Ho-Seok Sa

Periorbital lipogranuloma: a previously unknown complication of autologous fat injections for facial augmentation

Background Autologous fat injection into the face is a commonly used technique in plastic surgery. Autologous fat is claimed to be a safe soft-tissue filler without a foreign body reaction. This article reports on several cases of periorbital lipogranuloma after autologous fat injection for facial augmentation. Methods This was a retrospective, non-comparative and interventional case series. The authors identified nine patients with periorbital lipogranuloma. All patients had a history of previous autologous fat injection into the face by different plastic surgeons. A medical record review was performed for clinical history, radiological and histopathological studies, and treatment. Results Nine patients developed periorbital granuloma after autologous fat injection for facial augmentation. Eight of the patients had received two injections of autologous fat, and seven patients had undergone a second injection with their cryopreserved fat tissue. Erythematous swelling of the upper eyelid was refractory to antibiotic and steroid treatment, and surgery was required to resolve the inflammatory reactions in six cases. Histopathological evaluation revealed features of a lipogranulomatous reaction, with collection of histiocytes and foreign-body type giant cells around variable-sized microcysts containing lipid materials. Conclusions Lipogranuloma can develop in the eyelid following autologous fat injection to the forehead or glabella. Clinicians should be aware of this potential complication of a granulomatous reaction following autologous fat injection. Techniques for the injection and preservation of autologous fat should be refined.

IgG4-related disease in idiopathic sclerosing orbital inflammation

Aims To investigate the frequency of IgG4-related disease (IgG4-RD) among patients previously diagnosed with idiopathic sclerosing orbital inflammation (ISOI), and to compare the clinical features and treatment outcomes of patients with ISOI associated with IgG4-RD and those without IgG4. Methods Retrospective clinicopathological series of 24 patients with ISOI diagnosed between June 2001 and June 2010. Biopsy specimens were immunostained for IgG-expressing and IgG4-expressing cells. Clinical data of patients with IgG4-RD and ISOI unrelated to IgG4 were obtained from patient records. Results Of 24 patients, 11 patients (45.8%) were identified with IgG4-RD. 10 patients (10/11, 90.9%) presented with bilateral lacrimal gland enlargement, and seven of those also had submadibular gland enlargement. One patient (1/11, 9.1%) presented with a superior orbital mass. All patients were successfully treated with steroids and/or radiotherapy or had an indolent clinical course. 13 patients (54.2%) were identified with ISOI unrelated to IgG4. Eight patients (8/13, 61.5%) showed unilateral orbital involvement, and nine patients (9/13, 69.2%) had orbital lesions not involving the lacrimal glands. Treatment modalities for ISOI unrelated to IgG4 were varied and less effective: eight patients (61.5%) relapsed following initial treatment with steroids or radiation, and additional therapies were required to enter remission. Conclusions IgG4-RD may be identified frequently in patients with ISOI, and distinguishing features may be bilateral lacrimal gland enlargement with associated submandibular gland enlargement. Patients with IgG4-RD may have better treatment outcomes with less aggressive treatment modalities than those with ISOI unrelated to IgG4. An additional workup for IgG4-RD should be considered in all histopathological biopsy specimens suspicious of ISOI.

A New Method of Medial Epicanthoplasty for Patients with Blepharophimosis-Ptosis-Epicanthus Inversus Syndrome

PURPOSE To describe a medial epicanthoplasty technique using the skin redraping method and review the surgical outcome in patients with blepharophimosis-ptosis-epicanthus inversus syndrome (BPES). DESIGN Retrospective, noncomparative, interventional case series with the description of a new surgical technique. PARTICIPANTS Sixteen consecutive Asian patients with BPES. METHODS The charts of patients with BPES who underwent medial epicanthoplasty using the skin redraping method were reviewed retrospectively. Preoperative and postoperative inner intercanthal distance (IICD), interpupillary distance (IPD), horizontal palpebral fissure length (HPFL), and visibility of the scar were measured. The ratio of the IICD to IPD (IICD ratio) was calculated. MAIN OUTCOME MEASURES Postoperative improvement in IICD ratio and the visibility of the surgical scar. RESULTS The preoperative median IICD ratio was 1.65 (range, 1.49-1.83) and decreased to 1.27 (range, 1.02-1.48) postoperatively. The median reduction in IICD ratio was 21.7% (range, 16.7%-38.2%) (P<0.001, Wilcoxon signed-rank test). Fourteen patients (87.5%) had no visible scarring or scarring only visible under close inspection. Two patients (12.5%) had a more apparent scar, but no patient had severe scarring that required revision. CONCLUSIONS Medial epicanthoplasty using the skin redraping method is an effective technique in the treatment of epicanthus inversus and telecanthus in patients with BPES, with excellent cosmetic outcomes.

Surgical correction of epiblepharon using an epicanthal weakening procedure with lash rotating sutures

Background To describe a new surgical technique in patients with lower eyelid epiblepharon using an epicanthal weakening procedure with lash rotating sutures. Methods Charts of patients with epiblepharon who underwent surgical correction using an epicanthal weakening procedure with lash rotating sutures were reviewed retrospectively. The preoperative severity of corneal erosion was graded and compared with the postoperative keratopathy. Postoperative surgical outcomes, complications and subjective satisfaction were also evaluated. Results 202 eyes of 101 patients were evaluated in this study. The preoperative cilia-corneal touch was corrected and keratopathy was improved, especially towards the medial aspect of the lower lid. There were four eyes (2.0%) of recurrent cilia-corneal touch, but none required reoperation. Cosmetic outcomes were considered to be ‘very satisfied’ in 95 patients, ‘satisfied’ in 6 patients, and no patients indicated ‘neutral’ or ‘dissatisfied’ results. Conclusions In patients with epiblepharon with an epicanthal fold, surgical correction using an epicanthal weakening procedure with lash rotating sutures is a simple and effective method for correction, particularly when evaluating the medial portion of the lower eyelid. This method also produces a favourable cosmetic outcome with minimal scar formation.

A Solitary Fibrous Tumor with Giant Cells in the Lacrimal Gland: A Case Study

Orbital solitary fibrous tumor (SFT) has recently been proposed as the encompassing terminology for hemangiopericytoma, giant cell angiofibroma (GCAF), and fibrous histiocytoma of the orbit. The lacrimal gland is a very rare location for both SFT and GCAF. A 39-year-old man presented with a painless left upper eyelid mass. An orbital computed tomography scan identified a 1.1 cm-sized well-defined nodule located in the left lacrimal gland. He underwent a mass excision. Histopathologic examination showed a proliferation of relatively uniform spindle cells with a patternless or focally storiform pattern. Dilated vessels were prominent, but angiectoid spaces lined with giant cells were absent. Floret-type giant cells were mostly scattered in the periphery. The tumor was immunoreactive for CD34 and CD99, but negative for smooth muscle actin and S-100 protein. This is the first Korean case of SFT of the lacrimal gland with overlapping features of GCAF, suggesting a close relationship between the two entities.

Upper fornix approach combined with a superior lateral cantholysis: a minimally invasive approach to the superonasal intraconal space

PurposeTo present a new minimally invasive approach to the deep superonasal orbit.MethodsThis retrospective study reviewed seven consecutive patients who underwent orbital surgery using an upper conjunctival fornix approach combined with a superior lateral cantholysis for tumors in the superonasal intraconal space. Charts were reviewed for demographic, radiological, clinical, and surgical data including surgical outcome and morbidities for each patient.ResultsSix benign tumors of the superonasal intraconal orbit were successfully exposed and removed using this approach, and one malignant tumor was biopsied for diagnosis. Histopathology revealed cavernous haemangioma (3 cases), solitary fibrous tumor (2 cases), schwannoma (1 case), and diffuse large B cell lymphoma (1 case). Visual acuity and ocular motility were unchanged or improved in all cases. There were no visible scars or other complications related to this approach.ConclusionThe upper fornix approach combined with a superior lateral cantholysis is a novel technique that provides safe and excellent exposure of the deep superonasal orbit. In addition, it avoids the unnecessary morbidity of upper lid splitting, medial rectus muscle detachment, or bone removal.

Dermolipoma surgery with rotational conjunctival flaps.

Purpose:  To describe a useful technique of surgical resection of dermolipomas.

Conjunctival Hypertrophic Scar Following Cryotherapy for Retinopathy of Prematurity

A 6-year-old boy was referred to our hospital with symblepharon and lateral canthal deformity in both eyes, which developed 6 years ago. The patient was born at 27 weeks gestation. He had received cryotherapy for retinopathy of prematurity. One month after cryotherapy, he developed a conjunctival scar with symblepharon in both eyes and underwent symblepharon lysis at another hospital 5 years prior. Ocular examination revealed an extensive conjunctival hypertrophic scar with symblepharon and limitation of extraocular movements. An excisional biopsy, lateral canthoplasty, and symblepharon lysis with conjunctival autograft from the contralateral eye were performed in the left eye. Histopathologic examination revealed diffuse proliferation and infiltration of collagenous tissue.

Generation of customized orbital implant templates using 3-dimensional printing for orbital wall reconstruction

ObjectivesTo describe and evaluate a novel surgical approach to orbital wall reconstruction that uses three-dimensionally (3D) printed templates to mold a customized orbital implant.MethodsA review was conducted of 11 consecutive patients who underwent orbital wall reconstruction using 3D-printed customized orbital implant templates. In these procedures, the orbital implant was 3D pressed during surgery and inserted into the fracture site. The outcomes of this approach were analyzed quantitatively by measuring the orbital tissue volumes within the bony orbit using computed tomography.ResultsAll 11 orbital wall reconstructions (6 orbital floor and 5 medial wall fractures) were successful with no post operative ophthalmic complications. Statistically significant differences were found between the preoperative and post operative orbital tissue volumes for the affected orbit (24.00 ± 1.74 vs 22.31 ± 1.90 cm3; P = 0.003). There was no statistically significant difference found between the tissue volume of the contralateral unaffected orbit and the affected orbit after reconstruction (22.01 ± 1.60 cm3 vs 22.31 ± 1.90 cm3; P = 0.182).Conclusion3D-printed customized orbital implant templates can be used to press and trim conventional implantable materials with patient-specific contours and sizes for optimal orbital wall reconstruction. It is difficult to design an orbital implant that exactly matches the shape and surface of a blowout fracture site due to the unique 3D structure of the orbit. The traditional surgical method is to visually inspect the fracture site and use eye measurements to cut a two-dimensional orbital implant that corresponds to the anatomical structure of the fracture site. However, implants that do not fit the anatomical structure of a fracture site well can cause complications such as enophthalmos, diplopia and displacement of the implant.

Clinicoserological factors associated with response to steroid treatment and recurrence in patients with IgG4-related ophthalmic disease

Purpose To investigate the factors associated with response to steroid treatment and recurrence in patients with IgG4-related ophthalmic disease (ROD). Methods Twenty-eight patients with biopsy-proven IgG4-ROD treated between March 2010 and January 2017 were included in this retrospective study. Clinical features, serum IgG4 levels, systemic involvement, treatments and treatment outcome, factors associated with response to treatment and recurrence were assessed. Result Thirteen men and 15 women (mean age 50.8 years) were evaluated over mean follow-up period of 27.3 months. Elevated serum IgG4 levels (>1.35 g/L) and systemic disease were noted in 9 (32%) and 18 patients (64%), respectively. The lacrimal gland was involved in all patients, and 22 patients (78.6%) had bilateral involvement. Most patients (82%) responded well to systemic steroids, but 12 (43%) relapsed after the initial steroid treatment, requiring additional therapies to achieve remission. Complete response to initial steroid treatment was associated with elevated serum IgG4 levels before treatment (P=0.001) and bilateral orbital involvement (P=0.050). Recurrence was associated with elevated serum IgG4 levels before treatment (P=0.007), lower dose (P=0.057) and shorter duration of initial steroids (P=0.042). Patients with recurrence eventually required significantly more steroids than those without recurrence (P=0.011). Conclusions Patients with IgG4-ROD responded well to systemic steroid treatment, but recurrence was common, particularly among those with elevated serum IgG4 levels and shorter duration of initial steroid treatment. Low-dose maintenance treatment with systemic steroids should be considered to avoid recurrence in patients with elevated serum IgG4 levels.