Won Ha

Comparison of Blepharoptosis Correction Using Müller-aponeurosis Composite Flap Advancement and Frontalis Muscle Transfer.

Background: Treatments for severe blepharoptosis are well documented and include the most common operations for restoring upper eyelid ptosis, which are levator surgery and frontal muscle transfers; however, the choice of treatment is still controversial. There are different approaches to the restoration of upper eyelid ptosis, and the choice will be based on ptosis severity and the surgeon’s skill and experience. Methods: Two hundred and fourteen patients presenting with a levator function of between 2 and 4 mm received ptosis correction between 1991 and 2010 at our clinic. Of these, 71 patients underwent Müller aponeurosis composite flap advancement for correction of 89 eyelids, and frontalis muscle transfer was performed on 143 patients (217 eyelids). Postoperative results were evaluated with an average follow-up period of 23 months. Results: The preoperative average for marginal reflex distance (MRD1) in the Müller aponeurosis composite flap advancement group was 1.25 mm, and in the frontal muscle transfer group, it was 0.59 mm. The area of corneal exposure (ACE) was 57.2% in the Müller aponeurosis composite flap advancement group and 53.6% in the frontal muscle transfer group. The postoperative average distance was not significantly different for the 2 techniques. In the Müller aponeurosis composite flap advancement group, MRD1 was 2.7 mm and ACE was improved to 73.5%. In the frontal muscle transfer group, MRD1 was 2.3 mm and ACE was 71.2%. Undercorrection and eyelid asymmetry were the most frequently observed postoperative complications for both techniques. Conclusions: In our study, we confirmed that Müller aponeurosis composite flap advancement and the frontalis transfer technique are both effective in the correction of severe blepharoptosis; our results showed no significant differences between the 2 techniques.

Three cases of acquired simulated brown syndrome after blowout fracture operations.

Brown syndrome is known as limited elevation of the affected eye during adduction. It is caused by a disorder of the superior oblique tendon, which makes it difficult for the eyeball to look upward, especially during adduction. It is classified into congenital true sheath Brown syndrome and acquired simulated Brown syndrome. Acquired simulated Brown syndrome can be caused by trauma, infection, or inflammatory conditions. The surgical restoration of blowout fractures can also lead to limitations of ocular motility, including Brown syndrome. We report on three patients with acquired simulated Brown syndrome, who complained of diplopia and limitation of ocular motility after operations to treat blowout fractures.

Sepsis Leading to Mortality after Augmentation Rhinoplasty with a Septal Extension Graft and Fat Grafting

Infection is the most serious complication after rhinoplasty, with rates reported to range from 2.6% to 5.3% [1]. In that study, most infections were found to be localized and improved after removal of the implant and appropriate antibiotic therapy. Although a case report has described staphylococcal spinal osteomyelitis after septoplasty as a consequence of bacteremia [2], no case of sepsis resulting in death after rhinoplasty has been reported. We report the case of a male patient who expired due to infection after rhinoplasty with a septal extension graft, silicone implant, and fat grafting, and then review and discuss the relevant literature. A 27-year-old previously healthy male patient underwent blepharoplasty, augmentation rhinoplasty with a silicone implant, a septal extension graft with a strut graft, and the grafting of retroseptal fat that was harvested during blepharoplasty at the local hospital onto the nasal tip for tip projection. Erythema occurred in the nasal tip and columella on the first postoperative day, and ceftriaxone was therefore prescribed. On the second postoperative day, the patient complained of a general itching sensation caused by an allergic reaction, and the antibiotic regimen was then changed to a combination of ciprofloxacin and amikacin. Nevertheless, the erythema of the nasal tip worsened and wound disruption occurred (Fig. 1). On the tenth postoperative day, the silicone implant and septal extension graft were removed in our hospital (Fig. 2). Intraoperatively, extensive tissue necrosis and signs of infection were observed in the septal mucosa (Fig. 3). Fig. 1 Preoperative view. Erythema on the nasal tip and columella is shown. The incision wound was disrupted. Fig. 2 Intraoperative view. The silicone implant was removed. The onlay graft and columellar strut graft are shown. Fig. 3 Intraoperative view. (A, B) The septal extension graft was removed. Extensive tissue necrosis and signs of infection were observed in the septal mucosa. This picture was taken on the day of the operation in our hospital and ten days after surgery at a ... For infection control, 400 mg of ciprofloxacin was administered twice a day and massive irrigation was performed. However, fever occurred and symptoms related to sepsis appeared on the third day (Table 1). Therefore, 1,500 mg of amoxicillin was prescribed as a broad-spectrum antibiotic pending the results of the susceptibility test. Five days after the debridement, the wound culture from the grafted fat was identified as methicillin-resistant Staphylococcus epidermidis. We changed the antibiotic prescription to 1 g of vancomycin twice a day based on the results of the susceptibility test. Nonetheless, the patients general condition worsened. We transferred the patient to a tertiary care university hospital, but he eventually expired three days later. Table 1 Changes in the laboratory results of the patient over the course of the infection The nasal septum adjoins the brain, and a case of S. pneumoniae meningitis after septoplasty as a result of this anatomical feature has been reported [3]. However, our patients cerebrospinal fluid was normal and no signs of meningitis, such as nuchal rigidity or mental status change, were noted. In the present case, the cultured organism was methicillin-resistant S. epidermidis, a type of so-called superbacteria. However, the patient showed no response to antibiotics, making it difficult to ascertain that S. epidermidis was the primary cause of sepsis. Administering broad-spectrum antibiotic therapy within one hour after the diagnosis of severe sepsis is recommended, and the antibiotic regimen should be reassessed every 24 hours for de-escalation. Reassessment of the antibiotic therapy needs to continue after the susceptibility test results are reported, and the antibiotic therapy must be changed when septic conditions are escalated. The choice of antibiotics depends on the suspected site of the infection, the setting in which the infection developed, the patients medical history, and local microbial-susceptibility patterns [4]. The blood culture, the results of which were only available after the patient expired, showed no growth. This may have been a false negative due to antibiotic coverage. The exact cause of sepsis was not determined by autopsy, which found no evidence of underlying disease related to impaired immunity, including leukemia and lymphoma. This was a rare case in a young man, although infections can easily spread from the septal mucosa, which has a rich blood supply, to the brain and to the entire body. Therefore, aggressive treatment of the affected area is the best strategy to prevent sepsis and meningitis and to save the patient in such cases.