Fan Huan

Diplopia and enophthalmos in blowout fractures.

Abstract The aim of this study was to compare the changes of diplopia and enophthalmos in patients with blowout fractures. Three hundred sixty-two patients who presented with blowout fractures between March 2006 and February 2011 were analyzed. The sequential time changes of diplopia and enophthalmos were measured in the operated group and the observed group according to (1) the duration of preoperative observation (early: within 7 days, late: 8–14 days, delayed: >15 days); (2) the defect size (minimal: <1 cm2, small: 1.1–2.0 cm2, medium: 2.1–3.0 cm2, large: >3.0 cm2); and (3) the age of the patients (<20, 21–40, 41–60, >61 years). Among the 362 patients, 242 (66.9%) had an operation, and 120 (33.1%) did not. The duration of preoperative observation did not affect the postoperative diplopia or enophthalmos. There were significant differences of enophthalmos among the operated groups with a different defect size at the preoperative period (P = 0.036 [Pearson &khgr;2]). There were significant differences of diplopia among the operated groups with different defect sizes at the 6 months’ follow-up period (P = 0.014 [Pearson &khgr;2]). The diplopia in the older age group (>60 years) was significantly greater than that of the other 3 groups at 6 months (P = 0.023) and at 12 months (P = 0.023, [Pearson &khgr;2]). We think surgery should be delayed until the swelling is decreased unless the medial rectus muscle is incarcerated. We also think that the defect size is not an important factor for whether to perform surgery. We think that the reason for the greater diplopia in the older age group is that the adaptation of binocular convergence is decreased in the older age group.

Size of the superior palpebral involuntary muscle (Müller muscle).

The aim of this study was to elucidate the width and length of the superior palpebral muscle by using anti-&agr;-smooth muscle actin antibody. Ten orbits of 5 adult Korean cadavers were used. Eyelids were cut in vertical planes through midpupilliary, medial limbus, and lateral limbus and in horizontal planes at the anterior border of the superior transverse ligament and 2 mm proximal to the upper tarsal border. Superior palpebral muscle was localized using mouse monoclonal anti-&agr;-smooth muscle actin and counterstained with light green for collagen. In enlarged pictures of sections, widths, lengths, and thicknesses of the superior palpebral involuntary muscle were measured with a curved scale and were analyzed.The levator palpebrae superioris muscle was divided into superficial and deep parts below the superior transverse ligament. The levator aponeurosis originated from the superficial part and the superior palpebral muscle originated from the deep part of the levator palpebrae superioris muscle. The aponeurosis was inserted into the upper border of tarsus. The superior palpebral muscle fibers arose 2.71 ± 0.64 mm posterior to the anterior border of the superior transverse ligament. The superior palpebral muscle was trapezoidal. The lengths of its sides were 15.58 ± 1.82 and 22.30 ± 5.25 mm, and its height was 13.70 ± 2.74 mm. The levator aponeurosis covered the superior palpebral muscle anteriorly. The width of the levator aponeurosis was approximately 4 mm wider than the superior palpebral muscle. The thicknesses of the superior palpebral muscle were 0.14 ± 0.13 mm at the anterior border of the superior transverse ligament, 0.45 ± 0.11 mm at the superior fornix level, and 0.10 ± 0.03 mm at the upper border of the tarsal plate. One vascular layer was between the levator aponeurosis and the superior palpebral muscle (upper vascular layer), and the other was between the superior palpebral muscle and the conjunctiva (lower vascular layer). At the superior fornix level, thickness of the upper and lower vascular layers was 0.28 ± 0.06 and 0.38 ± 0.21 mm, respectively. The result of our study might contribute to corrective blepharoptosis surgery.

Mapping thickness of nasal septal cartilage.

The aim of this study was to elucidate the thickness of the septal cartilage relating to septal advancement surgery. Fourteen Korean adult cadavers were used. A rectangular coordinate was used, with the x-axis horizontal on the maxillary crest and the y-axis a vertical right angle to the x-axis on the anterior nasal spine. The length and the height of the septal cartilages were divided evenly in 5 dimensions, and the thickness was measured of intersecting points of grating. The mean length and height of the cartilaginous septum was 3.31 ± 0.53 and 2.99 ± 0.47 cm, respectively. The thickness of the septal cartilage varied according to the site (0.74-3.03 mm). The thickest area was the septal base (0% of the septal height) anterior to the vomer (2.19-3.03 mm). The thinnest area (0.74-0. 97 mm) was just above the base area at 20% of the septal height. The anterior-inferior part of the site above the thinnest area was 1.03 to 1.22 mm in thickness and the superior-posterior part was 1.26 to 1.50 mm. The anterior-inferior part was thinner than the superior-posterior one. The thickness map of the nasal septum might be usefully applied in septal surgery, particularly in septal advancement.

Muscle fibre types of the lumbrical, interossei, flexor, and extensor muscles moving the index finger

Abstract The aim of this study was to determine the fibre types of the muscles moving the index fingers in humans. Fifteen forearms of eight adult cadavers were used. The sampled muscles were the first lumbrical (LM), first volar interosseous (VI), first dorsal interosseus (DI), second flexor digitorum profundus (FDP), second flexor digitorum superficialis (FDS), and extensor digitorum (ED). Six micrometer thick sections were stained for fast muscle fibres. The procedure was performed by applying mouse monoclonal anti-skeletal myosin antibody (fast) and avidin-biotin peroxidase complex staining. Rectangular areas (0.38 mm × 0.38 mm) were photographed and the boundaries of the muscle areas were marked on the translucent film. The numbers and sizes of the muscle fibres in each part were evaluated by the image analyser program and calculated per unit area (1 mm2). The proportion of the fast fibres was significantly (p = 0.012) greater in the intrinsic muscles (55.7 ± 17.1%) than in the extrinsic muscles (45.9 ± 17.1%). Among the six muscles, the VI had a significantly higher portion (59.3%) of fast fibres than the FDS (40.6%) (p = 0.005) or the FDP (45.1%) (p = 0.023). The density of the non-fast fibres was significantly (p = 0.015) greater in the extrinsic muscles (539.2 ± 336.8/mm2) than in the intrinsic muscles (383.4 ± 230.4/mm2). Since the non-fast fibres represent less fatigable fibres, it is thought that the extrinsic muscles have higher durability against fatigue, and the intrinsic muscles, including the LM, should move faster than the FDS or FDP because the MP joint should be flexed before the IP joint to grip an object.

The course of the intercostobrachial nerve in the axillary region and as it is related to transaxillary breast augmentation.

PurposeThe aim of this study was to precisely determine the course of the intercostobrachial nerve (ICBN) in the axillary region and as it is related to bony landmarks, and all of this might be of use for transaxillary breast augmentation. MethodsThirty hemithoraxes of 15 fresh cadavers of Korean adults were dissected. After removal of the skin, the ICBN from its origin was identified. The point of emergence (EP) and the branching point (BP) were marked on translucent paper. ResultsThe ICBN appeared at the second intercostal space approximately (mean ± SD; 33.4 ± 12.7) mm lateral to the midclavicular line and 9.8 ± 6.4 mm medial to the lateral border of the pectoralis minor (P minor) muscle. The mean (SD) distance from the lower border of the second rib to the EP was 5.2 ± 2.0 mm. The mean ± SD distance from the upper border of the third rib to the EP was 12.7 ± 3.3 mm. It traveled inferolaterally (mean ± SD) 15.1 ± 10.4 degrees from the horizontal plane) 39.4 ± 19.2 mm to reach to the BP. The BP was located at the second intercostal space approximately (mean ± SD) 59.4 ± 21.2 mm lateral to the midclavicular line and 28.5 ± 18.2 mm lateral to the lateral border of the P minor muscle. The mean ± SD distance from the lower border of the second rib to the BP was 11.3 ± 5.4 mm. The mean ± SD distance from the upper border of the third rib to the BP was 6.3 ± 7.1 mm. At the BP, the ICBN gave off a medial brachial cutaneous nerve, and this coursed superolaterally [mean (mean ± SD, 50.7 ± 15.1 degrees from the horizontal plane) toward the medial surface of the upper arm. The mean ± SD depth of the ICBN from the superficial surface of the pectoralis major and P minor was 22.7 ± 5.7 mm and 15.0 ± 5.2 mm, respectively. ConclusionWhen performing mammary augmentation, care should be taken not to dissect the undersurface of the P minor at the second intercostal space to avoid injury to the ICBN.

Comparison of facial trauma in late middle age (55-64 years) and old age (older than 65 years).

AbstractIn this study, we attempted to compare facial trauma of late-middle-age patients (55–64 years, LM group) and old-age patients (>65 years old, OL group). The goal of this study was to evaluate the natural history of facial trauma in geriatric patients.The medical record of patients older than 55 years seeking treatment for facial trauma between March 2006 and February 2009 were reviewed, and parameters were collected. Seven hundred seventy-two patients (553 male, 219 female) were analyzed. There were 438 patients of the LM group (55–64 years old) and 334 patients of the OL group (>65 years old).In men (n = 553), the number of patients within the LM group (n = 336, 60.8%) was greater than the number in the OL group (n = 217, 39.2%). Of the 219 women, the number within the OL group (n = 117, 53.4%) was greater than that within the LM group (n = 102, 46.6%) (P = 0.000, &khgr;2). Facial lacerations comprised a significantly higher proportion in the OL group (79.3%) than that in the ML group (70.1%), whereas facial bone fractures were more frequent in the ML group (29.9%) than in the OL group (20.7%), which was significant (P = 0.004, &khgr;2). Assault and automobile accidents were significantly more frequent in the ML group (n = 65 [15.1%] and n = 31 [7.2%], respectively) than the OL group (n = 20 [6.0%] and n = 11 [3.3%]), whereas falls and pedestrian accidents were more significantly frequent in the OL group (n = 30 [9.0%] and n = 23 [6.9%], respectively) than in the LM group (n = 30 [7.0%] and n = 19 [4.4%]) (P = 0.000, &khgr;2). During the hours of the day, between 4 to 6 PM and 6 to 8 PM, injuries occurred more frequently in the OL group (14.5% and 12.4%, respectively) than in the LM group (10.5% and 11.0%, respectively). At the times of 8 to 10 PM and 10 PM to midnight, however, injuries occurred more frequently in the LM group (17.1%, 12.1%, respectively) than in the OL group (12.1% and 8.2%, respectively) (P = 0.03, &khgr;2). Frequency of injuries at home within the OL group (n = 68, 22.2%) was significantly higher than within the LM group (n = 55, 14.4%) (P = 0.001, &khgr;2), whereas frequency of injuries at the workplace of the LM group (n = 47, 12.3%) was significantly higher than that of the OL group (n = 16, 5.2%) (P = 0.001, &khgr;2). Alcohol ingestion at the time of injury was significantly more frequent in the LM group (n = 146, 34.1%) than in the OL group (n = 57, 17.3%) (P = 0.000, &khgr;2). In regard to diabetes, the OL group (35.6%) showed a higher prevalence than that of the LM group (25.4%; odds ratio, 2.65).Prevention of injury is important for elderly patients. It is worthy of notice that more than one fourth (26.8%) were in a drunken state at the time of injury. There were no significant differences in the days of hospitalization or in the interval from injury to operation. However, there were significant differences in the place of the injuries, causes of injuries, and time of injuries, which is important in the prevention of injuries. Attention should be paid to assault and automobile accidents in the LM group and to falls and pedestrian injuries in the OL group. Thus, injury prevention should be prepared for differently for both LM and OL groups.

Muscle fiber types of human orbicularis oculi muscle.

The aim of this study was to elucidate the muscle type of the preseptal, pretarsal, and ciliary parts of the orbicularis oculi muscle in humans using immunostaining. The eyelids of 5 Korean adult cadavers were used (3 male and 2 female cadavers; age range, 50-85 years). A 1:1000 mouse monoclonal anti-skeletal myosin antibody solution (fast, M4276; Sigma, St Louis, MO) was used for immunostaining. On sagittal sections, preseptal, upper pretarsal, midpretarsal, lower pretarsal, and ciliary (muscle of Riolan) parts were selected, and 0.38 × 0.038-mm rectangular areas (0.1444 mm2) were photographed. The number and size of the muscle fibers in each part of the orbicularis oculi muscle were evaluated by the image analyzer program and calculated per unit area (1 mm2). On the whole, fast fibers (mean, 87.8% ± 3.7%; range, 85.6%-91.7%) occupied a significantly larger portion of the muscle (P = 0.000 [t-test]) than nonfast fibers (mean, 12.2% ± 3.7%; range, 8.3%-14.4%). Among the 3 areas (preseptal, pretarsal, and ciliary parts), the ciliary part had a significantly (P = 0.019 [Scheffé]) higher portion (91.7%) of fast fibers than the pretarsal part (86.6%). The diameter of the fast fibers (mean, 17.7 ± 2.6 &mgr;m) was significantly greater (P = 0.000 [t-test]) than the nonfast fibers (mean, 13.0 ± 2.1 &mgr;m). Our results showed that the eyelid has a higher proportion of fast muscle fibers than the mouth (pars peripheralis, 73% fast fibers; and pars marginalis, 66% fast fibers). Thus, closing of the eyelids is faster than closing of the mouth; however, the duration or power associated with closing of the mouth is stronger than closing of the eyelids.

Width of the levator aponeurosis is broader than the tarsal plate.

The aim of this study was to compare the width of the levator aponeurosis and tarsal plate in different levels grossly and histologically. Twelve eyelids of 6 Korean adult cadavers were used. Ten eyelids were dissected, and 2 were prepared for histologic study. Widths of the tarsal plate at its lower border, midheight, and upper border were 21.8 ± 1.8, 16.2 ± 1.6, and 8.3 ± 1.0 mm, respectively. The widths of the levator aponeurosis at the lower border, midheight, and upper border of the tarsal plate were 32.0 ± 2.2, 29.2 ± 3.5, and 27.2 ± 3.9 mm, respectively. Its width was 19.9 ± 4.3 mm at the anterior border of the superior transverse ligament. The width of the levator aponeurosis was broader than tarsal plate at all 3 levels. The medial brims of the levator aponeurosis at the lower border, midheight, and upper border of the tarsal plate were 3.6 ± 1.1, 5.1 ± 1.0, and 6.2 ± 1.1 mm, respectively. The lateral brims of the levator aponeurosis at the lower border, midheight, and upper border of the tarsal plate were 6.6 ± 0.9, 7.9 ± 2.6, and 12.7 ± 3.7 mm, respectively. The width of the levator aponeurosis is broader than the tarsal plate at all levels. This result might be useful in upper-eyelid surgery.

Levator sheath revisited.

Abstract The aim of this study was to reconfirm the detailed histologic structure of the levator aponeurosis and superior transverse ligament, which were first described by Whitnall. Twenty-eight upper eyelids from 28 Korean adult cadavers (mean age, 79.5 [SD, 11.3] years; 16 males and 12 females) were used. Sagittal sections on the midpupillary line were made, and 10-&mgr;m-thick sections were prepared. Twenty-five were stained with Masson trichrome, and 16 were prepared for immunohistochemical staining for smooth muscle fibers using mouse monoclonal anti–smooth muscle Ab. The levator palpebrae superioris muscle was covered with its fascial sheath along its course. The superficial part of the fascia sheath that covered the upper aspect of the levator palpebrae superioris just behind the aponeurosis was condensed to form a definite ligamentous band. In front of this ligamentous condensation, the sheath becomes abruptly so thin that it appears to end in a free border, but it could be traced forward as a very delicate layer up to the supratarsal border. The orbital septum consisted of 2 layers. The whitish outer (superficial) layer descends to interdigitate with the levator aponeurosis with loose connective tissue, and then it disperses inferiorly. The inner (deep) layer initially follows the superficial one, and then it reflects at the levator aponeurosis and continues posteriorly with the levator sheath. In most of the specimens, the levator aponeurosis consisted of a single layer in 27 (96.4%) of 28 eyelids. Only 1 eyelid has been observed to show a double-layered levator aponeurosis (3.6%). Some immunostained smooth muscle fibers in the lower side of the levator aponeurosis ran along its entire course. We reconfirmed the levator sheath covering the levator aponeurosis, and it continued anteriorly with the inner layer of the orbital septum, as Whitnall described. This information will be helpful when performing upper eyelid surgeries.

Location of the mandibular branch of the facial nerve according to the neck position.

Abstract The aim of this study was to elucidate the exact location of the mandibular branch of the facial nerve according to different neck positions. Twenty-two hemifaces of 11 fresh human cadavers were used (age range, 53–89 y; mean age, 72.3 ± 10.5 y; 8 men and 3 women). Working through skin windows, the distance from the mandibular border to the mandibular branch of the facial nerve (border–nerve distance or BND) was measured at 3 points: (1) the mandible angle (gonion or Go point), (2) the point where the mandibular branch of the facial nerve crosses the facial artery (FA point), and (3) the one-fourth point from the gonion to the menton (1/4 point). Threads were hung on the skin windows along the mandibular border. With the neck in the neutral position and then full flexion (15 degrees), extension (15 degrees), and left and right rotations (30 degrees), the distance of the mandibular branch from the thread of the mandibular border was measured using calipers. In the neutral position, the mandibular branch was 3.50 ± 2.82 mm above the mandibular border at the Go point, 5.34 ± 2.98 mm above the mandibular border at the FA point, and 5.28 ± 1.86 mm above the mandibular border at the 1/4 point. At all 3 points, flexion or extension of the neck did not significantly move the mandibular branch. At the Go point and FA point, there was no significant difference between the ipsilateral rotation position and the contralateral rotation. Yet at the1/4 point, the BND decreased (4.32 ± 2.60 mm) with the neck in ipsilateral rotation and the BND increased (5.97 ± 2.62 mm) with the neck in contralateral rotation. There was a significant difference between the ipsilateral rotation position and the contralateral rotation position (P = 0.020, t-test). Surgeons should keep in mind that at the 1/4 point, the mandibular branch of the facial nerve moves downward 1.10 ± 1.42 mm with the neck in ipsilateral rotation and moves upward 0.49 ± 1.84 mm with the neck in contralateral rotation.