Ki-Young Ahn

Use of laser Doppler flowmetry for estimation of the depth of burns.

&NA; The trend for treatment of deep second degree burns and third degree burns is toward early excision and skin grafting. The ability to predict burn depth accurately as early as possible is important for early excision and skin grafting. This study prospectively evaluated the ability of laser Doppler flow measurements, obtained within 72 hours after burn injury, to predict the depth of burn wounds. A Periflux system 4001 laser Doppler flowmeter was used to measure the cutaneous microflow circulation of 100 selected points of burn wounds on 44 inpatients and of 1680 selected points on 120 volunteers from March of 1993 to February of 1994. The mean value of superficial second degree burns checked by laser Doppler was 194.6 perfusion units (PU). The value of deep second degree burns was 59.7 PU, and the value of third degree burns was 5.1 PU. The mean normal cutaneous blood flow of 120 volunteers (control group) was between 4 and 9 PU, except on the head, neck, hand, and foot. Blood flow of more than 100 PU correctly predicted (90.2 percent of cases) a superficial second degree burn. Blood flow between 100 and 10 PU correctly predicted (96.2 percent of cases) a deep second degree dermal burn. That of less than 10 PU correctly predicted (100 percent of cases) a third degree burn. There was also a significant correlation between initial flow measurements and the depth of burn wounds. We conclude that laser Doppler flow measurements performed early after burn injury are useful in predicting the depth of burn wounds. Laser Doppler flowmetry has the advantage of being easy to use and noninvasive and of providing immediate results for early determination of burn depth. Laser Doppler flowmetry is useful in selecting patients for early excision and grafting of burn wounds. (Plast. Reconstr. Surg. 101: 1516, 1998.)

Botulinum toxin A for the treatment of facial hyperkinetic wrinkle lines in Koreans

There are a number of different causes for facial wrinkle lines, such as aging, gravity, and chronic pulling of mimetic muscles on the face. Among these, pulling by mimetic muscles on the skin not only involves facial expression but also has a great role in forming facial wrinkle lines as a result of repetitive action, such as dynamic or hyperkinetic wrinkle lines. Botulinum toxin A is currently being used for eliminating facial hyperkinetic wrinkles by causing paralysis of the underlying mimetic muscles. Because there are some histologic differences between Asians and Caucasians, such as thick dermis and more abundant collagen fiber, etc., the chronic pulling by mimetic muscles on the skin is expected to affect facial wrinkles differently. Therefore, the purpose of this study was to determine the efficacy of botulinum toxin A injection in eliminating facial hyperkinetic wrinkle lines among Korean patients. This study included 38 patients and 59 injection sessions from January of 1996 to April of 1997. We used Botox containing 100 U. Toxin was diluted with 4 ml of sterile normal saline and yielded 2.5 U for each 0.1 cc. A dose of 5 to 10 U was used in each muscle. Ages ranged from 26 to 56 years. There were 33 women and 5 men included in this study. Thirty-two of the patients were followed from 3 months up to 12 months after injections. The number of injection sessions that were performed on each patient was as follows: one session, 23 patients; two sessions, 10 patients; three sessions, 4 patients; four sessions, 1 patient. The number of injections per target site among these 38 patients was as follows: lateral canthal area, 33; glabellar area, 9; forehead, 9; nasal dorsum, 5. The most common duration of effective response was about 4 months, but in eight patients the period was over 5 months. After the response, complete recovery took about 1 or 2 months. Two patients felt unsatisfied, five patients felt slightly improved, and 25 patients retained only a slight line and were satisfied with the results. None of the patients experienced complete removal of wrinkle lines. Adverse effects included altered facial looks or appearances, mild local swelling, and ecchymosis at the injection sites. No systemic side effects were noted. Based on these results, the injection of botulinum toxin A seems to be an effective method of eliminating wrinkle lines on the upper third of the face in Korean patients, and it was a simple and effective nonsurgical procedure.

A comparative study of the surgical treatment of axillary osmidrosis by instrument, manual, and combined subcutaneous shaving procedures

Between 1986 and 1996, 128 patients underwent surgery for axillary osmidrosis via en bloc removal of subcutaneous cellular tissue. The patients were followed for 6 months to 7 years (average follow-up, 25 months). The authors propose three categories in which they classified shaving procedures: instrumental shavings (N = 84), manual shavings (N = 96), and combined shaving procedures (N = 76). A modified Inabas shaver was used in instrument shavings. Combined shaving is mixture of instrument and conventional manual shaving. All patients were asked to complete a questionnaire postoperatively. This follow-up demonstrated that 92.9% of patients who underwent instrument shaving, 95.8% of patients who underwent manual shaving, and 97.4% of patients who underwent combined shaving experienced no odor or occasional, very mild axillary odor postoperatively. Postoperative scar formation was either invisible or excellent in 92.9% of instrument shavings, and 92.1% of patients who underwent the combined procedure reported either a hairless axilla or a marked decrease of axillary hair. The total satisfaction rate in the combined procedure was 94.7%, which is a better result than the instrument (92.9%) and the manual (91.7%) shaving procedures. The wound complication rate per patient with the combined procedure was 13.2%. There was no scar contracture or limitation in arm abduction. The combined subcutaneous shaving procedure using the modified Inabas shaver has the advantages of rapid and accurate shaving, low incidence of hematoma formation, enhanced wound healing, and easy postoperative care. Therefore, en bloc resection of subcutaneous cellular tissue by combined shaving is a viable option for treatment of axillary osmidrosis.

blepharoptosis Repair by Selective Use of Superiorly Based Muscle Flaps

&NA; Thirty‐three patients with severe blepharoptosis were treated by the superiorly based orbicularis oculi muscles, interdigitated orbicularis oculi‐frontalis muscle flaps, or frontalis muscle flaps. The superiorly based muscle flaps are modifications of direct transplantation of the frontalis muscle to the tarsal plate on the basis of anatomic study that the frontalis muscle and its fascia are connected with the orbicularis oculi muscle at the eyebrow region. The selection of muscle flaps is based on the extent of levator function of patients. When eyelid excursion is moderate (3 to 5 mm), the orbicularis oculi muscle flap technique was effective. For patients with weak eyelid excursion (2 to 4 mm), the interdigitated orbicularis oculi‐frontalis muscle flap was the procedure of choice. For patients with minimal eyelid excursion (less than 2 mm), frontalis muscle flap technique is indicated. The majority of patients recorded as satisfactory results according to the criteria of Souther and Jordan after an average follow‐up period of 18.5 months. Even though four patients showed undercorrection, there has been no complete failure or laxity of the advanced flaps in our series. The orbicularis oculi muscle technique or the interdigitated orbicularis oculi‐frontalis muscle flap technique offers several advantages over the conventional frontalis muscle flap technique, such as being a simple technique with a good operative field, single incision on supratarsal fold, no depression on the forehead, no risk of neurovascular injury, and relatively easy technique with less complication. The frontalis muscle flap technique is better in patients with less than 2‐mm eyelid excursion to avoid recurrence even if the superiorly based frontalis muscle flap technique has some inherent shortcomings.

Endoscopic application in aesthetic and reconstructive facial bone surgery.

Twenty-three cases of endoscopically assisted facial bone surgery were performed over the past 3 years. Our series is consistent with 16 cases of aesthetic contouring surgery and 12 treatments of facial bone fracture, including three cases for recontouring of frontal bone, three cases for recontouring of zygoma, endoscopically assisted correction of three zygomatic and blowout fractures, four cases for rhinoplasty and septoplasty for deviated nose, and three cases for mandible contouring surgery. To accomplish this technique, a rigid 4-mm, 30-degree down-angled endoscope was used. The frontal bone or zygomatic arch was approached endoscopically through two or three small incisions on the frontal or temporoparietal scalp. All endoscopic instruments were then manipulated through these incisions. The approach for endoscopically assisted rhinoplasty is the same as with standard rhinoplasty procedures. The approach for zygoma complex and maxillary sinus needs an intraoral incision. Recontouring of zygoma, mandible, and nasal dorsum by an air-driven burr and rasp was performed with endoscopic visual assistance. A plate and screw fixation for zygomatic arch fracture requires an additional small skin incision over the plate for the trocar method. The duration of follow-up ranged from 6 months to 30 months. The postoperative course was satisfactory with a few complications. The extra time needed for the endoscopic procedures was less than 1 hour. Endoscopically assisted facial bone surgery can be performed with adequate visualization and direct manipulation of all facial bones. Complications usually associated with extensive incisions in the bicoronal approach may be avoided. Poor visualization in the conventional approach for operation of orbit, nose, maxillae, and mandible may be avoided by use of the endoscope. This technique may prove to be ideal for aesthetic surgery for facial skeleton with smaller scar and less morbidity.

Mapping of the human body skin with laser Doppler flowmetry

The purpose of this study was to evaluate cutaneous blood flow in the human body to better establish normal flow ranges and to determine whether the location, side of the body, sex, and age affect the flow range at seven different sites. From March 1993 to February 1994 a Periflux system 4001 laser Doppler flowmeter was used to measure the cutaneous microflow circulation of 1,680 selected points in 120 volunteers. The mean normal cutaneous blood flow of 120 volunteers was between 4 and 9 perfusion units (PU) except in the head, neck, hand, and foot. Mean cutaneous blood flow measurements were as follows: the upper arm, 6.6 ± 1.20 PU (mean ± SE); the forearm, 6.7 ± 1.95 PU; the thorax, 7.1 ± 1.72 PU; the flank, 6.3 ± 1.23 PU; the abdomen, 5.3 ± 1.79 PU; the thigh, 4.8 ± 1.34 PU; the lower leg, 4.6 ± 1.39 PU (p < 0.05). The blood flow of the thorax was highest and was 54% higher than the lower leg. The group of teenagers had the highest cutaneous blood flow, with an average value of 6.9 ± 0.62 PU. The group of subjects in their sixties proved to have the lowest cutaneous blood flow—32% less than the teenagers. Gender differences were not noted. There were no significant differences in blood flow in regard to the side of the body.

Endoscopic-assisted correction of the deviated nose.

Abstract. The approach to nasal bone classic corrective rhinoplasty is an almost-blind technique, where the results depends on feeling by the surgeons hand. To overcome these drawbacks, endoscopic-assisted corrective rhinoplasty and septoplasty were performed for 16 cases of deviated noses between January 1995 and May 1997. The average follow-up period was 18 months. All patients were evaluated by symmetrical nasal pyramid, recurrence of the bony deflection, and septal deviation. The postoperative courses were satisfactory in most cases, with few complications. Compared with 28 cases of classic rhinoplasty, the patient satisfaction rate was high (87.5% in endoscopic-assisted rhinoplasty, 71.4% in classic rhinoplasty), and the complication and revision rate was low (0% in endoscopic assisted rhinoplasty, 14.3 and 7.1% in classic rhinoplasty). But extra time (about 40 min) and greater expense were required for endoscopic-assisted rhinoplasty. It appeared to us that endoscopic control during corrective rhinoplasty and septoplasty is a big step toward obtaining better results in bony and cartilage resection with extreme precision under monitor control and magnification. This technique is not an open approach but permits one to see more of the nasal skeleton and bony septum, the cause of the deformity, and the immediate effect of the corrective measures used. The use of an endoscope in corrective rhinoplasty for deviated noses provides an expanded field of vision, direct manipulation of lesions, and better aesthetic and functional results.

Botulinum toxin a for the treatment of hyperkinetic wrinkle lines.

Three-hundred forty-nine patients have received facial wrinkle treatment using botulinum toxin type A, or Botox (Allergan, Inc., Irvine, Calif.), in 617 sessions at Daegu Catholic University Hospital between January of 1996 and June of 2002. The most common sites of injection were the crows’ feet, followed by the forehead, glabellar frown lines, and nasal dorsum. Patients who received regular repeated treatments for more than 3 years comprised about 10 percent of the entire group, indicating a low rate of repeated treatments compared with the high rate of satisfactory results. The reasons for the low rate of repeated treatments may include the expense of the procedure, fear of painful injections, vague apprehension about the term “toxin,” and the relatively shorter duration of effect compared with other rejuvenation methods. No case was seen in which the duration of effect increased with repeated treatments. However, in one patient, glabellar frown lines disappeared after repeated injections in three sessions. This was considered to be due to habitual correction of grimace in the glabellar area after repeated injections of Botox. There was no evidence to suggest that the effectiveness of the procedure might have waned due to the production of antibodies to Botox following repeated treatments. Local side effects varied according to each target site. In forehead wrinkles, which we injected with a total of 20 U of Botox, the most common side effect was eyebrow ptosis, which was observed in approximately one third of patients with forehead wrinkles, all of whom were over the age of 55 years. Therefore, when treating forehead wrinkles, it is important to reduce the amount of Botox in older patients and to perform the procedure at least one finger breadth above the eyebrows. To obtain a lasting, safe effect with Botox treatment, it is important to achieve a maximal durable clinical effect using the smallest possible injection dose. To achieve this, the injection must be made accurately, according to anatomical knowledge of the facial expression musculature. Electromyographic guidance may be necessary in treatments such as eyebrow lifting1 or a gummy smile2 to avoid undesirable effects such as eyelid ptosis or drooping of mouth corner. For the past 3 years, we have been using only Restylene when treating nasolabial wrinkles. However, Botox and Restylene (Q-Med AB, Inc., Uppsala, Sweden) combined have proved effective and durable in the treatment of the thick and deep wrinkles at the glabellar site or fine wrinkles on the upper lips. In addition, such combination treatments have been used to reduce the area of the surgical procedure and to hasten recovery, allowing a prompt return to everyday life following surgical rejuvenation procedures such as conventional face lifts and upper or lower blepharoplasty. Besides treating facial wrinkles using intentional selective local muscular paralysis, Botox can also be used in aesthetic and cosmetic procedures such as contouring of the lower face3,4 and calf muscle contouring.