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Recently, dermal fillers have been used with increasing frequency to improve facial contours for cosmetic purposes. The appreciable increase in such filler procedures has led to more adverse events and complications. Herein, we report the clinical significance and differential diagnosis of delayed multiple granulomas that occurred in a patient with a history of an injection of an unknown substance as a filler 20 years previously. She was also taking oral steroids and tacrolimus for immune suppression after a kidney transplant that she received 10 years before she presented with granulomas.

Background Nasal fracture and orbital blowout fracture often occur concurrently in cases of midface blunt trauma. Generally, these multiple fractures treatment is surgery, and typically, the nasal bone and orbit are operated on separately. However, we have found that utilizing a transconjunctival approach in patients with concurrent nasal bone fracture and orbital blowout fracture is a useful method. Methods The participants in the present study included 33 patients who visited the Plastic Surgery outpatient department between March 2014 and March 2017 and underwent surgery for nasal fracture and orbital blowout fracture. We assessed patients’ and doctors’ satisfaction with surgical outcomes after indirect open reduction via a transconjunctival approach for the treatment of nasal bone fracture with associated orbital blowout fracture. Results According to the satisfaction scores, both patients and doctors were satisfied with transconjunctival approach. Conclusion We presented here that our method enables simultaneous operation of nasal fracture accompanied by orbital blowout fracture, rather than treating the two fractures separately, and it allows precise reduction of the nasal fracture by direct visualization of the fracture site without any additional incisions or difficult surgical techniques. Also, by preventing the use of excessive force during reduction, this method can minimize damage to the nasal mucosa, thereby reducing the incidence of nasal bleeding.

Performing rhinoplasty using filler injections, which improve facial wrinkles or soft tissues, is relatively inexpensive. However, intravascular filler injections can cause severe complications, such as skin necrosis and visual loss. We describe a case of blepharoptosis and skin necrosis caused by augmentation rhinoplasty and we discuss the patient’s clinical progress. We describe the case of a 25-year-old female patient who experienced severe pain, blepharoptosis, and decreased visual acuity immediately after receiving a filler injection. Our case suggests that surgeons should be aware of nasal vascularity before performing an operation, and that they should avoid injecting fillers at a high pressure and/or in excessive amounts. Additionally, filler injections should be stopped if the patient complains of severe pain, and appropriate measures should be taken to prevent complications caused by intravascular filler injections.

Alloplastic materials used for orbital fracture reconstruction can induce complications, such as infection, migration, extrusion, intraorbital hemorrhage, and residual diplopia. Silicone is one of the alloplastic materials that has been widely used for decades. The author reports a rare case of spontaneous extrusion of a silicone implant that was used for orbital fracture reconstruction 30 years earlier. A 50-year-old man was admitted to the emergency room for an exposed substance in the lower eyelid area of the left eye, which began as a palpable hard nodule a week earlier. The exposed material was considered to be implant used for previous surgery. Under general anesthesia, the implant and parts of the fibrous capsule tissue were removed. Several factors hinder the diagnosis of implant extrusions that occur a long period after the surgery. So, surgeons must be aware that complications with implants can still arise several decades following orbital fracture reconstruction, even without specific causes.

Nevus sebaceus is a hamartoma of the sebaceous gland that occurs congenitally, from which various secondary tumors can arise with a prevalence of 5%-6%. Benign neoplasms commonly arise from nevus sebaceous, but they have a very low malignant potential. Two neoplasms may occasionally arise within the same lesion, but it is rare for three or more neoplasms to occur in a nevus sebaceus simultaneously. A 61-year-old male patient was admitted to our hospital for a 4 cm×2.5 cm growing tumor in a verrucous form arising within a periauricular nevus sebaceus in the post auricle of the left ear that had developed 30 years earlier. The nodule was diagnosed as 3 different types of tumors: trichilemmoma, desmoplastic trichilemmoma, and basal cell carcinoma. To our knowledge, this is the first report of the coexistence of three different tumors arising from nevus sebaceous. It contain malignant neoplasm also. Surgeons should be aware of the need for close monitoring and early complete surgical excision of sebaceous nevus in order to improve patient outcomes.

Transient anisocoria is rare during blowout fracture reconstruction. We report a case of transient anisocoria occurring during medial blowout fracture reconstruction and review the relevant literature. A 54-year-old woman was struck in the face and was admitted for a medial blowout fracture of the left eye. During the operation, persistent bleeding occurred. To control this bleeding, a 1% lidocaine solution with 1:200,000 epinephrine was applied to the orbital wall with cotton pledgets. In total, 40 mL of local anesthetic was used for the duration of the operation. After approximately three hours of the surgery, the ipsilateral pupil was observed to be dilated, with sluggish response to light. By 3 hours after the operation, the mydriasis had resolved with normal light reflex. In conclusion, neurological and ophthalmologic evaluation must be performed prior to blowout fracture surgery. Preoperative ophthalmic evaluation is simple and essential in ruling out any preexisting neurologic condition. Moreover, surgeons must be aware of the fact that excessive injection of lidocaine with epinephrine for hemostasis during orbital wall surgery can result in intraoperative anisocoria. Anisocoria-related situations must be addressed in a proficient manner through sufficient understanding of the mechanism controlling the pupillary response to various stimuli.

Background We conducted this study to analyze the values of the key cephalometric angular measurements of the mandible using 3-dimensional (3D) computed tomography scans. Methods In the 106 enrolled patients, a 3D cephalometric analysis was performed to measure the angular variables of the mandible. These values were compared between the two sides and between the two sexes. Results The frontal measurements revealed that the mandibular body curve angle was larger on the left (Lt) side (right [Rt], 141.24±7.54; Lt, 142.68±6.94; P=0.002) and the gonial angle was larger on the right side (Rt, 134.37±8.44; Lt, 131.54±7.14; P0.05). Further, the transverse measurements revealed that the mandibular body curve angle was larger on the right side (Rt, 140.28±7.05; Lt, 137.56±6.23; P Conclusions These results provide an average of the mandibular angular measurements for the Korean population, establishing a standard for determining surgical patient groups and outcome evaluations in the field of mandible contour surgery.

Leiomyosarcomas (LMSs) are rare malignant tumors of the smooth muscles, and superficial LMS is a type of LMS that develops on the skin. Superficial LMS of the head is exceedingly rare and represents only 1%-5% of all superficial LMS cases [1]. LMSs are classified as cutaneous or subcutaneous depending on the primary site of origin. A primary cutaneous LMS derives from the erector muscles of the hair and sweat glands in the dermis. Subcutaneous LMS is considered to arise from the muscular coat of a vessel [2]. It mostly develops in people in the age group of 40-60 years and is twice more likely to occur in women than in men. The most common sites of LMS development are the legs (50%-75%), followed by the arms (20%-30%), trunk (10%-15%), and face (1%-5%) [3]. We report a case of LMS in a 13-year-old boy. LMS developed on the face of the child. A case like this has thus far not been reported internationally, and the present study contributes to the knowledge on LMS disease characteristics. A 13-year-old boy was admitted because of a protruding and painless mass on his right jaw. The tumor size had been increasing for 10 months, and the lesion was approximately 20 mm in diameter at the time of admission (Fig. 1). There were no palpable cervical lymph nodes. Fig. 1 A preoperative photograph of the patient showing a 30-mm-sized tumor under the right jaw. A solitary oval-shaped mass with increased contrast and measuring 28 mm×18 mm was observed at the superficial masseter muscle and the mandibular ramus during preoperative contrast-enhanced computed tomography (Fig. 2). At first, hemangioma was suspected. Accordingly, a catheter was placed in the right external carotid artery through the right femoral artery, and embolization through the facial artery was performed using Gelfoam. However, instead of decreasing, the tumor size gradually increased during the 2 months of postoperative follow-up. Fig. 2 A preoperative computed tomography scan showing a hypervascular mass with increased contrast. Under general anesthesia, a pale, yellowish mass, measuring 33 mm×23 mm×20 mm, on the subcutaneous layer was resected via an intraoral incision (Fig. 3). On the postoperative biopsy, LMS involving adipose and vascular tissues accompanied by dystrophic calcification and a mitotic count of 3/10 high-power fields was observed (Figs. 4, ​,55). Fig. 3 An oval-shaped mass was revealed via an intraoral incision. Fig. 4 High-power microscopic examination revealed atypical spindle cell proliferation with a long fascicular or short bundle pattern. The red arrow denotes atypical mitosis (H&E, ×400). Fig. 5 Immunohistochemically, desmin staining (desmin immunohistochemistry, ×200) was positive. Low-power microscopic examination revealed a hypercellular solid mass without necrosis or hemorrhage and composed of spindle cells. The lesion infiltrated to the adipose tissue, probably the subcutaneous fat layer. The high-power view showed cellular atypism with frequent mitotic figures (at least one/high-power field) (Fig. 4). Immunohistochemically, desmin and actin were positive, but CD34 or cytokeratin was negative (Fig. 5). SYT/SS18 fluorescence in situ hybridization revealed no t(X;18)(p11.2;q11.2) translocation. Therefore, the pathologic diagnosis was LMS. LMSs are classified as cutaneous or subcutaneous depending on the primary site of origin. Cutaneous forms, which arise from the arrector pili muscles of the hair follicles or the dartos muscles of the genital skin, are associated with epidermal changes, such as ulceration, umbilication, and discoloration. Subcutaneous forms, which arise from the smooth muscle lining of arterioles and veins in the subcutaneous tissue, are not associated with surface changes and usually grow relatively fast [2]. Differentiation into one of these two subtypes is not always straightforward because the local growth of tumors of either type may involve invasion of the dermal and subdermal layers. However, differentiating between cutaneous and subcutaneous LMSs is important because they have different prognoses. Cutaneous LMSs have a local recurrence rate of 14%-50%, but the potential for distant metastasis is very low. In contrast, subcutaneous LMSs recur locally in 40%-60% of cases and metastasize in 20%-60% of cases [2]. The present case was determined to belong to the subcutaneous type. Clinically, the tumor did not protrude out of the skin, and no epidermal changes such as ulceration were observed. This is significant because it is difficult to identify and diagnose subcutaneous-type tumors if there are symptoms indicative of a cutaneous type. LMS is extremely rare in patients below the age of 15 years. A literature search revealed a single study by Bernstein and Roenigk [4], who reported two pediatric patients with LMS localized on the shoulder or the scalp. There is no report of LMS of the lower jaw in a pediatric patient. Although a 30-mm solitary mass with increased contrast was found on computed tomography at the time of the initial hospital admission, the correct diagnosis was delayed due to the lack of knowledge on LMS. Pain is the most common symptom of LMS, occurring in 80%-95% of patients. Pruritus, burning, and bleeding are also common [2]. In our patient, no such symptoms were observed before the histological diagnosis was established, and no physical trauma was detected. Histologically, superficial cutaneous LMSs are characterized by poorly circumscribed fascicles of spindle-shaped cells in the dermis. The tumor is highly cellular, with elongated, blunt-tipped nuclei. LMSs are characterized by co-expression of vimentin, desmin, and muscle-specific actin [2]. The recommended treatment for superficial LMS is wide local excision with a 20- to 50-mm lateral margin [5]. Routine lymphadenectomy is not indicated unless the lymph node disease is evident. There is no evidence to support the use of chemotherapy in the treatment of these tumors [1,2]. Here, we report a case of a 30-mm LMS that developed on the jaw of a pediatric patient. As this is an extremely rare facial tumor, it is difficult to diagnose in the absence of obvious symptoms. It is particularly important to differentiate a tumor of the subcutaneous type, which is not manifested by changes on the surface of the skin such as protrusion or ulceration, from a hemangioma or lymphoma. An incorrect or delayed diagnosis may lead to increased tumor size, invasion to proximal tissues, or remote metastasis. Therefore, we need to consider the possibility of LMS during the diagnosis of a facial tumor in children. We hope that this study provides useful information for clinicians and researchers investigating the biological characteristics of superficial LMS.

Purpose The forced duction test (FDT) is important during the surgical treatment of ocular motility disturbance due to orbital wall fracture, but the lack of objective standards yields various test results based on individual examiners' subjective assessments. Methods Medial limbus abduction values of the affected eye were measured during preoperative and postoperative FDT, and the values were compared with those of the normal eye. Results More accurate results were obtained using the modification of the FDT in the surgical repair of medial orbital wall fracture with entrapments. Conclusions The modified FDT used here in medial orbital wall fracture with limited ocular motility can contribute to more effective and positive surgical outcomes by providing an objective reference point.

Due to the three-dimensional configuration of the auricle and cartilage, surgeons encounter significant challenges in the reconstruction of auricular defects in anterior regions such as the antihelix and triangular fossa. Local flaps, skin grafting, and wedge excision are currently used in these locations. Postauricular flaps are the most common of these techniques, due to their advantages that include low morbidity, a well-hidden scar, direct closure, and good color match to the ear skin [1]. However, the lack of underlying vasculature and perichondrium may lead to graft necrosis. Moreover, wedge excision cannot be performed in patients with defects of the antihelix or triangular fossa because such patients are vulnerable to severe ear deformities. We modified a flip-flop flap to reconstruct anterior defects of the ear across the antihelix and triangular fossa. Our technique is a one-stage, random-pattern island flap surgery, and allows a shorter operation time and reduced losses at the donor site, while still leading to satisfactory treatment outcomes. Here, we describe our technique and its outcome. This study was reviewed and approved by the ethics review board of the Inje University Health Center. A 70-year-old man visited us with a chief complaint of Bowen's disease in the right ear. The patient underwent excision of the tumor with adequate circumferential and deep margins, including the perichondrium. The defect, located throughout the antihelix and triangular fossa, was oval in shape and 2.0×1.8 cm in size, with exposed cartilage (Fig. 1). Fig. 1 The defect, located throughout the antihelix and triangular fossa, was oval in shape and 2.0×1.8 cm in size, with exposed cartilage. We decided to create a 30% overlap in the medial direction. Under local anesthesia, we performed preoperative marking for the skin island, based on the size of the anterior auricular defect, for which we intended a 30% overlap in the medial direction (Fig. 1). A cartilage window was then drawn at the center of the overlap between the marked area and the actual defect. Thus, we attempted to provide an entrance for skin flap placement (Fig. 2). Fig. 2 After creating a skin island, we removed a small, slender piece of cartilage to provide an entrance for the skin flap. After being drawn on the anterior auricular surface, the pattern was marked on the back and then redrawn. It was then redesigned by extending the top side by approximately 10 mm, in line with the sulcus axis, thus leaving the lower base intact. In other words, it was shaped into an elongated orb alongside the axis of the sulcus. We thus made it easier to reduce the tension in the central pedicle during rotation and to suture the donor site. We placed one third of the skin island over the mastoid area and the remaining two thirds of the skin island over the postauricular surface. After excising the designated area, we elevated the skin flap while preserving the central subcutaneous pedicle. Once the flap was observed to be sufficiently elevated, we rotated it at an angle of 120° around the long axis through the cartilage window (Fig. 3). The flap was closed using interrupted prolene 6-0 sutures, and the postauricular donor site was closed using continuous vicryl 5-0 and prolene 5-0 sutures. Fig. 3 Schematic diagram. (A) Schematic illustration of a conventional flip-flop flap. There is an exact match in surgical design between the anterior defect site and the posterior donor site. The lateral side (**) of the donor site exits anteriorly through ... The donor site was easily closed through direct repair, without other procedures. No differences were observed in the color and thickness of the skin between the flap and the anterior auricle. Moreover, the patient did not develop postoperative infections or flap loss. Furthermore, at a follow-up, the patient had no ear asymmetry or other complications, such as notable scarring (Fig. 4). Fig. 4 Five-month postoperative follow-up views. (A, B) Anterior and posterior aspects of the ear. In 1972, Masson [2] first reconstructed anterior auricular defects using subcutaneous pedicle postauricular flaps. These flaps have also been referred to as revolving or flip-flop flaps, or as posterior auricular rotation flaps, and they have been reported to be appropriate for reconstructing defects on the scapha, triangular fossa, antihelix, and conchal bowl. The advantages of this technique include the availability of well-vascularized skin for the coverage of large auricular defects and a one-stage operative procedure [3]. Since first being introduced, Masson's flap has been used by many surgeons. Due to the short length and immobilization of the subcutaneous pedicle, however, it has limitations in lowering the ear projection and the depth of the sulcus. In order to increase flap mobility, some authors have described postauricular axial pattern flaps, in which the posterior auricular artery or the superior auricular artery is used as a pedicle [4]. However, these flaps are disadvantageous in that they require careful dissection and may result in morbidity. Therefore, because they are not used frequently, other researchers have developed a de-epithelialized postauricular flap; its advantages include higher safety and mobility compared to the subcutaneous pedicle flap and lower morbidity than the axial flap. Nonetheless, it is problematic that additional procedures are required for de-epithelialization, and ear deformities may occur as a result of the increased area of the postauricular donor site. Our technique can be summarized as follows. First, we approached the postauricular donor site proximally to the sulcus in the medial direction rather than in same region as the defect. Thus, we were able to obtain a sufficient amount of postauricular skin, even in patients with defects of the outer edge of the ear, such as the antihelix or scapha. Second, we rotated the postauricular skin island at an angle of 120°, unlike conventional methods in which it is rotated at an angle of 180° through the cartilage [5]. This is useful when there is no parallel relationship between the axis of the largest defects and that of the sulcus or when the angle is approximately 90°. Aligning the maximum width of the defect to the postauricular sulcus axis, which has sufficient space, reduced the size of the defect in the donor region while simultaneously allowing a safe blood supply. Third, we did not create the cartilage window at the center of the flap island, but instead made it as small as possible in the overlapping region between the defect and the donor site. Thus, we increased the stability of the skin flap by preventing the pedicle from being entangled. We modified a postauricular island flap to reconstruct defects across the antihelix and triangular fossa. Our technique was useful not only in maintaining the contour and three-dimensional structure of the auricle, but also in shortening the operation time and recovery period.

Background We conducted this study to identify the correlation between the time to surgery and that to recovery from postoperative diplopia. Methods In the current single-center, retrospective study, we enrolled a total of 11 patients (n=11) who were diagnosed with white-eyed blowout fracture and underwent surgical operation at our institution between January 2009 and January 2013. To identify the correlation between the time to surgery and that to recovery from postoperative diplopia, we divided our patients into the three groups: the group A (time to surgery, Results In our series, mean age at the onset of trauma was nine years (range, 5-16 years); the mean time to surgery was 30 days (range, 2-60 days); and the mean follow-up period was one year (range, 6 months-2 years). Our results showed that the time to recovery was shorter in the patients with a shorter time to surgery. Conclusions We found that the degree of recovery from impaired ocular motility and diplopia was the highest in the patients undergoing surgical operations within 48 hours of the onset of trauma with the reconstruction of the fracture sites using implant materials.

Background Recently, the number of thyroid surgery cases has been increasing; consequently, the number of patients who visit plastic surgery departments with a chief complaint of swallowing deformity has also increased. We performed a scar correction technique on post-thyroidectomy swallowing deformity via platysma flap with Z-plasty and obtained satisfactory aesthetic and functional outcomes. Methods The authors performed operations upon 18 patients who presented a definitive retraction on the swallowing mechanism as an objective sign of swallowing deformity, or throat or neck discomfort on swallowing mechanism such as sensation of throat traction as a subjective sign after thyoridectomy from January 2009 till June 2012. The scar tissue that adhered to the subcutaneous tissue layer was completely excised. A platysma flap as mobile interference was applied to remove the continuity of the scar adhesion, and additionally, Z-plasty for prevention of midline platysma banding was performed. Results The follow-up results of the 18 patients indicated that the definitive retraction on the swallowing mechanism was completely removed. Throat or neck discomfort on the swallowing mechanism such as sensation of throat traction also was alleviated in all 18 patients. When preoperative and postoperative Vancouver scar scales were compared to each other, the scale had decreased significantly after surgery (P Conclusions Our simple surgical method involved the formation of a platysma flap with Z-plasty as mobile interference for the correction of post-thyroidectomy swallowing deformity. This method resulted in aesthetically and functionally satisfying outcomes.

Background The purpose of this study is to analyze the current attitudes toward professionalism, the core values, and the type of professionalism among plastic surgeons in Korea to establish a code of ethics regarding the role of professionalism for plastic and reconstructive surgeons. Methods From March 9, to July 1, 2012, face-to-face and mail surveys were conducted targeting the 325 participants (256 specialists and 69 residents) who are registered members of the Korean Society of Plastic and Reconstructive Surgeons. The proportion of each response given to an item was obtained through statistical processing through frequency analysis. The Mann-Whitney U test was used to compare the differences in the responses between the resident group and the specialist group. Results The survey results on the perception of professionalism in plastic surgery showed that a high proportion (90.5%) of the respondents viewed the future of plastic surgeons as bright. Through evaluation of the importance of the value items,"professional dominance" (4.58 pts), "autonomy" (4.45 pts), "lifestyle" (4.34 pts), and "commercialism" (4.31 pts) were assessed as critical values. "Altruism" (3.84 pts), "interpersonal competence" (3.79 pts), and "social justice" (3.61 pts) were viewed as lesser values. This difference showed the characteristics of an entrepreneurial outlook. Conclusions Plastic surgeons should pursue excellence, humanism, accountability, and altruism in order to overcome the crisis of professionalism in plastic surgery. In order to develop the necessary competencies of professionals, vocational education should be arranged by the Korean Society of Plastic Surgeons, and an appropriate code of ethics should be established.

Background If a chronically infected abdominal wound develops, complications such as peritonitis and an abdominal wall defect could occur. This could prolong the patient's hospital stay and increase the possibility of re-operation or another infection as well. For this reason, a solution for infection control is necessary. In this study, surgery using a rectus abdominis muscle myofascial splitting flap was performed on an abdominal wall defect. Methods From 2009 to 2012, 5 patients who underwent surgery due to ovarian rupture, cesarean section, or uterine myoma were chosen. In each case, during the first week after operation, the wound showed signs of infection. Surgery was chosen because the wounds did not resolve with dressing. Debridement was performed along the previous operation wound and dissection of the skin was performed to separate the skin and subcutaneous tissue from the attenuated rectus muscle and Scarpa's fascial layers. Once the anterior rectus sheath and muscle were adequately mobilized, the fascia and muscle flap were advanced medially so that the skin defect could be covered for reconstruction. Results Upon 3-week follow-up after a rectus abdominis myofascial splitting flap operation, no major complication occurred. In addition, all of the patients showed satisfaction in terms of function and esthetics at 3 to 6 months post-surgery. Conclusions Using a rectus abdominis myofascial splitting flap has many esthetic and functional benefits over previous methods of abdominal defect treatment, and notably, it enabled infection control by reconstruction using muscle.

Stafne bone cavity is a rare mandibular defect that was first reported by Edward C. Stafne in 1942. It commonly presents with a well-demarcated, asymptomatic, unilateral radiolucency that indicates lingual invagination of the cortical bone. A 52-year-old female patient who with nasal bone fracture, visited the hospital. During facial bone computed tomography (CT) for facial area evaluation, a well-shaped cystic lesion was accidentally detected on the right side of the mandible. Compared to the left side, no swelling or deformity was observed in the right side of the oral lesion, and no signs of deformity caused by mucosal inflammation. 3D CT scans, and mandible series x-rays were performed, which showed a well-ossified radiolucent oval lesion. Axial CT image revealed a cortical defect containing soft tissue lesion, which has similar density as the submandibular gland on the lingual surface of the mandible. The fact that Stafne cavity is completely surrounded by the bone is the evidence to support the hypothesis that embryonic salivary gland is entrapped by the bone. In most cases, Stafne bone cavity does not require surgical treatment. We believe that the mechanical pressure from the salivary gland could have caused the defect.

PURPOSE Frontal sinus fracture management remains controversial and involves preserving function whenever possible or obliterating the sinus and duct as required by the fracture pattern. The purpose of this study was to introduce the simple and effective method in the surgical treatment of the anterior wall of frontal sinus fractures. METHODS All 11 patients who presented with anterior wall fractures of the frontal sinus between 2009 and 2013 were included in this study. Two 7-mm stab incisions were made on each side of the fracture, a titanium screw with an attached wire was fixed to the fractured fragment, and an elevator was used to apply force in the opposite vector. One titanium screw was also fixed to the firm normal frontal bone, and the reduction was conducted by observing the C-arm until the fractured fragment reached the height of the normal side. RESULTS No patients showed any recurrent displacement or infection during the follow-up period, nor did any patient complain of or demonstrate forehead paresthesia. The surgical scar was less than 3 cm in all 11 patients, and all of them reported satisfaction with the results. CONCLUSION We obtained the results of an open reduction while using a less invasive method in the surgical treatment of the anterior wall of frontal sinus fractures.

There are 2 predominant mechanisms that are used to explain the pathogenesis of orbital blowout fracture; these include hydraulic and buckling mechanisms. Still, however, its pathophysiology remains uncertain. To date, studies in this series have been conducted using dry skulls, cadavers, or animals. But few clinical studies have been conducted to examine whether the hydraulic mechanism is involved in the occurrence of pure orbital blowout fracture. The authors experienced a case of a 52-year-old man who had a pure medial blowout fracture after sustaining an eye injury because of a high-pressure air gun. Our case suggests that surgeons should be aware of the possibility that the hydraulic mechanism might be involved in the blowout fracture in patients presenting with complications, such as limitation of eye movement, diplopia, and enophthalmos.

Although the bone-shaving procedure is the optimal alternative treatment of craniofacial fibrous dysplasia affecting the maxilla and zygoma, it is difficult to determine the appropriate amount of bone to be removed. The authors therefore developed a novel method for bone shaving using three-dimensional printing technology on computed tomography (CT) scans and screws as a guide. In our method, we implanted screws of predetermined lengths into surgical sites and then performed a burring within the visual field. By using screws, the exact amount of bone could be removed, as determined preoperatively. Thus, the operation time was shorted and the method was less effort intensive. Moreover, this procedure had reduced risk of radiation exposure owing to frequent use of CT, and had a low cost. This simple new method is more precise and effective, and shows satisfactory cosmetic outcomes than those with current bone-shaving practices.

BACKGROUND Acute auriculocephalic angle refers to an ear with helix that is spaced closely to the cranium. An increasing number of patients with acute auriculocephalic angle wish to undergo corrective operation for aesthetic purposes. However, there is a paucity of data regarding acute auriculocephalic angle. This paper proposes a treatment protocol for patients with acute auriculocephalic angle. METHODS We performed a retrospective analysis of patients undergoing acute auriculocephalic angle (4 patients, 6 ears). Patient records were reviewed for demographic data as well as auricular measurements at preoperative, immediate postoperative and final follow-up evaluations. RESULTS All of the patients were men with a mean age of 36.5 years (range, 23-52 years). The mean follow-up period was 47.5 months (range, 28-60 months). Postoperative auriculocephalic angle was close to the normal auriculocephalic angle (25°-30°) without notable scars. Moreover, the patients had minimal contractions of the skin flaps without any hematoma or relapse. CONCLUSION We propose the following three treatment protocols for patients with acute auriculocephalic angle: the posterior auricular muscle should be sufficiently released, the mastoid area should be augmented using implants, the skin should be repositioned with a superior auricular flap.

Hemangiopericytoma is rare in occurrence worldwide, including Korea. It was initially described by Stout and Murrary [1] in 1942. It is derived from a type of smooth muscle cell attached to pericytoma, capillaries also known as Zimmerman pericytes, and it is characterized by a "staghorn" shape on microscopic findings, in other words, a tumor with a diffuse pattern of branching, and dilated, thin-walled blood vessels surrounded by short spindle cells. Hemangiopericytoma has the very unusual characteristic of growing slowly, mainly in the lower extremities and pelvic retroperitoneum, but it can also be found in any part of the body such as the head and neck [1,2]. We introduce here a case of hemangiopericytoma found in the nasolabial fold because it rarely occurs in that area. Hemangiopericytomas in the head and neck are uncommon, but have been found in the neck, orbit, nasal cavity, parapharyngeal area, or tongue. A 57-year-old male with no specific underlying disease was admitted to our hospital due to an increasing mass in the nasolabial fold as the chief complaint. The mass had been growing in size for 1 year. The mass was painless, non-fixed, movable, and round in shape. The mass grew in size until the nasolabial fold was more pronounced than the opposite side. The skin and buccal mucosa area around the mass were intact, and there was no drainage (Fig. 1). The computed tomography and magnetic resonance imagining findings showed a well-defined, solid mass with isoattenuation and heterogeneous enhancement in the premaxillary area (2.4×3.4×3.5 cm3) (Fig. 2). Fig. 1 Preoperative photograph shows a mass near the right nasolabial fold. Fig. 2 T1-weighted magnetic resonance imagining findings show a solid mass enhanced in the premaxillary area (2.4×3.4×3.5 cm3). The operation was carried out under general anesthesia. The mass was large and considered to be a hemangioma or any other benign mass. However, the possibility of malignancy was not completely ruled out, and the incision was made through the nasolabial fold for minimal scarring. An approximately 5 cm incision was made along the right nasolabial fold, undermining the muscle layer. Complete excision of the mass was performed, and the mass was slightly irregular in shape and encapsulated, and was not attached to the surrounding tissues (Fig. 3). Fig. 3 Photograph of an extracted specimen after complete excision. Microscopically, the tumor was composed of variably sized ectatic vessels showing a staghorn configuration and surrounding closely packed spindle or ovoid cells (Fig. 4). The tumor cells showed a small amount of pale cytoplasm and mild nuclear atypia, but had a low mitotic rate (less than 1 mitosis in 10 high power fields [HPF]). The tumor cells were diffusely positive in CD34 and CD99 immunostains (Fig. 5). There was no evidence of a tumor in the surgical margin. Postoperative chemotherapy and radiotherapy were not performed. Fig. 4 Tumor composed of ectatic, staghorn-shaped vessels and closely packed tumor cells, showing short spindle to round cells with a small amount of pale cytoplasm (H&E, ×200). Fig. 5 The tumor cells are positive for CD34 based on the immunostain (×100). The patient did not mention any particular complaints for 3 months after surgery. There were no obvious facial changes or an awkward appearance when talking or showing emotions. The affected nasolabial fold had no significant difference from the opposite side. It seems that the dermal elasticity and subcutaneous adipose layer, which define the shape of the nasolabial fold, were not affected by the operation or the mass. Hemangiopericytoma is characterized as a slow growing painless mass. When it occurs in the head and neck, patients are admitted to the hospital with symptoms caused by the mass physically affecting the surrounding tissues. The tumor is composed of spindle or round CD34 positive cells surrounding staghornshaped vessels. However, these features are overlapped with a solitary fibrous tumor; nevertheless, a solitary fibrous tumor has more prominent collagen, less prominent vessels, and less cellular pattern than a hemangiopericytoma. The clinical features of both tumors are also similar. Recently both types of tumors are considered to be the same entity with the two ends of one process. Hemangiopericytoma has a varied spectrum of biological behavior: benign to malignant. The prediction of the clinical behavior of hemangiopericytomas is not clear. Generally, a large size (>5 cm), increased mitotic rate (>4 mitosis/10 HPF) with the presence of atypical mitosis, high cellularity, pleomorphic tumor cells, and foci of hemorrhage and necrosis predict a highly malignant course [3,4]. The main treatment of hemangiopericytoma is complete surgical excision. Preoperative embolization can be helpful for decreasing the size of the mass. Radiotherapy, chemotherapy, or a combination of both can effectively improve the survival rates when the mass is inoperable or cannot be completely removed, or metastasis occurs. Hemangiopericytoma has a varied spectrum of biological behavior: benign to malignant. Multiple articles have shown non-eventful life-long results after complete excision of hemangiopericytomas; however, it is better to consider a hemangiopericytoma to be malignant throughout a patient's lifespan because the tumor has the possibility of metastasis or recurrence. Therefore, long-term follow-up seems to be essential [4].

Squamoid eccrine ductal carcinoma (SEDC) is an exceedingly rare tumor that shows both squamous differentiation and adnexal ductal differentiation. As our review of the literature revealed, only a total of 7 cases were reported to date. We report an additional case of SEDC occurring on the scalp of a 53-year-old man. Despite complete excision by conventional technique with clear margin, the lesion recurred within a 3-month period, with regional lymph node metastasis. The tumor was completely removed, and the large scalp defect was reconstructed by using scalp rotation flap. We present a case of recurrent SEDC on the scalp, and we surgically resected this tumor. In addition, the large scalp defect was reconstructed successfully with scalp flap, and no recurrence has been observed in the patient's postoperative follow-ups.

We report a case of a 23-year-old man with cerebral infarction and permanent visual loss after injection of a hyaluronic acid gel filler for augmentation rhinoplasty. The patient was admitted to the hospital with complaints of loss of vision in the right eye, facial paralysis on the right side, and paralysis of the left limbs with severe pain during augmentation rhinoplasty with filler injection. Brain magnetic resonance imaging and computed tomography showed ophthalmic artery obstruction and right middle cerebral artery infarction. Acute thrombolysis was performed to treat the infarction; however, the patient's condition did not improve. Intracerebral hemorrhage in the right temporal/frontal/occipital/parietal lobe, subarachnoid hemorrhage, and midline shifting were observed on brain computed tomography after 24 hours after thrombolysis. Emergency decompressive craniectomy was performed. After the surgery, the patient continued to experience drowsiness, with no improvement in visual loss and motor weakness. Three months later, he could walk with cane. This case indicates that surgeons who administer filler injections should be familiar with the possibility of accidental intravascular injection and should explain the adverse effects of fillers to patients before surgery.

The authors present a new standardized type of gearless traction machine drive system with a PM motor for high-speed elevators. Some control functions which are indispensable for improving the performance of elevator systems have been addressed. Stringent evaluation, environment and life tests ensure that the presented system is not only high-performance but long-lasting and more reliable.

Aesthetic nasal augmentation has increased in popularity among Asian populations, and nasal bone fracture is the most common type of facial bone fracture. In Asia, the frequency of nasal bone fractures is also increasing among patients who have undergone silicone augmentation rhinoplasty. The increasing prevalence of this injury presents a challenge to the surgeon. Thirty-six patients who had previously undergone augmentation rhinoplasty with silicone implant presented with nasal bone fracture from June 2007 through December 2011. The patients were grouped into three categories: patients with fractures in the high level (type I), patients with fractures in the low level (type II), and patients with fractures throughout the entire nasal bone, from base to top (type III). The largest group comprised patients with type I fractures (n = 24, 67%), followed by type II (n = 4, 11%), and Type III (n = 8, 22%) fractures. Symptoms and surgical outcomes for nasal bone fractures may be different in patients with silicone implants. A novel classification system for nasal bone fractures is required, as is a new approach to diagnosis and treatment.

We present the rare case of a violence-related accident involving a periorbital foreign body and surgical treatment. A 43-year-old man was brought to the hospital with a foreign body lodged in his left eyelid. A ballpoint pen penetrated the upper lid and orbital floor and reached the maxillary sinus.The spring of the ballpoint pen was observed in the radiograph, but the other parts of the ballpoint pen were not seen.The ballpoint pen was retrieved along the path of insertion. The fractured part of the orbital floor was slightly enlarged with a drill to allow visual access during surgery. Plastic pieces and the spring of the pen were removed under endoscopy inside the maxillary sinus. The inferior orbital wall was successfully reconstructed and there were no postoperative complications.The unique features of this case include the nature of the foreign body and its trajectory; removal was particularly challenging because the foreign body was not clearly visible in the radiograph.

Purpose Transvenous embolization has become the treatment of choice for carotid cavernous sinus fistula (CCSF). We report a case of coil embolization of CCSF using a superior ophthalmic vein (SOV) approach. Methods We have used the SOV approach on 5 patients with dural arteriovenous fistulas involving the cavernous sinus. Diagnostic facial contrast-enhanced computed tomography, brain magnetic resonance imaging, and contrast angiography and cerebral angiography revealed a CCSF. Fistula occlusion using an external SOV approach of CCSF was performed. Results Angiography performed on both sides demonstrated complete occlusion of the fistula. We had good result with coil embolization via SOV approach. We have a 100% success rate with no major complication. Conclusions The coil embolization via SOV approach is a safe and effective treatment. The SOV can be channeled by allowing the insertion of detachable coils in the fistula. We suggest that there is need to training plastic surgeon to be experienced.

Purpose Closed reduction is commonly used for the treatment of nasal bone fractures. If the fracture is impacted, accurate reduction is difficult. Therefore open reduction is often required. Materials and Methods Between January 2010 and December 2011, we used a Kirschner wire and a C-arm intraoperatively for accurate closed reduction of impacted nasal bone fractures. Results During the follow-up period of 4 weeks to 6 months, all patients had satisfactory cosmetic results. Conclusions The effectiveness of open reduction was obtained without noticeable scarring with our method of closed reduction using a Kirschner wire and a C-arm.

The authors performed aesthetic correction of hypertrophic frontal sinus in 3 patients with protruded supraorbital region by using beveled osteotomy. Under general anesthesia, a bicoronal incision was performed followed by dissection through the subgaleal plane to the supraorbital ridge. Subsequently, the anterior wall of the frontal sinus was sectioned with a reciprocating saw and an osteotome by using the beveled osteotomy technique. Beveled osteotomy is a technique applied during sectioning of the anterior wall of the frontal sinus whereby the upper portion of the sinus remains intact and the lower portion of the sinus is changed. The technique used by the authors differed from the conventional method in that the existing shape of the outer wall of the frontal sinus was preserved when osteotomy was performed. This technique therefore preserves a more natural contour of the forehead and is advantageous in that it does not require additional interventions.

Copyright © 2012 The Korean Cleft Palate-Craniofacial Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.kcpca.or.kr ISSN 2287-1152 57 청소년기에 발견된 상구순 누공의 치험례

143 Copyright © 2012 The Korean Cleft Palate-Craniofacial Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.e-acfs.org pISSN 2287-1152 eISSN 2287-5603 변형된 정중옆 이마피판을 이용한 코끝 재건례