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Abstract: The skin redraping method for medial epicanthoplasty is characterized by some shortcomings which warrants modification. In this study, clinical data of 193 patients who underwent medial epichanthoplasty by the modified skin redraping technique or the classic skin redraping technique were reviewed retrospectively. The patients underwent operation between May 2018 and June 2020 and were followed up for not less than 6 months. Interepicanthal distance, interpupillary distance, patient satisfaction, and postoperative complications were evaluated. In terms of interepicanthal distance/inter-pupillary distance ratio ( P > 0.05) and satisfaction score ( P = 0.759), the modified skin redraping technique and the classic skin redraping technique were similar. In the classic skin redraping group, there were 3 cases of visible scarring in the lower eyelid, corresponding to significantly more cases than in the modified skin redraping group (n = 0, P < 0.001). There were more out-fold cases in the modified skin redraping group (76/90) than in the classic skin redraping group (17/88) ( P < 0.001). Utilizing the modified skin redraping medial epicanthoplasty can prevent medial hooding of the upper eyelid, reduce the probability of visible scarring, and produce more out-fold with concurrent double eyelidplasty compared with classic skin redraping epicanthoplasty. Level of evidence: IV., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Objective: To establish a preoperative evaluation procedure by measuring the volume of dead space using MRI in patients with ischial pressure injuries., Methods: Patients with spinal cord injury and ischial pressure injuries who underwent treatment between August 2016 and November 2019 were included in the study. Preoperative MRI scan was conducted on all patients. The volume estimation and three-dimensional (3D) reconstruction were performed based on MRI data using a 3D Slicer. Based on the resulting volume, a muscle flap that could fit the dead space was selected. Surgery was performed with the selected muscle flap, and a fasciocutaneous flap was added, if necessary., Results: A total of eight patients with ischial pressure injuries were included in the study. The mean patient age was 59.0 ± 11.0 years. The mean body mass index was 26.62 ± 3.89 kg/m2. The mean volume of dead space was 104.75 ± 81.05 cm3. The gracilis muscle was the most selected muscle flap and was used in four patients. In five of eight cases, a fasciocutaneous flap was used as well. The mean follow-up period was 16 months, and by that point, none of the patients evinced complications that required surgery., Conclusions: To the authors' knowledge, this is the first report on volumetric evaluation of dead space in ischial pressure injuries. The authors believe that the 3D reconstruction process would enable adequate dead space obliteration in ischial pressure injuries. The authors propose that preoperative MRI scans in patients with ischial pressure injury should become an essential part of the process., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Scars are significant complications of wound healing and associated with negative physical, psychological, and cosmetic effects. Scar revision and laser treatment have been used over the past century to improve many different types of scars. Here, we evaluated the effectiveness of early combined carbon dioxide ablative fractional laser (AFL) and pulsed dye laser (PDL) treatment after scar revision. Fourteen patients who underwent scar revision were enrolled. All patients were treated with both a 10,600-nm AFL and a 595-nm PDL commencing 2 weeks after scar revision and continuing at 4-week intervals for a total of 4 treatments. Vancouver Scar Scale scores were evaluated before treatment and 5 months after the final treatment. All Vancouver Scar Scale scores improved significantly except that of scar height. We encountered no adverse complications (wound disruption, or hyper- or hypopigmentation) during follow-up. Early combined carbon dioxide AFL and PDL treatment after scar revision effectively and safely minimized scar formation., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 by Mutaz B. Habal, MD.)

Abstract: In unilateral cleft lip and palate patients, the alar base is displaced inferoposterolaterally due to the depression of the pyriform aperture in the cleft side, and the drooping of the nostril rim is provoked by displacement of the alar base. This study was conducted between May 1998 and December 2012. In total, 82 patients with secondary unilateral cleft lip nasal deformities were treated using alar base augmentation. The patients were divided into two groups according to the degree of their preoperative alar base asymmetry. Patients with alar base asymmetry <3 mm were treated with a soft tissue augmentation procedure. Those with alar base asymmetry >3 and <6 mm were treated with a bony augmentation procedure. Soft tissue augmentation was conducted in 42 patients, and bony augmentation was conducted in 40 patients. In the soft tissue augmentation group, the degree of alar base asymmetry was improved from 2.42 ± 0.38 mm preoperatively to 0.45 ± 0.21 mm postoperatively (P  < 0.05). In the bony augmentation group, the degree of alar base asymmetry was improved from 4.33 ± 0.50 mm preoperatively to 0.81 ± 0.20 mm postoperatively (P  < 0.05). In the amount of alar base augmentation, there were statistically significant differences between the soft tissue augmentation group and the bony augmentation group (P  < 0.05). This clinical study shows that secondary cleft lip nasal deformities can be corrected with alar base augmentation using soft tissue and bony augmentation and that these procedures can provide reliable, satisfactory, and safe clinical outcomes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 by Mutaz B. Habal, MD.)

Recently, absorbable plates have been used for various types of facial fractures. However, in the case of mandibular fractures, a large amount of force is applied after fixation. Thus, a firm fixation is necessary. In particular, unfavorable fractures are more frequent in mandibular fractures. Therefore, plates should be strong enough to withstand forces at the time of surgery. The purpose of this study was to determine clinical efficacy and usefulness of unsintered hydroxyapatite (u-HA)/poly (L-lactide) (PLLA) composite system by clinical application and follow-up of fixation in patients with mandible fracture. A total of 13 patients with mandible fractures were assessed for compliance with the selection criteria. Fracture site was confirmed with radiographic findings including X-ray and facial computed tomography images. Subjects who fulfilled all criteria underwent operation using HA/PLLA composite fixation system (OSTEOTRANS; Takiron Co Ltd, Osaka, Japan). After reduction of fracture site through oral or skin incision, we placed OSTEOTRANS plates on fracture line and performed rigid fixation with OSTEOTRANS-MX screws. Follow-up was performed at 1 week, 1, 3, and 6 months after surgery. Occlusion and mouth opening were checked by physical examination and radiographic finding. We also confirmed bone approximation status, bony gap change, and bone union status. All patients finished every follow-up. They were satisfied with outcomes without complications such as malocclusion, foreign body sensation, or tenderness. This study confirms that OSTEOTRANS can be used appropriately for mandibular fractures.

Aplasia cutis congenita (ACC), also called cutis aplasia, is a rare congenital abnormality characterized by focal defect of the skin at birth, frequently involving the scalp, but may affect any region of the body. Approximately 80% of patients have the defect confined to the skin and generally less than 2 cm diameter, which can be managed conservatively with dressing alone. However, some patients present large cutaneous defects and aplasia of the underlying skull may also be present. The main complications of large defects include meningeal infection, bleeding, and thrombosis, which may be deadly. Some controversy remains in the literature regarding ACC treatment, with surgical and conservative treatment modalities having proponents and opponents.This article presents the first case of a newborn with full-thickness ACC lesion of the vertex healed by conservative treatment with application of acellular dermal matrix.

Background: Limitation in performing restoration of orbital structures is the narrow, deep, and dark surgical field, which makes it difficult to view the operative site directly. To avoid perioperative complications from this limitation, the authors have evaluated the usefulness of computer-assisted navigation techniques in surgical treatment of blowout fracture., Methods: Total 37 patients (14 medial orbital wall fractures and 23 inferior orbital wall fractures) with facial deformities had surgical treatment under the guide of navigation system between September 2012 and January 2015., Results: All 37 patients were treated successfully and safely with navigation-assisted surgery without any complications, including diplopia, retrobulbar hematoma, globe injury, implant migration, and blindness., Conclusions: Blowout fracture can be treated safely under guidance of a surgical navigation system. In orbital surgery, navigation-assisted technology could give rise to improvements in the functional and aesthetic outcome and checking the position of the instruments on the surgical site in real time, without injuring important anatomic structures.

Background: Medication administration errors are the most common type of error in pediatric medicine. Preventing medication errors is an important part of ensuring safe and quality patient care for pediatric patients. Few studies have described this issue from the perspective of the parents of pediatric patients., Purpose: This study describes parents' administration of medication to their children at home and the understanding of these parents of adverse drug events (ADEs)., Methods: A cross-sectional survey design was used to gather data from 179 parents of pediatric patients at two pediatric units at a hospital and three children's daycare centers in Korea. Data were collected from July to August 2012 using a self-reported questionnaire., Results: Participants reported administering antipyretics (94.4%), decongestants (89.4%), and antibiotics (77.7%) to their children at home. The major source of medication information was instruction sheets. Parents more commonly used dosing cups (43.6%) and droppers (32.9%) when administering liquid medication to children. Furthermore, 12.3% of the children experienced ADEs. Only 48% of the participants were provided information on ADEs, 15.1% were unsure about the recommended dosage, and 11.2% were unsure of the recommended method for administering the medication. Analysis of variance and post hoc tests showed that level of parental education and monthly income each had a significant impact on participant understanding of ADEs., Conclusions/implications for Practice: This study suggests that parents should be educated about ways to avoid common medication errors in children. In addition, in the case of low-income families, home visits should be carried out to understand how to reduce home medication errors and provide drug-related information to parents. Strategies are needed to reduce pediatric home medication errors and minimize ADEs and to provide medication information to parents.

Background: Ptosis of the upper eyelid, blepharoptosis, is defined as an abnormally low-positioned upper eyelid margin in the primary gaze, which results in narrowing of the palpebral fissure and opening. Blepharoplasty, including a double-eyelid fold operation, is the most common aesthetic operation in the East Asian population. Patients who want to undergo blepharoplasty often have mild to moderate blepharoptosis., Methods: A retrospective review was conducted of the medical records and preoperative and postoperative photographs of 74 patients who underwent simultaneous blepharoptosis correction and double-eyelid surgery between January of 2007 and October of 2011. All patients had mild (1 to 2 mm) or moderate (3 to 4 mm) bilateral blepharoptosis and excellent or good levator function (>8 mm). All patients underwent levator aponeurosis-Müller muscle complex advancement through three partial incisions., Results: A primary blepharoptosis operation was performed in 46 patients, with a secondary operation performed in 28 patients. Double-eyelid fold operations were performed in all cases. The average preoperative margin reflex distance 1 measured 0.8 ± 0.19 mm. No intraoperative complications occurred. The average postoperative margin reflex distance 1 was 3.6 ± 0.25 mm. There was a statistically significant difference between preoperative and postoperative distance values (p < 0.05). Excellent results occurred in 62 patients (83.8 percent), good results occurred in 11 (14.9 percent), fair results occurred in one (1.35 percent), and poor results did not occur., Conclusion: Blepharoptosis correction with levator aponeurosis-Müller muscle complex advancement through three partial incisions is an effective technique for young patients with mild to moderate blepharoptosis who do not want incision scars., Clinical Question/level of Evidence: Therapeutic, IV.

A canalicular laceration is the most common injury of the lacrimal drainage system and can result from direct or indirect injury to the canalicular system. If the wounds are not managed properly, they can lead to scarring, stenosis, and inflammation, which may lead to symptomatic epiphora. We successfully reconstructed canalicular lacerations using Mini-Monoka tubes (FCI Ophthalmics, Marshfield Hills, MA) under microscopic magnification.We treated 14 patients for canalicular lacerations at the Soonchunhyang University Bucheon Hospital between August 2009 and October 2012. All patients underwent placement of a Mini-Monoka tube and a mucosal canalicular anastomosis microscopically to reconstruct monocanalicular lacerations. The tubes were removed at 6 to 8 months postoperatively, and follow-up was 8 to 12 months. No complications related to the Mini-Monoka tube, such as punctual plug migration, eye irritation, inflammation, granuloma formation, or erosion, occurred during the follow-up period.The goal of reconstructing a lacerated canaliculus is accurate approximation of the injured end of the canaliculus to facilitate mucosal healing and to prevent a canalicular obstruction. We believe that microscopic canalicular reconstruction with a Mini-Monoka tube is a safe, reliable, and straightforward method with fewer complications and is more effective for preventing iatrogenic injury in the unaffected canaliculus and minimizing patient discomfort.

Purpose: To investigate the long-term clinical course of scleromalacia with calcified plaque as a complication of cosmetic conjunctivectomy with topical mitomycin C (MMC) application and to introduce a surgical method for this complication using calcified plaque removal and/or conjunctival flap surgery., Methods: Eleven patients (15 eyes, 17 lesions) were included in this retrospective study. The calcified plaque was removed with forceps and pterygium knife, and the thinned scleral lesion was covered with a conjunctival flap from an intact superior or inferior conjunctiva., Results: There were no cases of scleral thinning or calcified plaque recurrence in patients who underwent conjunctival flap surgery. The mean interval between previous cosmetic conjunctivectomy with postsurgical topical MMC and the first surgical treatment for complications was 20.0 ± 6.4 months. The mean postoperative follow-up duration after last conjunctival flap surgery or calcified plaque removal was 11.6 ± 4.0 months., Conclusions: Scleral calcification and thinning progress as time passes after cosmetic conjunctivectomy with postsurgical topical MMC. Calcified plaque removal with conjunctival flap surgery can be an effective surgical management for this complication, returning blood supply to a thinned sclera.

Background: One limitation of orthognathic surgery is the narrow surgical field, which makes it difficult to view the operative site directly. Thus, many perioperative complications can occur. In this study, we evaluated the usefulness of computer-aided navigation techniques in orthognathic surgery., Methods: We enrolled 10 patients (3 men and 7 women) with facial deformities who were treated between July 2010 and February 2011. A Le Fort I osteotomy, sagittal split ramus osteotomy, and reduction malarplasty were performed with guided navigation., Results: All 10 patients were treated successfully using the computer-assisted navigation surgery. Using the navigation system, instruments were visualized on a monitor in real time and all maneuvers were performed safely., Conclusions: Orthognathic surgery, such as a Le Fort 1 osteotomy, sagittal split ramus osteotomy, and reduction malarplasty, can be performed safely under the guidance of a surgical navigation system. Navigation systems enable surgeons to carry out preoperative plans accurately without injuring important anatomic structures because the positions of the instruments can be visualized on site in real time.

Explosive oral cavity injuries make restoring optimal oral function a challenge. An explosion in the oral cavity can cause burns and concomitant smoke inhalation injury to the upper airway.We present the case of a patient in whom the middle and lower thirds of the face were destroyed when a firecracker exploded in his oral cavity. Gunpowder tattooing caused by the explosion was present on the retropharyngeal space. He had an open fracture of the mandibular symphysis and inhalation burns of the upper airway were suspected. Tracheostomy was performed because we could not rule out inhalation burns of the upper airway. After close observation, his cardiopulmonary function and vital signs were stable, and we prepared him for reconstructive surgery.

Orbital floor fractures are among the more challenging injuries faced by plastic surgeons. Enophthalmos is defined as backward, usually downward, displacement of the globe into the bony orbit. We describe reconstruction of the orbital floor slope in orbital floor fractures that prevents postoperative complications, especially posttraumatic enophthalmos. Thirty-three patients with orbital floor fractures were treated using reconstruction of the orbital floor slope between April 2009 and July 2010. The patients ranged in age from 12 to 54 years. There were 31 males and 2 females. All patients were operated on using a transconjunctival approach under general anesthesia. The orbital floor was reconstructed with poly-l/d-lactide sheets in all cases. Preoperatively, 23 [Float1]patients (69%) had enophthalmos, and 12 patients (36%) had symptomatic diplopia. The enophthalmos was corrected in 20 patients (86%), and the diplopia resolved in 10 (83%). Extrinsic ocular movement was impaired preoperatively in 1 patient (3%), but resolved after surgery. No patient had impaired visual acuity preoperatively or postoperatively. The results suggest that orbital floor reconstruction considering the orbital floor slope is a safe, reliable method with fewer complications that is more effective at preventing posttraumatic enophthalmos.

Pneumosinus dilatans is a rare disease in which 1 or more paranasal sinuses are dilated without functional alteration. The frontal sinus is the most commonly affected site, with involvement of the maxillary sinus being rare. Asymmetrical facial contour is the most common sign, and nasal obstruction and pain may also be present. We describe 6 cases of maxillary pneumosinus dilatans with histories of protrusion of the malar region. Plane radiography and computed tomography revealed abnormal expansion of the maxillary sinus without thinning of the bony wall, leading to a diagnosis of maxillary pneumosinus dilatans. Surgical decompression and maxilloplasty were achieved by electrical burring, greenstick downward fracture, or ostectomy of the anterior wall of the maxillary sinus and subsequent repositioning of the removed bony fragments with miniplates. The postoperative course was uneventful, and facial contours were improved on physical and radiologic examination. No recurrence was detected in any case, and good cosmetic results were achieved. In this article, the authors present surgical options for the treatment of pneumosinus dilatans of the maxillary sinus, including a review of the literature.

In scaphocephaly, traditional distraction osteogenesis increases only the bitemporal width. We describe distraction osteogenesis with a pivot plate for scaphocephaly, which not only increases the bitemporal width but also decreases the anteroposterior length. Three patients with scaphocephaly were treated using distraction osteogenesis with a pivot plate between January 2005 and June 2006. These children underwent cranial reshaping by gradual distraction using an external distraction device and pivot plate. The distraction rate was 1 mm/d, and the latency period was 5 days. The follow-up period after distraction osteogenesis ranged from 16 to 24 months. No specific complications, such as accidental removal of the distraction devices, infection, or neurologic problems in any patient, occurred. The mean distraction was 45 mm. The mean cranial index was 73.6. Distraction osteogenesis for scaphocephaly is still in the development stage, but it is becoming accepted as a useful method because of its many advantages. Distraction osteogenesis with a pivot plate for scaphocephaly is better than other distraction osteogenesis techniques because it induces increased bitemporal width and decreased anteroposterior length synchronously.

Purpose: To compare changes in human corneal thickness after the instillation of proparacaine with those after oxybuprocaine instillation with time over a period of 10 minutes., Methods: Eighteen healthy young participants were recruited. Proparacaine was used in the right eye and oxybuprocaine in the left. Right and left baseline corneal thicknesses were measured every 30 seconds for 10 minutes using a noncontact specular microscope by 1 observer. Baseline corneal thickness was defined as the average of all values taken over 10 minutes. Changes in corneal thickness were measured every 20 seconds for 10 minutes after the administration of 1 drop of 0.5% proparacaine onto the right cornea and 1 drop of 0.4% oxybuprocaine onto the left cornea., Results: Mean baseline right cornea thickness was 531 +/- 45 microm, and that of the left cornea was 531 +/- 42 microm. The corneal thickness after proparacaine increased by 8.6 microm ( approximately 4.5-12.6 microm, 95% CI) and then returned to baseline within 80 seconds. Corneal thickness after applying oxybuprocaine increased by 7.7 microm (3.6-11.2 microm, 95% CI) and then returned to baseline within 80 seconds. There was a second transient increase about 5 minutes later after proparacaine instillation but no additional transient increase after oxybuprocaine instillation., Conclusion: Oxybuprocaine is similar to proparacaine in terms of the severity of its effect on corneal thickness. Corneal thickness instability may occur for 5 minutes after proparacaine administration. Changes in corneal thickness after topical anesthetic instillation should be considered when performing measurements for refractive surgery or central corneal thickness in glaucoma patients.