Hyoseob Lim

Mandibular tubercle resection: a means of maximizing the benefits of reduction mandibuloplasty.

Background: A square mandible is considered unattractive in Asia; as a result, mandibular reduction is the most common type of operation performed. The authors review the importance of mandibular tubercles in the lower margin of the parasymphysis area and introduce their resection techniques and results. Methods: From April of 2005 to September of 2009, 178 patients underwent tubercle resection in the parasymphyseal area. The procedures used were as follows: mandibular angle reduction in 139, genioplasty in 39, and mandibular angle reduction with simultaneous malar reduction in 58 patients. In the chin area, horizontal osteotomy was performed in 35 patients to reduce chin length. Other patients underwent mandibular tubercle resection and burring. Results: With the exception of one patient who developed hyperesthesia in the left lower lip 2 years after the procedure, all patients achieved satisfactory aesthetic results after mandibular tubercle resection and concurrent mandibular reduction. Conclusion: The authors consider mandibular tubercle resection, either as a single procedure or combined with mandible reduction, essential for patients who require a slimmer, more feminine lower face.

Is craniofacial asymmetry progressive in untreated congenital muscular torticollis

Background: Although craniofacial asymmetry is frequently involved in patients with congenital muscular torticollis, it has not been evaluated appropriately. The authors analyzed preoperative craniofacial asymmetry objectively and confirmed the relationship between craniofacial asymmetry and aging in congenital muscular torticollis patients who underwent surgical release. Methods: The authors retrospectively measured preoperative craniofacial asymmetry using the Cranial Vault Asymmetry Index and intercommissural angle and reviewed preoperative rotational and flexional deficit of neck movement for 123 congenital muscular torticollis patients who underwent surgical release at Ajou Medical Center from February of 2007 to February of 2011. The relationships among Cranial Vault Asymmetry Index, intercommissural angle, rotational deficit, flexional deficit, and age were analyzed. Mean values of dependent variables were compared after patients were grouped by age. Results: Mean age at operation was 82.5 months (range, 5 to 498 months). Seventy-one percent (n = 87) of patients had a significant cranial asymmetry and 87 percent (n = 107) had a significant facial asymmetry. In correlation analysis, intercommissural angle increased proportional to age (r = 0.334, p = 0.000), especially before 3 years (r = 0.42, p = 0.001). Cranial Vault Asymmetry Index was unrelated to age or rotational or flexional deficit. Rotational deficit decreased proportional to age (r = −0.229, p = 0.032). By analysis of variance test, intercommissural angle and rotational deficit between the age groups were statistically significantly different (p < 0.05). Conclusions: In congenital muscular torticollis, facial asymmetry is progressive if the contracted sternocleidomastoid muscle is not released, although cranial asymmetry is already determined in those younger than 6 months. Early correction of torticollis should be considered to prevent progression of facial asymmetry in congenital muscular torticollis patients. CLINICAL QUESTION /LEVEL OF EVIDENCE: Risk, III.

Molecular classification of basal cell carcinoma of skin by gene expression profiling

Non‐melanoma skin cancers (NMSC) including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are more common kinds of skin cancer. Although these tumors share common pathological and clinical features, their similarity and heterogeneity at molecular levels are not fully elaborated yet. Here, by performing comparative analysis of gene expression profiling of BCC, SCC, and normal skin tissues, we could classify the BCC into three subtypes of classical, SCC‐like, and normal‐like BCCs. Functional enrichment and pathway analyses revealed the molecular characteristics of each subtype. The classical BCC showed the enriched expression and transcription signature with the activation of Wnt and Hedgehog signaling pathways, which were well known key features of BCC. By contrast, the SCC‐like BCC was enriched with immune‐response genes and oxidative stress‐related genes. Network analysis revealed the PLAU/PLAUR as a key regulator of SCC‐like BCC. The normal‐like BCC showed prominent activation of metabolic processes particularly the fatty acid metabolism. The existence of these molecular subtypes could be validated in an independent dataset, which demonstrated the three subgroups of BCC with distinct functional enrichment. In conclusion, we suggest a novel molecular classification of BCC providing insights on the heterogeneous progression of BCC.

A Simple Strategy in Avulsion Flap Injury: Prediction of Flap Viability Using Wood's Lamp Illumination and Resurfacing with a Full-thickness Skin Graft

Background Extensive degloving injuries of the extremities usually result in necrosis of the flap, necessitating comprehensive skin grafting. Provided there is a sufficient tool to evaluate flap viability, full-thickness skin can be used from a nonviable avulsed flap. We used a Woods lamp to determine the viability of avulsed flaps in the operation field after intravenous injection of fluorescein dye. Methods We experienced 13 cases during 16 months. Fifteen minutes after the intravenous injection of fluorescein dye, the avulsed skin flaps were examined and non-fluorescent areas were marked under Woods lamp illumination. The marked area was defatted for full-thickness skin grafting. The fluorescent areas were sutured directly without tension. The non-fluorescent areas were covered by defatted skin. Several days later, there was soft tissue necrosis within the flap area. We measured necrotic area and revised the flap. Results Among all the cases, necrotic area was 21.3% of the total avulsed area. However, if we exclude three cases, one of a carelessly managed patient and two cases of the flaps were inappropriately applied, good results were obtained, with a necrotic area of only 8.4%. Eight patients needed split-thickness skin grafts, and heel pad reconstruction was performed with free flap. Conclusions A full-thickness skin graft from an avulsed flap is a good method for addressing aesthetic concerns without producing donor site morbidity. Fluorescein dye is a useful, simple, and cost-effective tool for evaluating flap viability. Avulsed flap injuries can be managed well with Woods lamp illumination and a full-thickness skin graft.

Modified folding radial forearm flap in soft palate and tonsillar fossa reconstruction.

Wide excision of cancer arising from the tonsillar fossa and soft palate has several functional sequelae (e.g., speech, swallowing, chewing, and breathing) that require surgical restoration of the pharyngeo-palatal structure and optimal velopharyngeal function. For this purpose, several kinds of surgical procedures have been introduced. Our method to reconstruct the tonsillar fossa and soft palate entails folding the flaps and reconstructions at the same time as the oral and nasal planes, with some modifications.Patient 1 was a 64-year-old man with left soft palate cancer. After wide excision of the tumor, the defect size of the nasal floor was 3 × 3 cm, and that of soft palate and tonsillar fossa was 8 × 5 cm. Patient 2 was a 49-year-old man with left tonsil cancer. The defect size of the nasal floor was 3 × 3 cm, and that of left lateral wall of the tonsillar fossa was 8 × 3 cm. For reconstruction of oral, nasal, and tonsillar plane, we designed the flap fit to the defect site, especially cutting of the edge of the square plane of the flap to a round shape.Both patients achieved good functional recovery without surgical complications. The average speech intelligibility score in the 2 patients was 10. Swallowing functional score was 4 in both patients. Creative reconstruction with modified radial forearm free flap for tonsillar and soft palate area makes it possible to restore velopharyngeal function to levels close to the preoperative condition.

Cutaneous paraganglioma of the vertex in a child.

Paraganglioma is a neuroendocrine neoplasm that may develop at various body sites, including the head, neck, thorax, and abdomen. Approximately 85% of paragangliomas develop on the abdomen, 12% develop on the chest, and only 3% develop on the head and neck. These tumors are found in locations that parallel the sympathetic chain ganglion in the thoracolumbar regions and parasympathetic nervous system in craniosacral regions, and all head and neck paragangliomas arise from the parasympathetic nervous system. Although the skin has a rich neural network, it is devoid of ganglia. There has been only 1 report of a paraganglioma on the scalp of a child. We describe a 3-year-old child with a primary cutaneous paraganglioma of the vertex scalp and review the literature on paragangliomas.

Aesthetic blepharoptosis correction with release of fibrous web bands between the levator aponeurosis and orbital fat.

Background Blepharoplasty remains one of the most frequent operations in Asia. The most common complaint of Asian patients is a limitation of eye opening, and a substantial proportion of patients have puffy eyelids, supratarsal folds in the upper eyelid, and a narrow palpebral fissure, thus exhibiting a tired and sleepy appearance. To correct these features, an accurate understanding of upper eyelid anatomy is essential, especially concerning the levator aponeurosis, orbital fat, and orbital septum. Methods After a strip of orbicularis oculi muscle was removed through usual transcutaneous blepharoplasty incision, we excised the submuscular soft tissue to expose the fusion line of the septum and the levator aponeurosis. Blunt dissection was carried out between the levator aponeurosis and the orbital fat. During dissection, a three-dimensional fibrous web connecting the orbital fat and levator aponeurosis, and continuing to just behind the Whitnall ligament, was observed in all patients. All of the connections with these fibrous bands were resected during the procedure using a Steven scissors while controlling bleeding. After this dissection, we reevaluated the degree of blepharoptosis in the upright position and checked the function of the levator palpebral muscle. We observed that mild and subclinical blepharoptosis was corrected without manipulation of the levator aponeurosis or the Müller muscle. Results Of the 32 patients evaluated, 22 were women and 10 were men. All of our patients had mild or subclinical blepharoptosis (<2 mm). The levator function was excellent or good in all patients. Most of these patients (29/32, 87.5%) were satisfied with the outcome after this operation. Conclusions The authors found that fibrous web bands between levator aponeurosis and orbital fat limit movement of the levator aponeurosis, which is a cause of eye opening limitation. In the current study, subclinical and mild blepharoptoses were corrected by releasing these fibrous bands without manipulating the levator aponeurosis or the Müller muscle. This method has been shown to be highly effective in correcting mild ptosis and can be applied during most surgical blepharoptosis techniques.

Blepharoptosis correction: repositioning the levator aponeurosis.

AbstractBlepharoplasty remains one of the most popular surgical procedures in Asia. The most common patient complaint leading to a blepharoplasty is limited eye opening causing a narrowing of the palpebral fissure. The typical Asian eye is characterized by puffiness, lack of a supratarsal fold in the upper eyelid, and a narrow palpebral fissure, exhibiting a tired and sleepy appearance. Almost all such patients believe that a simple double-eyelid operation is able to make the eye look bigger with eversion of the eyelashes into a more charming configuration. Some of these patients actually have mild to moderate blepharoptosis, which can present both functional and aesthetic problems. Numerous surgical procedures have been developed to correct ptosis because proper correction can be difficult to achieve. The authors found abnormal lateral deviation of the levator aponeurosis in patients with blepharoptosis and suggest that this abnormality is a major cause of blepharoptosis, particularly in Asians. The authors assessed the effectiveness of a levator aponeurosis medial repositioning technique rather than levator resection or levator plication for mild or moderate ptosis. No disadvantage was attributed to this technique when it was used to correct 87 patients with mild ptosis. Eighty of the 87 patients achieved a good result with the first operation. Undercorrection was observed in 6 patients, and a hematoma was corrected in 1 patient. However, no other major complications related to the technique were encountered. Herein the authors describe their operative technique and present the long-term follow-up results. The authors propose that anatomic repositioning of a laterally deviated levator aponeurosis using the described repositioning technique is highly effective for correcting mild ptosis and can be applied during most surgical blepharoptosis procedures in Asian patients.

Supraorbital nerve neuroma caused by blind curettage of an infected epidermal cyst.

A 38-year-old woman presented with a tender mass with mild erythematous change above the left eyebrow area. She had received curettage in another clinic after a diagnosis of infected epidermal cyst 5 years previously. On examination, a round, irregular scar and a mass of 1-cm diameter associated with mild erythematous region were observed above the right eyebrow.Exploration disclosed a 1-cm neuroma with mild adhesion to a branch of the supraorbital nerve. The neuroma was completely removed. However, although partial transection of the supraorbital nerve was performed during surgery, the nerve was not repaired. The open wound was repaired securely. A histopathologic examination of the resected specimen resulted in a diagnosis of traumatic neuroma. The patient had no forehead numbness before or after surgery.

Postoperative Changes in Isolated Medial Orbital Wall Fractures Based on Computed Tomography

Abstract The treatment has been improved on the accurate reduction of blow-out fracture for many decades. But still, it has been limited to reduce completely when surgeons are approaching by conventional technique. The authors analyzed the postoperative results using computed tomography (CT) scans after conventional open reduction of isolated medial wall fracture. Thirty-seven patients with isolated medial wall fracture were reviewed. All patients underwent preoperative, immediate, and postoperative CT scans. Two surgeons have performed the surgery by conventional open reduction with transcaruncular approach and absorbable mesh insertion. The authors evaluated changing orbital volume and distance, comparing the immediate and 6 months postoperative outcomes with preoperative outcome. The differences between immediate postoperative and 6 months postoperatively data were statistically evaluated. The authors used the distant value to minimize bias of CT view selection. Significant differences from the 2 kinds of data were observed (Pu200a<u200a0.05 for volume, Pu200a<u200a0.01 for distance, Paired t test). Bone remodeling process after conventional open reduction of orbital wall has not been fully understood. Most popular technique is conventional open reduction and mesh insertion but it is not easy for surgeons to reduce fractured bones completely. The authors analyzed the bone remodeling after incomplete reduction. These results suggest that the decreased measurements might be caused from the scar contracture with fibrosis. This research is very limited to explain the change while bone remodeling is progressed. Further research should be continued to discover the understanding of the process.