Marked Ptosis Research Articles

Comparison of the recovery time of remimazolam besylate and propofol for gastrointestinal endoscopy sedation in elderly patients.

Background: Recovery time is a crucial factor in ensuring the safety and effectiveness of both patients and endoscopy centers. Propofol is often preferred due to its fast onset and minimal side effects. Remimazolam is a new intravenous sedative agent, characterized by its rapid onset of action, quick recovery and organ-independent metabolism. Importantly, its effect can be specifically antagonized by flumazenil. The primary goal of this study is to compare the recovery time of remimazolam besylate and propofol anesthesia during endoscopic procedures in elderly patients. Methods: 60 patients aged 65-95 years who underwent gastrointestinal endoscopy were randomly and equally assigned to two groups: the remimazolam group (Group R) and the propofol group (Group P). The primary measure was the recovery time, defined as the time from discontinuing remimazolam or propofol until reaching an Observer's Assessment of Alertness and Sedation scale (OAA/S) score of 5 (responds readily to name spoken in normal tone). The time required to achieve an OAA/S score of 3 (responds after name spoken loudly or repeatedly along with glazed marked ptosis) was also recorded and compared. Results: The recovery time for Group R (2.6 ± 1.6 min) was significantly shorter than that for Group P (10.8 ± 3.0 min), with a 95% confidence interval (CI): 6.949-9.431 min, p <0.001. Similarly, the time to attain an OAA/S score of 3 was significantly less in Group R (1.6 ± 0.9 min) compared to Group P (9.6 ± 2.6 min), with a 95% CI: 6.930-8.957 min, p <0.001. Conclusion: Our study demonstrated that remimazolam anesthesia combined with flumazenil antagonism causes a shorter recovery time for elderly patients undergoing gastrointestinal endoscopy compared to propofol. Remimazolam followed by flumazenil antagonism provides a promising alternative to propofol for geriatric patients, particularly during gastrointestinal endoscopy.

Comparative Study between No Vertical Scar Reduction Mammoplasty and Subcutaneous Mastectomy with Free Nipple and Areola Grafting in Management of Post Bariatric Marked Breast Ptosis

Comparative Study between No Vertical Scar Reduction Mammoplasty and Subcutaneous Mastectomy with Free Nipple and Areola Grafting in Management of Post Bariatric Marked Breast Ptosis

An Algorithm for Correction of Mild Tuberous Breast Deformity in Augmentation Mammaplasty: Camouflage or Correct?

Tuberous breast deformity (TBD) is a common abnormality, particularly in patients presenting for breast augmentation. Failure to correct each regional abnormality, including the inframammary fold, lower pole deficiency, nipple-areola complex widening or herniation, or any degree of ptosis, will result in exaggeration of the deformity and a poor aesthetic outcome. To describe an algorithm, including novel techniques, to address each region of mild TBD in patients undergoing breast augmentation. This is a retrospective review and description of the senior author's (K.T.) techniques for correction of early-stage TBD from 2016 to 2021. One hundred forty-two patients underwent a stepwise approach to correct milder TBD features when undergoing breast augmentation. The authors propose a regional algorithm for management of TBD, to allow mostly single-stage correction, except in cases with marked ptosis, severe asymmetry, or marked macroareola.

Comparative Study between No Vertical Scar Reduction Mammoplasty and Subcutaneous Mastectomy with Free Nipple and Areola Grafting in Management of Post Bariatric Marked breast ptosis

Comparative Study between No Vertical Scar Reduction Mammoplasty and Subcutaneous Mastectomy with Free Nipple and Areola Grafting in Management of Post Bariatric Marked breast ptosis

Thiamine-responsive pyruvate dehydrogenase complex deficiency presenting as recurrent muscle weakness: Identification of a novel mutation (p.T111I) in the PDHA1 gene.

Thiamine-responsive pyruvate dehydrogenase complex deficiency presenting as recurrent muscle weakness: Identification of a novel mutation (p.T111I) in the PDHA1 gene.

Severe ophthalmic involvement in granulomatosis with polyangiitis resistant to cyclophosphamide

A 63-year-old female presented with acute right vision loss, optic disc edema, headache, and elevated inflammatory markers. She had positive cANCA and was diagnosed with granulomatosis with polyangiitis. She developed nodular scleritis (Fig. 1A) and evolved to right orbital apex syndrome with marked pain, diffuse ophthalmoplegia, and ptosis. Despite treatment with intravenous steroids and 3 doses of cyclophosphamide, her vision worsened to no light perception. Rituximab was started, and it stopped the disease progression. Unfortunately, the patient's vision remained unchanged with diffuse optic atrophy and scleromalacia. Enhancement of the sclera (Fig. 1B) and orbital apex (Fig. 1C, D) are demonstrated on T1-weighted magnetic resonance imaging with gadolinium enhancement.

Glabellar Rejuvenation in Forehead Lift: Reversed Periosteum or Dermal Fat Graft to Cover Pedicled Glabellar Flap.

Forehead aging is characterized by wrinkles, loss of skin elasticity, brow ptosis, and soft-tissue atrophy. For patients with prominent rhytids and marked brow ptosis, forehead lift is still the most effective treatment with a persisting result. In order to eliminate the glabellar wrinkles, forehead lift usually requires the removal of the corrugator supercilii muscle and procerus, which can lead to glabellar flattening or depression. Instead of muscle removal, the corrugator supercilii muscle, procerus, and the underlying galea were dissected as a pedicled glabellar flap. Then reversed periosteum or dermal fat graft was used to cover the glabellar flap to restore the glabellar volume. From January 2005 to November 2014, a total of 164 coronal and 42 trichophytic forehead lifts were performed. Reversed periosteum was used to cover the glabellar flap in 191 patients while dermal fat graft was applied in 15 patients with a follow-up period ranging from 6 months to 10 years. There was no irregularity or depression in the glabellar region in the group of reversed periosteal flap. The take of dermal fat graft placed over the glabellar flap was minimal. Complications from surgical procedures occurred in 2.91% of the patients. There was 1 asymmetry, 4 patients with higher than desired frontal hairline for implantation of autologous follicular units, and 1 patient with scar hyperplasia. There was no hematoma or nerve injury, no permanent numbness, and no alopecia. The techniques are simple and effective to eliminate the glabellar wrinkles and maintain or restore the glabellar volume.

Abstract P-506: INFANTILE BOTULISM IN SINGAPORE

Aims & Objectives: Infantile botulism is rare worldwide. We present the first case in Singapore. Methods A 9 month old developmentally normal and appropriately immunized boy was admitted to our hospital with a 3 day history of severe lethargy, poor suck and constipation. He was unable to sit without support or lift his head. Examination revealed generalized hypotonia, marked head lag, ptosis and drooling. There was symmetrical hypo-reflexia of all four limbs with minimal anti-gravity movements. He developed respiratory insufficiency from neuromuscular weakness on day 2 of hospitalisation. The following tests did not reveal a diagnosis; neuroimaging of brain, cerebrospinal fluid studies, electrolytes, thyroid function, muscle enzymes, metabolic and toxicology work up and antibody studies for myasthenia gravis. Stool studies were later confirmed positive for botulinum toxin A. He required non invasive ventilation, meticulous nursing care and chest physiotherapy in the intensive care unit. 50mg/kg of Botulinism Immune Globulin (BabyBIG®) procured from the Infant Botulism Treatment and Prevention Program California Department of Public Health was administered on day 16 of hospitalisation. Results Infantile botulism occurs when ingested spores of Clostridium botulinum germinate in the infant’s colon and release neurotoxins that prevent the release of acetylcholine at the synaptic cleft of motor neurons resulting in paralysis. Treatment is supportive but BabyBIG®, a human derived immunoglobulin against botulinum toxin has been shown to reduce length of hospital stay. Conclusions Botulism should be considered in any infant presenting with acute symmetrical flaccid paralysis and treated promptly with BabyBIG®.

An eleven year old boy with pain abdomen and early morning neuroparalytic syndrome

An 11 year old boy presented with pain abdomen and tenderness all over body when he got up from sleep early in the morning and subsequently had one vomiting after 30 min. He had no other significant past medical history. The child was shifted to nearby health facility where he was managed as a case of acute abdomen on the basis of suggestive history and clinical findings. Within 2 h after the onset of clinical features suggestive of acute abdomen the patient went on to develop marked ptosis and flaccid quadriplegia. The young boy underwent a sequence of clinical tests which were noncontributory. Based on the clinical picture, a differential diagnosis of hypokalemic paralysis, botulism, Miller Fischer syndrome and EMNS were considered. Through exclusion, the most probable diagnosis for the symptoms was elapid envenomation hence he was started on anti-snake venom (ASV) with working diagnosis of EMNS. Within 2 h, he began to show improvement. This recovery with ASV suggests the possibility of elapid envenomation.

Management of Rhinophyma

ABSTRACT Rhinophyma is a condition that can cause significant disfigurement as well as functional impairment of the nose. It results from hypertrophy and hyperplasia of the sebaceous glands and can be a manifestation of advanced staged rosacea. If left untreated, not only can it cause disfigurement, rhinophyma can also result in nasal airway obstruction by marked ptosis and collapse of the external nasal valve. Surgical excision is the definitive treatment as rhinophyma does not spontaneously regress. Though various surgical techniques are available for the treatment of rhinophyma, a specific technique using tumescent anesthesia, sharp dissection, and argon beam coagulation has been found to be most efficacious. This technique and its advantages are described. How to cite this article Lian TS, Thompson RW. Management of Rhinophyma. Int J Head Neck Surg 2016;7(3):188-191.

Idiopathic Orbital Myositis in a 9-Year-Old Girl: A Case Report.

Idiopathic Orbital Myositis in a 9-Year-Old Girl: A Case Report.

Reduction Mammaplasty in Patients with a Medialized Nipple-Areola Complex

Sir:FigureWhen using traditional skin and dermoglandular markings for a breast reduction, a medialized nipple-areola complex can contribute to excessively short vertical limbs and tension on the closure/pedicle. This increased tension can predispose to abnormal nipple transposition with poor projection, wound dehiscence, or nipple-areola complex necrosis and/or diminished sensation.1,2 We propose a novel approach to preoperative marking of the keyhole skin pattern and superomedial breast reduction pedicle to compensate for a medially based nipple-areola complex. After institutional review board approval, a retrospective review was performed on all consecutive patients who presented for reduction mammaplasty from January of 2003 through January of 2009. The meridians of the breasts are marked based on the point of greatest projection or ptosis of the breast. The anticipated position of the nipple is then marked 2 cm above the inframammary fold along the breast meridian. Patients are recognized to have a “medialized” nipple-areola complex if the transposed nipple-areola skin is completely off the breast meridian. If so, the medial vertical limb of the Wise reduction skin pattern is increased in centimeters using a 1:1 ratio based on the lateral margin of the nipple-areola complex and the breast meridian, up to a total vertical limb of 10 cm. Beyond this length, medial pole distortion is increased, and the patient may be better suited for an inferior dermoglandular breast reduction. At the time of closure, the pedicle is also given a small backcut along the horizontal limb. This allows the dermoglandular pedicle to rotate into position superiorly, and augments the T-junction closure by bolstering vascularized tissue. A total of 32 patients were noted to have a medialized nipple-areola complex and underwent this technique. Two (6 percent) minor complications were recorded at follow-up, including one seroma that resolved following aspiration in the office, and one superficial skin cellulitis that responded to oral antibiotics. Twenty-five patients (78 percent) rated their results as excellent, and seven patients (22 percent) rated their results as fair. No partial or complete nipple-areola loss was noted in any patient. No patients described their outcome/satisfaction as poor. This is the first report to address the anatomical issue of a medialized nipple-areola complex while using the Wise pattern skin incision and superomedial dermoglandular pedicle for reduction mammaplasty. We have used this technique on 32 consecutive patients and consider it a superior method of managing a medially based nipple-areola complex, by decreasing the tension introduced on the pedicle and final closure, and improving the pedicle arc of rotation. The most common complications following classic skin patterns are based on either increased tension or decreased vascularity at the T-junction closure, as demonstrated by incisional dehiscence, partial skin loss, and inframammary scarring.3,4 Also, in the setting of small reductions or a medialized nipple-areola complex, the pedicle may be difficult to rotate for proper inset. The short medial vertical limb unfortunately prevents this rotation and instead displaces tension across the pedicle base and the T-junction skin closure.2 By instead planning ahead for this problem by lengthening the medial limb of the reduction pattern, this problem can be easily obviated. This modification to the superomedial reduction mammaplasty allows for a tension-free transposition of the nipple-areola complex to an ideal position on the breast mound for aesthetically pleasing results. By increasing the length of the medial vertical limb of the pattern, a reduction on the tension of the nipple/pedicle and final suture line is created without added glandular resection (Fig. 1 and Table 1).Fig. 1: (Left) Preoperative views demonstrating marked breast ptosis with a medialized nipple-areola complex. (Right) Postoperative views with excellent breast mound projection and a centralization of the nipple-areola complex along the breast central meridian.Table 1: Patient Demographics and Operative MeasurementsMatthew L. Iorio, M.D. Matthew Endara, M.D. Ivica Ducic, M.D., Ph.D. Department of Plastic Surgery, Georgetown University Hospital, Washington, D.C. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Miller Fisher Syndrome Mimicking Ocular Myasthenia Gravis

PURPOSE.: Miller Fisher syndrome (MFS) is a rare immune-mediated neuropathy that commonly presents with diplopia after the acute onset of complete bilateral external ophthalmoplegia. Ophthalmoplegia is often accompanied by other neurological deficits such as ataxia and areflexia that characterize MFS. Although MFS is a clinical diagnosis, serological confirmation is possible by identifying the anti-GQ1b antibody found in most of the affected patients. We report a patient with MFS who presented with clinical signs suggestive of ocular myasthenia gravis but in whom the correct diagnosis was made on the basis of serological testing for the anti-GQ1b antibody. CASE REPORT.: An 81-year-old white man presented with an acute onset of diplopia after a mild gastrointestinal illness. Clinical examination revealed complete bilateral external ophthalmoplegia and left-sided ptosis. He developed more marked bilateral ptosis, left greater than right, with prolonged attempted upgaze. He was also noted to have a Cogan lid twitch. Same day evaluation by a neuro-ophthalmologist revealed mild left-sided facial and bilateral orbicularis oculi weakness. He had no limb ataxia but exhibited a slightly wide-based gait with difficulty walking heel-to-toe. A provisional diagnosis of ocular myasthenia gravis was made, and anticholinesterase inhibitor therapy was initiated. However, his symptoms did not improve, and serological testing was positive for the anti-GQ1b immunoglobulin G antibody, supporting a diagnosis of MFS. CONCLUSIONS.: Although the predominant ophthalmic feature of MFS is complete bilateral external ophthalmoplegia, it should be recognized that MFS has variable associations with lid and pupillary dysfunction. Such confounding neuro-ophthalmic features require a thorough history, neurological examination, neuroimaging, and serological testing for the anti-GQ1b antibody to arrive at a diagnosis of MFS.

The first reported case of human tick paralysis in Brazil: a new induction pattern by immature stages

Tick paralysis (TP) is a rare disease with rapid progression and potential fatal evolution. Immediately after the diagnosis, removal of all ticks from the body of the patient is mandatory. The present study reports for the first time a human case of the disease in Brazil. The patient had loss of muscle strength, decreased reflexes and marked palpebral ptosis. Six hours after removal of the last tick, the ptosis improved and on the following day, the patient had near total regression of the symptoms. This report emphasizes the possible presence of similar cases that should be promptly diagnosed and quickly treated. A new induction pattern for TP in humans associated with immature stages of ticks is also presented.

Mammaplasty: The “Super Flap” or the Superior Pedicle Extra Long Flap for Massive Breasts with Marked Ptosis or Gigantomastia

Very large breasts associated with ptosis frequently present a challenge to the plastic surgeon in choosing the ideal procedure to obtain a satisfactory result. A free nipple graft, which for many represents the best option in these conditions, has many disadvantages. The author's method of a superior pedicle flap allows for very long flaps, in some cases over 40 cm, and breast ptosis with the nipple at more than 55 cm from the suprasterna notch with preservation of the circulation to the nipple-areola complex. This procedure has been developed and modified from the French oblique method of Dufourmentel and Mouly converted to an inverted T, while the glandular resection is performed in a keel fashion behind the areola to house and give room for these very long flaps without undue compression on them and endangering the blood supply to the areola-nipple complex. The method is described in detail, the early and late results presented, and advantages and disadvantages discussed. It has stood the test of time as it has been used regularly for more than 20 years and has become our standard method. The method presented is especially suitable for very large breasts with ptosis; however, excellent results are also achieved for all other degrees of ptosis, with very little modification in the procedure needed to suit different breast sizes and shapes. Most of the time we obtain a pleasing and attractive breast. This method rarely resulted in complications and never required a blood transfusion.

Eyelid Mass Secondary to Injection of Calcium Hydroxylapatite Facial Filler

A 37-year-old woman presented with a 2-month history of fullness and ptosis of the left upper eyelid. Examination revealed a 6-cm x 2-cm mass in the left brow and upper eyelid, and a diffuse mass in the lower eyelid. Marked ptosis of the left upper eyelid and elevation of the left lower eyelid were noted. CT showed masses with a bone-like density in the left eyelid and periorbital soft tissue. A through history revealed that the patient had received calcium hydroxylapatite filler injection for nose augmentation 3 days prior to the development of the eyelid masses. The eyelid masses were excised and pathologically confirmed as calcium hydroxylapatite microspherules surrounded by collagen and histiocytes. Two months after surgery, the eyelid masses and ptosis of the left upper eyelid were completely resolved. To our knowledge, this is the first reported case of eyelid mass after injection of calcium hydroxylapatite facial filler for nose augmentation.

Delayed Presentation of Grease-Gun Injury to the Orbit

A 44-year-old man was examined for marked edema and ptosis of the right upper eyelid after grease from high-pressure hydraulic machinery penetrated his right orbit 20 days earlier. The diagnosis of residual grease in the injured orbit was confirmed by CT and MRI, and the clinical presentation. During orbital exploration, the grease was removed completely. Among the wide variety of orbital foreign bodies, grease is rarely reported. We present the sixth case of grease-gun injury to the orbit to be reported in the English language literature since 1964.

Algorithm for clinical evaluation and surgical treatment of gynaecomastia

Gynaecomastia can be classified on the basis of the main characterising factors, i.e. pathogenesis, histopathology and morphology. The morphological classifications of gynaecomastia currently made often use subjective parameters and qualifying adjectives. In this paper the authors propose a scheme for morphological classification of gynaecomastia which can serve as a guide for choosing the surgical technique, once the diagnosis of gynaecomastia as a benign pathology has been confirmed by preoperative examinations. A retrospective analysis was made of 121 cases of gynaecomastia operated on in the last 5 years. The extent of the clinical picture, the technique employed, the complications and the need to re-operate were observed and related. On the basis of this review the authors observed that when the nipple-areola complex is above the inframammary fold (grade I and grade II gynaecomastia), complete flattening of the thorax can be achieved by means of suction or ultrasound-assisted lipectomy and skin-sparing adenectomy. When the nipple-areola complex is at the same height as, or at most 1cm below the fold (grade III gynaecomastia), skin-sparing techniques are no longer sufficient to flatten the thorax, and it becomes necessary to remove the redundant skin by means of periareolar removal of epidermis. In cases of marked ptosis, when the nipple-areola complex is more than 1cm below the fold (grade IV gynaecomastia), reduction mastoplasty becomes necessary, with upper repositioning of the nipple-areola complex; in these cases central pedicle techniques make it possible to limit scarring in the periareolar areas. In the preoperative phase this simple classification may help in choosing the most suitable treatment, thus avoiding insufficient or invasive treatments and undesirable scars.

Occlusion Therapy of Unilateral Amblyopia with Botulinum Toxin Induced Ptosis

In order to evaluate the role of botulinum toxin induced ptosis as an occlusion method to treat unilateral deep strabismic amblyopia in two uncooperative children, we injected 0.2 ml of diluted botulinum toxin in the levator palpaebrae; low sedation was necessary in one of the two children. In both cases a marked ptosis was achieved, which lasted about four weeks and then gradually resolved completely. The visual acuity of the ablyopic eye increased in both children, making patching easy thereafter. One child developed amblyopia in the injected eye, which was handled successfully using part-time occlusion. No other side effects were noted. Whether this new method could be a simple, safe and effective alternative method of occlusion for the treatment of deep amblyopia in uncooperative children needs to be proven with a larger series of children.

386 PUBLICATION Re-irradiation and hyperthermia after macroscopic complete resection for locoregional recurrent breast cancer in previously irradiated area

Gynaecomastia can be classified on the basis of the main characterising factors, i.e. pathogenesis, histopathology and morphology. The morphological classifications of gynaecomastia currently made often use subjective parameters and qualifying adjectives. In this paper the authors propose a scheme for morphological classification of gynaecomastia which can serve as a guide for choosing the surgical technique, once the diagnosis of gynaecomastia as a benign pathology has been confirmed by preoperative examinations.A retrospective analysis was made of 121 cases of gynaecomastia operated on in the last 5 years. The extent of the clinical picture, the technique employed, the complications and the need to re-operate were observed and related.On the basis of this review the authors observed that when the nipple-areola complex is above the inframammary fold (grade I and grade II gynaecomastia), complete flattening of the thorax can be achieved by means of suction or ultrasound-assisted lipectomy and skin-sparing adenectomy. When the nipple-areola complex is at the same height as, or at most 1 cm below the fold (grade III gynaecomastia), skin-sparing techniques are no longer sufficient to flatten the thorax, and it becomes necessary to remove the redundant skin by means of periareolar removal of epidermis. In cases of marked ptosis, when the nipple-areola complex is more than 1 cm below the fold (grade IV gynaecomastia), reduction mastoplasty becomes necessary, with upper repositioning of the nipple-areola complex; in these cases central pedicle techniques make it possible to limit scarring in the periareolar areas.In the preoperative phase this simple classification may help in choosing the most suitable treatment, thus avoiding insufficient or invasive treatments and undesirable scars.