• Archives of Plastic Surgery
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• v.32 no.2
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• pp.219-226
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• 2005

Muller's muscle-levator aponeurosis advancement procedure was performed to correct mild to moderate congenital blepharoptosis with moderate to good levator function and to correct severe aquired blepharoptosis with poor levator function. Through the blepharoplasty incision, the upper half of the tarsal plate was exposed and the orbital septum was opened to show the levator aponeurosis. The Muller's muscle was dissected from the superior margin of the tarsal plate and from the posteriorly located conjunctiva with sharp scissors. The Muller's muscle and levator aponeurosis were advanced on the anterior surface of the tarsal plate as a composite flap and fixed approximately 3 to 4 mm inferior to the upper edge of the tarsal plate with three horizontal 6-0 nylon mattress sutures. The amount of advancement of the composite flap was controlled by the location of the upper eyelid margin 2 mm below the upper limbus in primary gaze after the first suture in the middle portion of the flap. The excess flap was trimmed off with scissors, but trimming was usually not necessary in cases of mild to moderate ptosis. Nine cases underwent this Muller's muscle-levator aponeurosis advancement procedure from September 2003 to September 2004. Five cases were congenital blepharoptosis with 2-4 mm ptosis and more than 5 mm of levator function, but three of the four acquired ptosis cases had more than 4 mm ptosis with poor levator function. The age of the patients ranged from 7 to 81 years. In operative results, all patients except one traumatic case were within 1 mm of the desired eyelid height in primary gaze. This procedure can provide not only tightening of the Muller's muscle but also advancement and firm fixation of the levator aponeurosis to the tarsal plate, yielding predictable results.

• Archives of Plastic Surgery
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• v.32 no.2
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• pp.262-266
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• 2005

In some blepharochalasis patients, upper blepharoplasty alone is not satisfactory because of narrow distance between eyebrow and eyelash. On that occasion, eyebrow lift is advisable. There are many methods of classical eyebrow lift, such as direct excision, transblepharoplasty approach, anterior hairline technique, and so on. But they are not so effective, have a tendency to recur and also give rise to side effects; unacceptable scar, facial nerve palsy, sensory loss and hematoma, etc. Some patients who have prominent nasolabial folds, are reluctant to perform face lift procedure due to psychologic or economic burden. The authors performed the eyebrow lift procedure separately or simultaneously with face lift or forehead lift. After making 2 or 3 slit incisions, we passed absorbable suture material, 3-0 vicryl, through suborbicularis oculi fat layer. Then it was passed through subperiosteal plane and fixated to the temporalis fascia. When patients complain prominent nasolabial folds, malar fat pad was elevated also in the same manner. This methods is effective and has minimal complication such as facial nerve palsy, scar, sensory loss. Recurrent tendency was rarely observed during follow-up. Dimples were observed at slit incision sites but they disappeared within 2 or 3 weeks. Eyebrow lift and malar fat lift by absorbable suture elevation with subperiosteal dissection is a simple and less morbid. Because of its effectiveness and little side effect or complication, this procedure can be a useful method.

• Archives of Plastic Surgery
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• v.43 no.2
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• pp.172-180
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• 2016

Background Conventional frontalis transfer may cause a range of complications. In order to overcome complications, we made modifications to the surgical technique, and compared the outcomes of patients who underwent conventional frontalis transfer with those of patients who underwent modified frontalis transfer. Methods We conducted a retrospective study of 48 patients (78 eyes) who underwent conventional frontalis transfer between 1991 and 2003 (group A) and 67 patients (107 eyes) who underwent modified frontalis transfer between 2004 and 2014 (group B). The frontalis transfer procedures were modified conform to the following principles. The tip of the frontalis muscle flap included soft tissue that was as thick as possible and the soft tissue on the tarsal plate was removed to the greatest extent possible. A double fold was created in cases of unilateral ptosis. In order to evaluate the objective effects of modification, preoperative and postoperative values of the marginal distance reflex 1 (MRD1), the corneal exposure area, and the decrease in eyebrow height were compared between the two groups. Results In group A, patients showed an improvement of 1.19 mm in the MRD1, a 6.31% improvement in the corneal exposure area, and a 7.82 mm decrease in eyebrow height. In group B, patients showed an improvement of 2.17 mm in the MRD1, an 8.39% improvement in the corneal exposure area, and an 11.54 mm decrease in eyebrow height. The improvements in group B were significantly greater than those in group A. Conclusions Modified frontalis transfer showed better results than the conventional procedure and provided satisfactory outcomes.

• Archives of Plastic Surgery
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• v.32 no.3
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• pp.304-310
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• 2005

Bulging of the lower eyelid & tear trough groove is regarded as a sign of aging. In the past, the surgical excision of the fat pad has been the mainstray of the management of lower palpebral bag in cosmetic blepharoplasty, Recently, fat pad sliding method has been introduced to make more attractive lower eyelids. We used the fat pad for covering the hollowness of the lower eye lid. And we use redundant fat pad for filling & augmentation of the lower eye lid by reflexion. Redraping of the orbicularis arc, with its accompanying midfacial fat repositioning, anatomically restores the cheek and lower lid to make more youthful contour. By redraping and fixing the orbicularis arc on the medial surface of the orbital rim, it becomes a more attractive midface and may prevent of ectropion. From August, 2002 to July, 2004 in correction of lower palpebral bulge & tear trough groove, these two technique were performed in 42 consecutive individuals (84 lower eyelid) for two-year period. Follow up ranged from 3 to 15 months. (an average of 9 months) Palpebral bulge & tear trough groove were corrected and obtained a youthful midface. Complication was rare. The advantages of these techniques are that: prevent in of secondary palpebral bulge and irregularity of lower eyelid by using of reflexed fat fad; prevent in of ectropion. Thus an attractive midface is obtained by redraping of orbicularis arc.

• Archives of Plastic Surgery
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• v.43 no.5
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• pp.402-410
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• 2016

Background In an increasing number of lawsuits doctors lose, despite providing preoperative patient education, because of failure to prove informed consent. We analyzed judicial precedents associated with insufficient informed consent to identify judicial factors and trends related to aesthetic surgery medical litigation. Methods We collected data from civil trials between 1995 and 2015 that were related to aesthetic surgery and resulted in findings of insufficient informed consent. Based on these data, we analyzed the lawsuits, including the distribution of surgeries, dissatisfactions, litigation expenses, and relationship to informed consent. Results Cases were found involving the following types of surgery: facial rejuvenation (38 cases), facial contouring surgery (27 cases), mammoplasty (16 cases), blepharoplasty (29 cases), rhinoplasty (21 cases), body-contouring surgery (15 cases), and breast reconstruction (2 cases). Common reasons for postoperative dissatisfaction were deformities (22%), scars (17%), asymmetry (14%), and infections (6%). Most of the malpractice lawsuits occurred in Seoul (population 10 million people; 54% of total plastic surgeons) and in primary-level local clinics (113 cases, 82.5%). In cases in which only invalid informed consent was recognized, the average amount of consolation money was KRW 9,107,143 (USD 8438). In cases in which both violation of non-malfeasance and invalid informed consent were recognized, the average amount of consolation money was KRW 12,741,857 (USD 11,806), corresponding to 38.6% of the amount of the judgment. Conclusions Surgeons should pay special attention to obtaining informed consent, because it is a double-edged sword; it has clinical purposes for doctors and patients but may also be a litigation strategy for lawyers.

• Archives of Plastic Surgery
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• v.33 no.1
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• pp.87-94
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• 2006

This study is to investigate the patients who had blepharoplasty for cosmetic purposes or facial nerve disorders. 21 patients were examined with an age from 17 to 63 years. Sixteen cases were classified as a normal group for investigation of the histopathologic change according to the age. The rest were patients of Bell's palsy(2), $Botox^{(R)}$ injection(2) and blepharospasm (1). We measured a mean diameter of myofiber and dimension's proportion of muscluar tissue per regular visual field. First, we measured a statistical significance according to the age in normal cases by grouping them into younger than 30-year-old, 30's, 40's, 50's and 60's. Second, we divided normal cases(16) into Group A and B by two bases for statistical analysis. In conclusion, although there were several differences as vacuolation, internalization of sarcolemnic nuclei between 35-year-old and 62-year-old patients in simple comparison, there was no uniform decrease according to the age. There were also no significant statistical changes in the value of a diameter of myofibers and dimension's proportion of muscular tissue according to the age in any of the two normal groups. But in $Botox^{(R)}$ injection and Bell's palsy, blepharospasm patients, two values showed remarkable difference compared to the normal group of same age.

• Archives of Plastic Surgery
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• v.35 no.4
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• pp.455-460
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• 2008

Purpose: We have classified blepharoptosis into the categories including pseudoptosis in Koreans and compared with other previous studies. Methods: Total of 250 patients(398 eyes) who underwent surgery for blepharoptosis from 1987 to 2006 were studied. By classification of Beard, patients were categorized into congenital, acquired and pseudo blepharoptosis and later they were reclassified by their etiologies. Also addition of pseudoptosis to the classification of Frueh, blepharoptosis were categorized into neurogenic type, myogenic type, aponeurotic type, mechanical type and pseudoptosis. And we divided these cases by the degree of blepharoptosis, levator function and the operation methods. Results: Out of the 250 patients, 175 patients were congenital type, 49 were acquired type and 26 were pseudoptosis. According to the mechanistic classification, 177 myogenic type, 30 aponeurotic, 7 mechanic, 8 neurogenic and 28 pseudoptosis were categorized. Regarding severity of blepharoptosis, there were 29.2% of mild, 40% of moderate, and 30.8% of severe cases. Out of the 398 cases, in terms of the operation methods, there were 39 aponeurosis plication, 184 levator resection, 5 Muller tucking, 60 Orbicularis oculi muscle flap, 66 frontalis transfer, and 21 blepharoplasty. Conclusion: The cause and degree of ptosis, and levator function are very important when considering the amount of resected muscle. There were only a few studies about blepharoptosis classification including pseudoptosis category. Therefore, through this study, we can investigate the relationship between the pseudoptosis and the others. This study could be useful for the making future management plans of blepharoptosis in Korean patients.

• Archives of Plastic Surgery
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• v.36 no.2
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• pp.200-204
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• 2009

Purpose: The epicanthal fold is a unique finding in the medial canthal area of many Asians. Various methods have been developed to eliminate this fold. However, excessive and prominent scarring in the medial canthal and nasal area and recurrence restricted application of epicanthoplasty. The authors performed a epicanthoplasty using Y-V advancement flap method in order to obliterate the epicanthal fold without making incisions in the nasal area and as a result, to avoid postoperative scarring. Methods: Sixty one patients underwent epicanthal fold correction using Y-V advancement flap method from July 1999 to February 2005. There were 4 males and 57 females with ages ranging from 9 to 60 years. The epicanthoplasty was performed combined with double eyelid operation, ptosis correction, augmentation rhinoplasty, nasal alar reduction, and nasal tip-plasty. Results: There were few complications in our studies, and most of the patients were satisfied with the results. Conclusion: Remarkable advantages of our Y-V advancement flap epicanthoplasty are as follows: 1) minimal postoperative scarring in the medial canthal area, 2) application of modified double eyelid operation, 3) wider opening of the medial palpebral fissure, 4 the correction of entropion or epiblepharon, 5) no recurrence.

• Archives of Plastic Surgery
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• v.40 no.5
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• pp.603-609
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• 2013

Background Although the conventional direct brow lift operation provides a simple means of managing lateral brow ptosis, the scars produced have been unacceptable. However, using the modifications proposed here, scarring showed remarkable improvement. This article reviews our experiences with the presented technique, mainly with respect to postoperative scarring. Methods Measured amounts of supra-eyebrow skin and subcutaneous fat were excised en bloc in the conventional manner under 'hyper-hydrated' local infiltration anesthesia. The lower flap and the edge of the upper flap were undermined above the muscular plane, and the orbicularis oculi muscle was directly suture-plicated and suspended upward to the distal frontalis muscle. Skin closure was performed in a basic plastic surgical manner. Results From April 2007 to April 2012, a consecutive series of 60 patients underwent surgery using the above method. The average width of the excised skin was 8 mm (range, 5-15 mm) at the apex of the eyebrow. Preoperative complaints were resolved without occurrence of significant complications. The surgical scars showed remarkable improvement and were negligible in the majority of the cases. Conclusions The direct brow lift operation combined with plication/suspension of the superior and lateral portion of the orbicularis oculi muscle provides a simple, safe, and predictable means of correcting lateral brow ptosis. The scars were acceptable to all of the patients. For proper management of the frontalis tone, upper blepharoplasty and/or repair of eyelid levator function must be considered in addition to brow lift procedures.

• Archives of Plastic Surgery
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• v.34 no.4
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• pp.420-425
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• 2007

Purpose:The mechanism of scar formation is not fully understood. Fibroblast is an important cell in wound healing process. We experienced a patient who was taking progesterone orally. Upper blepharoplasty was performed on her but, wound healing was delayed. We hypothesized that progesterone was the cause of delayed wound healing and fibroblast proliferation inhibition. We investigated the effect of progesterone in vitro on human dermal fibroblasts to study the effects on fibroblast proliferation. Methods: Human dermal fibroblasts from four persons were cultured initially. Progesterone is mixed to them at various concentrations, and fibroblast cell count was measured by MTT assay method at 570 nm. We confirmed that progesterone has some inhibitory effect on fibroblast proliferation and maximal inhibitory concentration of progesterone was determined. Then fibroblasts from a total of nineteen persons were cultured and the effects of progesterone were studied. Results: The initial study showed the maximal inhibitory concentration of progesterone to be $50{\mu}g/ml$. The main study showed that progesterone had 70.9% inhibitory effect on human dermal fibroblast in vitro. Conclusion: Progesterone has inhibitory effect on cultured human dermal fibroblast proliferation in vitro.