out-fold type double eyelidplasty, this anchor epicanthoplasty is the best method for correcting Asian epicanthal fold compared with other preexisting procedures. Other advantages of this technique are a wide range of applications and no compromise of medial, canthal skin to interfere with other epicanthoplasty techniques. Some disadvantages of this technique are technical difficulty and the possibility of active bleeding.     

Root z-epicanthoplasty in asian eyelids

In the eyelids of Asians, the presence of epicanthal folds and the absence of supratarsal folds are a unique feature. The resulting appearance leads many to seek cosmetic improvement in the medial canthal area. Although many techniques have been described for the elimination of epicanthal folds, scarring and complexity in design are still barriers for surgeons to overcome. From July of 1998 to May of 2000, the authors used root Z-epicanthoplasty on the eyelids of 30 Asian patients to correct epicanthal folds. Results were satisfactory in all patients, with no complications. Root Z-epicanthoplasty, as performed by the authors, is a simple design and procedure; there is minimal scarring in the medial canthal area and no tension.     

Surgical treatment of the epicanthal fold

A surgical technique is described for the correction of the epicanthal fold. Indications for its use are noted and emphasis is placed on its advantages. The procedure is simple to perform and uniformly gives good results.     

Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classification and treatment

The medial canthal tendon and the fragment of bone on which it inserts ("central" fragment) are the critical factors in the diagnosis and treatment of nasoethmoid orbital fractures. The status of the tendon, the tendon-bearing bone segment, and the fracture pattern define a clinically useful classification system. Three patterns of fracture are appreciated: type I--single-segment central fragment; type II--comminuted central fragment with fractures remaining external to the medial canthal tendon insertion; and type III--comminuted central fragment with fractures extending into bone bearing the canthal insertion. Injuries are further classified as unilateral and bilateral and by their extension into other anatomic areas. The fracture pattern determines exposure and fixation. Inferior approaches alone are advised for unilateral single-segment injuries that are nondisplaced superiorly. Superior and inferior approaches are required for displaced unilateral single-segment injuries, for bilateral single-segment injuries, and for all comminuted fractures. Complete interfragment wiring of all segments is stabilized by junctional rigid fixation. All comminuted fractures require transnasal wiring of the bones of the medial orbital rim (medial canthal tendon-bearing or "central" bone fragment). If the fracture does not extend through the canthal insertion, the canthus should not be detached to accomplish the reduction.     

New technique for correction of the microform cleft lip using vertical interdigitation of the orbicularis oris muscle through the intraoral incision

A microform cleft lip has three major components: (1) a minor defect of the upper vermilion border with loss of the mucocutaneous ridge; (2) a narrow ridge of tissue, resembling an exaggerated philtral column extending to the nostril sill; and (3) a deformity of the nostril. To attain the muscle continuity without an external scar on the upper lip, the author introduced a new method for the correction of a microform cleft lip deformity using vertical interdigitation of the orbicularis oris muscle through the intraoral incision to create the philtrum. Through the intraoral incision, a full-thickness incision is made down to the mucosa and the posterior portion of the muscle. Then, the remaining portion of the muscle is dissected. The medial and lateral muscle flaps are also detached from the oral mucosa and completely exposed and split into two leaves. The upper leaf of the lateral muscle flap is sutured to the dermis on the philtral dimple and base of the upper leaf of the medial muscle flap. Two leaves of each muscle flap are sutured together to create a vertical interdigitation to increase the thickness of the philtral column and to provide continuity of the muscle. A total of 12 patients with microform cleft lip were treated between August of 2001 and October of 2002. Seven of the patients were male and five were female, with an age range of 1 to 43 years. The follow-up period ranged from 6 months to 15 months, with an average follow-up of 9 months. The results of vertical interdigitation of the muscle were examined. All patients were satisfied with their results. The orbicularis oris muscle provided continuity and preserved good function. In all cases, the operation scar was not visible on the depressed philtral groove on the cleft side. Correction of cleft lip nasal deformity was performed in four patients and alar base advancement was performed in two patients. The advantages of the proposed procedure include the creation of an anatomically natural philtrum without an external visible scar through the intraoral incision, preservation of the continuity and function of the muscle, and sufficient augmentation of the philtral column by the vertical interdigitation of the muscle.     

Submammary flap for correction of severe sequelae from augmentation mammaplasty

A submammary flap was used in 20 patients with severe cicatricial retractions and loss of the inferior pole of the breast caused by inadequately treated mammary implant infections. This axial flap can be used with a medial pedicle, based on the perforating branches of the epigastric artery or the distal part of the internal mammary artery, or laterally based, nourished by the intercostal perforators. After 6 months, reimplantation was performed in 15 patients. The authors' follow-up ranged between 8 months and 6 years. This transverse adipocutaneous flap procedure is very simple to perform, the donor site is sutured primarily without additional undermining, and the resultant scar lies hidden within the submammary fold. It provides tissue with similar skin texture and color match. Its versatility allows it to be used as a full-thickness tissue replacement or partially or totally de-epithelialized for soft-tissue reconstruction. It can also be used as an island flap. For all of these reasons, in emotionally distressed patients with low compliance with surgical treatments and additional scars, this flap is the authors' flap of choice for reconstruction.     

Quantitative assessment of osseous, ocular, and periocular changes after hypertelorism surgery

The purpose of this study was to develop a methodology to quantify osseous, ocular, and periocular fat changes caused by correction of orbital hypertelorism to test the hypothesis that there is a quantitatively predictable relationship between the movement of the osseous orbit and that of the ocular globe. A retrospective review was performed of 10 patients who were status post unilateral or bilateral transcranial medial orbital translocation, for whom there were archival digital data for preoperative and postoperative (mean interval = 30 months) three-dimensional computed tomographic (CT) scans. In addition to standard demographic and surgical data, the clinical preoperative and postoperative interpupillary and intermedial canthal distances were recorded. By using a computer graphics workstation, the CT digital data were registered to four surgically unaltered anatomic fiducial points to allow longitudinal quantitative comparisons. The following three-dimensional measurements were made for each patient preoperatively and postoperatively: interdacryon and interocular centroid distances, and on a standard series of three horizontal and two vertical planes, the position of the medial and lateral orbital walls, and the thickness of the medial and lateral periorbital fat (20 orbits). CT digital distances were compared with similar clinical distances when possible. The age at operation ranged from 4.0 to 12.5 years (mean, 6.6 years). The reduction in interdacryon distance exceeded the reduction in intercentroid distance (mean interdacryon change = -5.3 mm versus mean intercentroid change = -2.7 mm). Although there was a strong correlation between the amount of reduction of the lateral orbital wall and intercentroid distances, there was only a moderate correlation between the reduction in the intercentroid distance and that of the medial orbital wall. Similarly, there was a moderate correlation between the decrease in thickness of the lateral periorbital fat and the reduction of intercentroid distance but not of the medial orbital fat. In conclusion, medial translocation of the orbit does not produce equivalent movement of the ocular globe; neither the intermedial canthal nor the interdacryon distance is a useful predictor of ocular centroid position; and if the goal of hypertelorism operation is reduction of interocular distance, then CT measurement of globe intercentroid distance is essential for outcome assessment.     

Rhytidectomy and the nasolabial fold.

I describe a technical modification in the Skoog face lift procedure that releases the deep attachments of the SMAS to the muscles of facial expression for maximal mobility of the medial cheek yet elevates the cheek flap as a composite of skin, subcutaneous tissue, and SMAS to enhance skin perfusion. My results with the procedure in 100 patients are analyzed by using functional zones of the nasolabial fold corresponding to underlying musculature and a simple grading system based on preoperative and postoperative photographs. Marked improvement in the nasolabial fold was noted in over 80 percent of patients by 6 and 12 months postoperatively. This effect seemed to last up to 4 years.     

Multiple, combined plications of the SMAS-platysma complex: breaking down the face-aging vectors

After analyzing how facial tissues are affected during the aging process, 36 rhytidoplasties were performed by plicating the superficial musculoaponeurotic system (SMAS)-platysma complex. Also, additional procedures were performed to improve the aesthetic result. Patients were followed for 3 to 33 months (median, 13 months); their ages ranged from 42 to 72 years (median, 53 years). Because the facial soft tissues present specific anatomic particularities and the force-vector determinants for facial ptosis are many and varied, specific plications were combined to obtain the desired results during a rhytidoplasty. Combinations of six different types of plications are described; some of them are used individually by various authors to manage the SMAS-platysma complex. Major complications did not occur, despite extensive cutaneous undermining, and morbidity was similar to that of other techniques that handle the SMAS. The results were satisfactory for all patients, and clinical improvement was noted in all cases. On the basis of these results, using combined plication to manage the SMAS-platysma complex during a rhytidoplasty is recommended. The opposing vectors should be considered when planning the combination of plications.     

A versatile breast reduction technique: Conical plicated central U shaped (COPCUs) mammaplasty

Background

There have been numerous studies on reduction mammaplasty and its modifications in the literature. The multitude of modifications of reduction mammaplasty indicates that the ideal technique has yet to be found. There are four reasons for seeking the ideal technique. One reason is to preserve functional features of the breast: breastfeeding and arousal. Other reasons are to achieve the real geometric and aesthetic shape of the breast with the least scar and are to minimize complications of prior surgical techniques without causing an additional complication. Last reason is the limitation of the techniques described before. To these aims, we developed a new versatile reduction mammaplasty technique, which we called conical plicated central U shaped (COPCUs) mammaplasty.

Methods

We performed central plication to achieve a juvenile look in the superior pole of the breast and to prevent postoperative pseudoptosis and used central U shaped flap to achieve maximum NAC safety and to preserve lactation and nipple sensation. The central U flap was 6 cm in width and the superior conical plication was performed with 2/0 PDS. Preoperative and postoperative standard measures of the breast including the superior pole fullness were compared.

Results

Forty six patients were operated with the above mentioned technique. All of the patients were satisfied with functional and aesthetic results and none of them had major complications. There were no changes in the nipple innervation. Six patients becoming pregnant after surgery did not experience any problems with lactation. None of the patients required scar revision.

Conclusion

Our technique is a versatile, safe, reliable technique which creates the least scar, avoids previously described disadvantages, provides maximum preservation of functions, can be employed in all breasts regardless of their sizes.     

The evaluation and management of lower eyelid retraction following cosmetic surgery

Lower eyelid retraction is a common complication after cosmetic surgery of the lower eyelids, midface, and the adjacent face. Lower eyelid retraction is defined as the inferior malposition of the lower eyelid margin without eyelid eversion. Lower eyelid retraction presents clinically with scleral show; round, sad-looking eyes; lateral canthal tendon laxity; and symptoms of ocular irritation, including photophobia, excessive tearing, and nocturnal lagophthalmos. These patients frequently require ocular lubricants, including artificial tears and ointments, which often provide only minimal alleviation of their symptoms. The author has observed that lower eyelid retraction is usually accompanied by midface descent. On the basis of surgical observations, the causes of lower eyelid retraction seem to be multifactorial and include scarring between the orbital septum and capsulopalpebral fascia (or lower eyelid retractors), lateral canthal tendon laxity, and midface descent. After describing the causes of lower eyelid retraction, the author presents a system for evaluating patients that can assist the surgeon in choosing the surgical procedure(s) required to correct the lower eyelid malposition. The surgeon must know how to tighten a lax lateral canthal tendon, be familiar with the anatomy of the lower eyelid from conjunctiva to skin side, and know how to surgically elevate the midface. The techniques for correcting lower eyelid retraction are also presented. Appropriate surgery, which is determined on the basis of the preoperative evaluation, has allowed for the correction of these previously difficult-to-treat lower eyelid malpositions with minimal complications.     

Modified operative technique for involutional lower lid entropion

The paper presents a modified operative technique for involutional lower lid entropion. The prospective noncomparative study of 101 lower eyelids of 88 patients undergoing surgery for involutional lower lid entropion was conducted in period from September 2005 until March 2012. Indication for the surgery was entropion, previously untreated, with moderate to severe horizontal lid laxity and no clinically relevant medial and lateral canthal tendon laxity. The operative technique is our modification of Quickert and Jones procedures. Photo was taken preoperatively and one month after surgery. Clinical follow-up was at 7th postoperative day, one month and six months after surgery and in case of the recurrence. Long-term follow-up was obtained via telephone interviews. There were 44 male (50%) and 44 female (50%) patients included in the study. The age of patients was in average 73.27 +/- 8.1 years (range 53-90 years). Early postoperative complication was localized lid swelling found in two patients starting 4-6 weeks postoperatively at the area of absorbable suture. It resolved spontaneously in two and three weeks respectively. There was recurrence of entropion in 11 eyelids (10.89%) of 10 patients. The mean interval between primary surgery and the recurrence was 17.45 +/- 14.84 months (range 4-48 months). In these eyelids Jones procedure was performed. However in four eyelids of four patients from the recurrent group an additional surgery needed to be performed after 6, 12, 12 and 17 months respectively. Our modification of surgical treatment for involutional lower lid entropion was effective in 89.11% of eyelids. Complications of the procedure were scarce.     

Ocular fixation with quadriceps tendon allograft

Management of difficult strabismus, such as strabismus fixus and paralytic strabismus, in order to maintain the alignment is complicated. There are many surgical approaches described in the current literature, together with notes on the materials used to stabilize these deformities. We present a new surgical approach using quadriceps tendon allograft for the correction of difficult strabismus such as strabismus fixus and paralytic strabismus. Our idea for using deep frozen quadriceps tendons developed from the fact that this is the most stable and strongest tendon in the whole body. Six patients with strabismus fixus (n = 1), paralytic strabismus secondary to extraocular muscle damage (n = 1) and combined cranial nerve palsy (n = 4) were operated on using a strip of deep frozen quadriceps tendon allograft suturedonto both the globe and the periosteum. The mean age of the patients was 44.33years. (range 17–71 years) All the patients were followed up for six months. The mean preoperative deviation in the six cases was 60 prism diopters(PD) (range 30–123 PD) The mean change in horizontal alignment at 1 month, 3 months and 6 months postoperatively was 54PD, 53 PD and 49.16 PD respectively. We had only one case of under correction. This may possible be due to the remaining function of the antagonist and/or the fact that we had used the distal end of the quadriceps tendon. When the patient (patient No. 5) who had 2 operations was excluded, the mean change in horizontal alignment was 48.6 PD,47.4PD and 43.6 PD. Post-operatively there was no infection or any other complications. According to our study of existing literature, these cases of deep frozen quadriceps tendon allograft application for the indications mentioned above are the first reported cases of its type. We conclude that ocular fixation with quadriceps tendon to the periosteum is a safe and effective option for the management of difficult strabismus. Further research on a larger cohort of patients and longer follow-up time are needed. This revised version was published online in July 2006 with corrections to the Cover Date.     

Aesthetic eyelid ptosis correction: a review of technique and cases

Upper eyelid ptosis can present both functional and aesthetic problems. Because proper correction of ptosis can be difficult to achieve, numerous surgical procedures have been developed. Plication of levator aponeurosis can be combined with aesthetic blepharoplasty and facial rejuvenation procedures to successfully address ptosis. The authors assessed the effectiveness of levator aponeurosis plication for correction of acquired upper eyelid ptosis in patients presenting for concomitant cosmetic facial procedures. The medical records of 74 consecutive patients (68 women and six men) who had upper eyelid ptosis correction in conjunction with cosmetic facial procedures from January of 1994 to January of 2000 were reviewed. During this period, 400 endoscopic forehead lifts and 479 face lifts were performed. The correction was performed through an external upper blepharoplasty approach removing an ellipse of skin and orbicularis muscle. Once the orbital septum was opened, a plication of the levator aponeurosis was accomplished by one or more horizontal mattress sutures of 6-0 clear nylon (with the first bite placed at or just medial to the vertical level of the pupil). The average follow-up period was 14 months. Long-term correction of the ptosis was excellent. The complications were minor, with the most common occurrence being asymmetry. Revisions were performed on only four patients. Correction of ptosis can be performed safely and effectively in conjunction with periorbital and facial rejuvenation. The technique described is simple, reliable, and reproducible.     

The vertical mammaplasty: a reappraisal of the technique and its complications

Since 1989, superior pedicle vertical scar mammaplasty as described by Lejour has been used in the authors' department as the only technique for breast reduction. From 1991 through 1994, a series of 170 consecutive patients (330 breasts) underwent an operation. In these patients, minor complications were observed in 30 percent of the patients and major complications in 15 percent. Surgical revision for scar or volume corrections was necessary in 28 percent of the breasts, which seemed unacceptable. Therefore, the original technique was modified by decreasing the skin undermining and avoiding liposuction in the breast. Primary skin excision was performed in the submammary fold at the end of the operation if the skin could not be puckered adequately. This modified technique was used from 1996 through 1999 in 138 consecutive patients (227 breasts). In the second series, minor complications were observed in 15 percent of the patients and major complications in 5 percent. However, the technical modifications did not significantly change the rate of secondary scar and volume corrections, which were still necessary in 22 percent of the breasts. In large breasts, the addition of a horizontal scar at the end of the operation did not change the rate of secondary revision, which however compares favorably with the figures obtained with the inverted T, superior pedicle mammaplasty.     

Frontalis Muscle Flap Suspension for the Correction of Congenital Blepharoptosis in Early Age Children

Background

We aimed to report our successful use of frontalis muscle flap suspension for the correction of congenital blepharoptosis in early age children.

Methods

This retrospective study included 61 early age children (41 boys, 20 girls) with an average age of 6 years (range, 3–10 years) with congenital blepharoptosis who received surgery during the period from March 2007 to January 2011. There were 39 cases of unilateral blepharoptosis and 22 cases of bilateral blepharoptosis, thus a total of 83 eyes were affected. If patient had bilateral blepharoptosis, both eyes were operated on in the same surgery. Patients were followed for 3 months to 5 years. The procedure was performed without complications in all cases.

Results

The postoperative healing grade was good in 81 eyes (97.6%); the correction of blepharoptosis was satisfactory, the double eyelid folds were natural and aesthetic, the eyelid position and the curvature were ideal, and the eyes were bilaterally symmetrical. The postoperative healing grade was fair in 2 eyes (2.4%); blepharoptosis was improved compared with that before surgery. At discharge, lagophthalmos was noted in 10 eyes of which 4 cases resolved by the last follow-up. The remaining 6 cases were mild. Eleven eyes received reoperation for residual ptosis after the first surgery. The curvature of the palpebral margin was not natural in 4 eyes. These unnatural curvature possibly was caused by an excessively low lateral fixation point or postoperative avulsion.

Conclusion

Frontalis muscle flap suspension under general anesthesia for the correction of congenital blepharoptosis in early age children can achieve good surgical results.     

Geometry of human vocal folds and glottal channel for mathematical and biomechanical modeling of voice production

Current models of the vocal folds derive their shape from approximate information rather than from exactly measured data. The objective of this study was to obtain detailed measurements on the geometry of human vocal folds and the glottal channel in phonatory position. A non-destructive casting methodology was developed to capture the vocal fold shape from excised human larynges on both medial and superior surfaces. Two female larynges, each in two different phonatory configurations corresponding to low and high fundamental frequency of the vocal fold vibrations, were measured. A coordinate measuring machine was used to digitize the casts yielding 3D computer models of the vocal fold shape. The coronal sections were located in the models, extracted and fitted by piecewise-defined cubic functions allowing a mathematical expression of the 2D shape of the glottal channel. Left-right differences between the cross-sectional shapes of the vocal folds were found in both the larynges.     

Further experience with the lateral arm free flap

Our experience with the lateral arm free flap over the last 7 years was reviewed in detail, placing emphasis on the clinical aspects and modifications of the flap. A total of 150 patients have undergone reconstructive procedures with the flap for small to medium-sized defects. This included 18 split flaps, 11 osteocutaneous flaps, 6 with vascularized triceps tendon, 5 neurosensory flaps, and 5 fascia-fat flaps. The donor-site scar was generally acceptable; only 3 patients required scar revision and 15 patients required debulking of the flaps. With use of the split flap for wide defects, tension-free primary closure of the donor site can be achieved. In most cases, a two-team approach may be adopted, thereby increasing the efficiency of this microvascular transfer.     

Anatomicohistologic study of the retaining ligaments of the face and use in face lift: retaining ligament correction and SMAS plication

Plastic surgeons have sought to improve nasolabial folds, jowls, jaw lines, and cervical contour with face-lifting procedures that are abundant in the literature. The retaining ligaments of the face support facial soft tissue in normal anatomic position, resisting gravitational change. As this ligamentous system attenuates, facial fat descends into the plane between the superficial and deep facial fascia, and the stigmata of facial age develop. In this study, surgical correction of the retaining ligaments and plication of the superficial musculoaponeurotic system (SMAS) to reposition the structures that have descended with gravitation are discussed. The anatomy of the facial retaining ligaments was studied in 22 half-faces of 11 fresh cadavers, and the localization, extension, and width of the ligaments were examined macroscopically and histologically. Surgical correction of the retaining ligaments and plication of the SMAS have been accomplished in 27 face-lift patients with this anatomicohistologic study taken into consideration. There was hematoma in one patient at the cheek region and a permanent dimple caused by postoperative edema in two patients, with a localization of one zygomatic and two parotidomasseteric ligaments. In one patient, hypesthesia in the mandibular nerve region was seen, which remitted at 14 weeks. There were no other complications, and with a follow-up of 24 months, excellent aesthetic results and a high level of patient satisfaction were encountered.     

Reconstruction of the medial half of the lower eyelid using a "switch" split-lid procedure

Reconstruction of the medial half of the lower eyelid has one major disadvantage: It produces a scar at right angles to the eyelid rim. In contrast, use of a "switch" split-lid procedure avoids this inconvenience. The lateral half of the lower eyelid is split in two lamellae. The inner layer is transferred medially, and the resulting defect is closed with a buccal graft. The outer layer is drawn laterally to cover the raw surface of the mucosal pedicle and graft. The surplus of skin over the lateral canthal area is removed. This procedure, which so far has been used in three patients, promises to be a useful alternative for reconstruction of the medial half, but not more, of the lower eyelid.