Medial Epicanthal Research Articles

Medial Epicanthoplasty with the Skin Re-Draping Technique: Technical Refinements for Predictable outcomes.

The epicanthus is a common feature of the Asian eyes. A prominent medial epicanthal fold gives the impression of a blunted affect and the procedure for its removal, the medial epicanthoplasty, is a very commonly requested by Asian patients. This may be performed as an isolated procedure or more commonly in combination with the upper blepharoplasty. Many conventional medial epicanthoplasty techniques are based on skin flaps transposition and excisions, usually variations of the V-Y, W or Z-plasties (1-4). While these have been variably successful at correcting the epicanthal fold, the common problem is significant scarring in the medial canthal and lower eyelid regions (5-8). This is particularly problematic in Asian patients with greater tendencies for hypertrophic scarring and scar hypo or hyper-pigmentation (9). Recently, the skin re-draping method, designed with incisions limited within the margins of the medial canthus and precise and targeted disruption of the underlying fibromuscular tissues, has emerged as the preferred surgical technique for many Asian surgeons because of its effectiveness and superior aesthetic outcomes(6, 10-12). This technique delivers the most inconspicuous incisions and is advantageous because it is effective in eliminating epicanthal folds of various severities. Precise execution of this technique is difficult, given the complex 3-dimensional anatomy of the epicanthus. This paper presents a detailed explanation of surgical concepts of the skin re-draping epicanthoplasty and provide a step-by-step guide to performing this procedure in a safe and effective manner.

Patient-specific factors for deformity after upper blepharoplasty in an Asian population.

The success of upper blepharoplasty depends on both surgeon experience and skill as well as patient factors. Therefore, we aimed to identify patient-specific characteristics that may contribute to poor prognoses by analyzing data derived from patients with various deformities after undergoing upper blepharoplasty. This study included 202 patients who underwent revision surgery for upper blepharoplasty. We explored relationships between types of deformities before revisions and relevant patient factors before initial surgery using statistical analyses. Age > 30 years, thick upper lid skin, medial epicanthus, and other patient factors were significantly associated with the deformities. Asymmetrical, disappeared, shallow, and low creases were the most prevalent deformities. For these four most prevalent deformities, the concordance indices and 95% confidence limits of the risk prediction models were 0.654 (0.575-0.734), 0.724 (0.637-0.810), 0.783 (0.702-0.863), and 0.750 (0.655-0.844), respectively. Among the four most prevalent prognostic deformities, significant patient factors included medial epicanthus, thick upper eyelid skin, weak levator palpebrae superioris, age > 30 y, and a short gap between eyes and brows. We also attempted to clarify the clinical importance of these patient factors. Our findings provide a guide and reference for future investigations into upper blepharoplasty.

A comparative retrospective analysis: myocutaneous flap versus skin flap in V-Y medial epicanthal fold reconstruction.

To evaluate the comparation of myocutaneous flap vs. skin flap in V-Y medial epicanthal fold reconstruction. The study, conducted from April 2017 to June 2022, involved two groups: group A, comprising 21 patients who underwent medial epicanthal fold restoration surgery using the V-Y advancement method with a skin flap, and group B, comprising 83 patients who underwent the same procedure, while with a myocutaneous flap for orbicularis oculi ring reconstruction. Intercanthal distances were measured preoperatively, recorded during preoperative and postoperative reviews, and assessed through a 4-point Likert satisfaction questionnaire. A total of 104 patients were followed up for 6 months postoperatively. In group A, preoperative intercanthal distances ranged from 28.7 mm to 38.2 mm, increasing to 30.2 mm-40.6 mm postoperatively, with a mean increase of 3.0 mm (P < 0.05). In group B, preoperative distances ranged from 28.8 mm to 38.0 mm, increasing to 32.2 mm-41.5 mm postoperatively, with a mean increase of 3.9 mm (P < 0.05). Group B exhibited a higher overall satisfaction rate compared to group A. The myocutaneous flap V-Y procedure, employing the principle of orbicularis oculi ring reconstruction, achieves more stable postoperative results than the flap-only V-Y procedure. Consequently, it can be regarded as the preferred surgical technique.

Medial Epicanthal Fold Correction Using a Y-W Epicanthoplasty in Asian Eyelids.

Many surgical techniques for managing epicanthal folds have been reported, but their main drawbacks include a noticeable scar in Asians, acute medial canthal angle, and applicability only in mild or moderate epicanthal folds. This study described a novel surgical technique, Y-W epicanthoplasty, and assessed the medial canthal shape and scarring in patients who underwent Y-W epicanthoplasty. Patients with moderate or severe epicanthal folds between January 2004 and February 2017 were included in this study. Pre- and postoperative intercanthal distance (ICD), inner canthal angle (ICA), and interpupillary distance (IPD) were measured. The ICD ratios (ICD/IPD) and extent of postoperative scarring were evaluated. A Y-W epicanthoplasty was performed on 18 patients. The ICD ratio of the total study cohort showed a significant reduction following surgery (preoperative ICD ratio=0.62±0.04, postoperative ICD ratio=0.58±0.03, P<0.001). The ICA was 51.8±7.7° and 49.8±5.6° in the pre- and postoperative periods, respectively (P=0.086) Eleven patients showed no apparent scar, and 6 patients were found to have minimal scarring that was visible only under close inspection. One patient had a hypertrophic scar that was successfully managed with triamcinolone acetonide injections. Y-W epicanthoplasty can provide good aesthetic results without a visible scar in patients with moderate-to-severe epicanthal folds. The Y-W epicanthoplasty avoids a medially extended skin incision and excessive tension on the skin flaps. Moreover, an acutely shaped or webbed medial canthus after epicanthoplasty can be prevented by adding a small triangular flap. The Y-W epicanthoplasty procedure is simple and straightforward, and it is appropriate for moderate-to-severe epicanthal fold correction.

Reoperation of epicanthal reconstruction using a modified reverse skin-redraping method.

With the increasing adoption of medial epicanthoplasty or reconstruction procedures, the number of patients undergoing reoperations is also increasing. However, the surgical techniques useful for reoperations and the potential difficulties during reoperations have not been adequately elucidated. We aimed to describe the use of our modified reverse skin-redraping technique to improve cosmetic outcomes in patients who had previously undergone epicanthal reconstruction. From January 2014 to January 2021, we performed reoperations using our modified reverse skin-redraping technique in patients who had previously undergone epicanthal reconstruction. The main reason for the reoperations was cosmesis. The patients' ages ranged from 21 to 46 years (average, 28.7 years), and the follow-up periods ranged from 6 to 12 months. A total of 389 patients (311 females and 78 males) underwent reoperations, of which 324 patients (83%) underwent 1 reconstructive surgery and 65 (17%) underwent reconstructive surgeries more than twice after primary epicanthoplasty. The postoperative intercanthal distances could be increased or decreased depending on the preoperative design. After reoperation, 22 patients (5.6%) required additional reoperation. Reoperation of epicanthoplasty is technically challenging. The scarred round shape of the medial epicanthus during the reoperation poses difficulties, and the optimal technique to be used remains unknown. We believe that selection of an individualized restoration method that suits the purpose of surgery is important for patients who require reoperations. In this respect, we suggest that our modified reverse skin-redraping method is a suitable option for improving esthetic outcomes.

A Novel Thunderbolt Z-Epicanthoplasty for Asians.

Although many epicanthoplasty techniques have been proposed, prominent hypertrophic scarring in the medial canthal region remains a problem. The aim of this study was to develop a novel design that has a less prominent scar with minimal tension. A total of 489 patients underwent thunderbolt Z-epicanthoplasty from July 2015 to April 2019, with or without blepharoplasty. A triangular myocutaneous flap was lifted from the upper part of the epicanthal fold. The surrounding area was dissected to remove the rigid connective tissue between the orbicularis muscle and the skin, which creates skin tension. A Z-shaped flap toward the inferomedial canthal portion was added to create space for the triangular flap to be transposed to change the straight incision into a curved zigzag incision (final scar in the shape of a "thunderbolt"), making the scar irregular and less conspicuous. Postoperatively, all patients were followed up for ≥ 12 months. Among the patients, epicanthus tarsalis (60.12%) and palpebralis (36.19%) were the commonest epicanthus types, followed by epicanthus supraciliaris (3.07%) and inversus (0.61%). The average preoperative intercanthal distance was 42.25 ± 1.66 mm. This distance decreased significantly to 37.14 ± 1.78 mm (average, 5.11 ± 0.21 mm; p = 0.036) at the 12-month postoperative follow-up. Mild cicatricial redness was observed in the medial canthal area in six patients (1.2%) during the early postoperative period. The redness diminished within 6 months postoperatively. All patients obtained natural and aesthetically pleasing results without prominent hypertrophic scarring or other complications in the medial canthal area. The thunderbolt Z-epicanthoplasty is safe and effective for treating medial epicanthal folds. It is potentially helpful in minimizing postoperative medial canthal scarring and can be applied to various types of epicanthal folds with long-lasting results. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . Non-Surgical Aesthetic IV.

Surgical Results and Patient Satisfaction After A New Surgical Technique for Asian Medial Epicanthoplasty: A Modified Skin Redraping Method Using a Horizontal Point Incision and Staged 'Y-Shaped' Dog Ear Correction.

The double eyelid operation is the most common cosmetic procedure conducted in Asians. However, the epicanthal fold presents a conundrum that limits the cosmetic results of double eyelid surgery. Despite not being a pathologic condition, numerous procedures have been developed and introduced to address this issue, but these techniques have potential disadvantages that include an unnatural ciliary position of the lower lids and prominent scarring. A total of 156 patients who underwent a double eyelid operation with medial epicanthoplasty using the modified skin redraping method using a horizontal point incision and staged dog ear correction between 2015 and 2019 at our medical center were enrolled in the study. A single senior plastic surgeon performed all surgical procedures. The Patient-Reported Outcome Measures (PROM) questionnaire was used to obtain objective satisfaction scores, and patient satisfaction scores were obtained using some criteria. Of 147 patients, 8 (0.05) complained of visible scarring at the medial epicanthal and upper fold line region; there were only 2 (0.01%) epicanthal fold recurrences and 1.36% wound-related complications. The PROM scores and patient satisfaction scores showed a strong positive linear correlation according to linear regression analysis (P < 0.001). We performed double eyelidplasty with epicanthoplasty by using "a modified skin redraping method using a horizontal point incision and a staged 'Y-shaped' dog ear correction." Few complications were encountered, and almost all patients were satisfied with their surgical outcome as determined by the PROM questionnaire.

Skin redraping for correction of lower eyelid epiblepharon combined with medial epicanthal fold: a retrospective analysis of 286 Asian children.

This study was performed to evaluate the clinical effect of skin redraping on lower eyelid epiblepharon accompanied by a medial epicanthal fold. This retrospective case series involved 572 eyes of 286 patients who underwent skin redraping surgery to treat lower eyelid epiblepharon accompanied by a medial epicanthal fold from January 2015 to May 2019. The postoperative surgical results were classified as "good", "fair" and "poor". The incision scars were assessed using the Vancouver scar scale. The patients' subjective satisfaction and incidence of complications were also documented. The mean patient age at the time of surgery was 6.9 ± 3.6 years (3-12 years), and the mean follow-up time was 32.6 ± 13.5 months (6-58 months). The clinical symptoms and severity of keratopathy were improved postoperatively. "Good" surgical outcomes were obtained in all patients, the mean Vancouver scar scale score was 1.1 ± 0.3, and hypertrophic scar formation did not occur. A total of 272 patients and their guardians were "very satisfied" with the cosmetic outcomes. Skin redraping was effective and endurable in the treatment of lower eyelid epiblepharon accompanied by a medial epicanthal fold. The postoperative scars were slight and nearly invisible, and no cases of recurrence were observed in this study.

Pituitary Stalk Interruption Syndrome: Baseline Characteristics and Long-Term Evolution of Two Pediatric Cases with Rare Presentation

Background and Aims&#x0D; Pituitary stalk interruption syndrome (PSIS) is characterized by the presence of a thin or absent pituitary stalk in association with a hypoplastic or aplastic anterior pituitary or an ectopic neurohypophysis [1,2]. The phenotype associated with PSIS has a high incidence of various combinations of hormonal deficiencies, sometimes associated with extra-pituitary birth defects [1]. The aim of our study is to illustrate the heterogeneity of PSIS through a complete description of the clinical, biological and imagistic differences between our cases.&#x0D; Case Reports&#x0D; We describe two rare pediatric cases. The first case was a 6-year-old boy admitted to our department with polyuro-polydipsic syndrome and underdeveloped external genitals. He had a history of neonatal micropenia and a family medical history of panhypopituitarism and midline malformations. Physical examination revealed normal stature (height: 117 cm, −0.4 SDS), obesity (BMI: 25.2 Kg/mp, over 97th percentile), micropenia (stretched penile length: 3 cm) and non-palpable testes. Initially, his urine output was 5000 mL/24 h, with a low urine specific gravity of 1005–1010, and no increase after water deprivation test, with an appropriate response after desmopresin administration. He presented normoglycemia. Serum gonadotropin (FSH, LH) and testosterone levels were low, with no response after GnRH-analogue stimulation test. IGF-1 levels were low-normal. His Copeptin value was decreased. Pituitary MRI showed anterior pituitary hypoplasia, absence of the pituitary stalk and neurohypophysis.&#x0D; The second case was a 4-year-old girl referred to our service for growth retardation. She had a history of neonatal prolonged jaundice and intermittent seizures, for which she was prescribed phenobarbital for 2 years. Her physical examination described short stature (height: 90.5 cm, −3.3 SD), underweight (BMI: 15.87 Kg/m2, 15–25th percentile), head dysmorphic features: medial epicanthal fold, depressed nasal bridge, anteverted nares, ogival palate. She had a bone age of 2 years. The initial evaluation diagnosed severe GH deficiency, and during the next 3 years of follow-up she developed ACTH, TSH and FSH-LH deficiencies. MRI examination indicated anterior pituitary hypoplasia, absence of pituitary stalk and ectopic neurohypophysis.&#x0D; Discussion&#x0D; Central diabetes insipidus is rarely reported in patients with PSIS (0–4%) [1,3]. Although GH deficiency was found almost ubiquitous in PSIS, our first patient had no growth retardation. Normal linear growth despite abnormal GH secretion was also reported [4]. Neonatal cholestasis was linked to ACTH deficiency, which can also be a cause of recurrent hyponatremia [1]. There were no signs of ACTH deficiency or hyponatremia in our second patient in the neonatal period. Few reports showed cases of PSIS that were diagnosed with acute epileptic seizures accompanied by hyponatremia [5]. The rapidly progressive evolution to combined pituitary deficiency observed in PSIS cases [4] with neonatal features was also recognized in our patients.&#x0D; Conclusions&#x0D; The phenotype associated with PSIS can be highly heterogeneous. It is important to increase the awareness of PSIS, especially in the neonatal period when the features of PSIS can be easily overlooked. We also emphasize the importance of patient follow-up as an essential part of an adequate management.

Intricacies of Upper Blepharoplasty in Asian Burden Lids.

Differences between Oriental and Caucasian eyelids have been explained in great detail in several reports in the past. The purpose of this article is to discuss the functional aspects of Asian double fold upper blepharoplasty and to present techniques that help to improve both the functional and cosmetic outcomes and satisfaction after surgery. The eyes of Asians are relatively small with thick skin in the eyelids and periorbital area. They typically lack the upper eyelid crease (creating the so-called double eyelid) due to burden factors like thick skin, hypertrophied orbicularis oculi muscle (OOM), submuscular fibroadipose tissue, thick orbital septum, abundant preaponeurotic fat, and lower positioned transverse ligament. Asian eyes may also have a superior visual field defect due to skin overriding the upper lid margin (skin-OOM-fat complex slide down). These burden factors result in the eyelashes appearing short and becoming misdirected and pressed toward the globe, causing functional discomfort. As a compensatory mechanism, Asian people tend to engage the frontalis muscle to lift the eyebrow to help them open their eyes. Along with aesthetic enhancement, double-eyelid surgery in Asian burden lids can improve the functional deficiencies helping the patients to open the eyes more easily. In addition, treatment of the Mongolian fold (medial epicanthal fold), caused by medial hypertrophy of preseptal OOM, augments the surgical results. In this report, we present the appropriate preoperative assessment, surgical technique, and postoperative care that should be employed to achieve consistently good functional and aesthetic outcomes in these patients.

Modified Infrabrow Excision Blepharoplasty for Severity of Medial Blepharochalasia.

Infrabrow excision blepharoplasty can be a satisfactory and useful alternative for patients with blepharochalasia. Sixty patients underwent modified infrabrow excision blepharoplasty from March 2017 to February 2018. The design of the skin excision was modified according to the severity of the medial blepharochalasia: (1) excision up to the medial limbus was performed if there was no medial blepharochalasia, (2) excision up to the medial epicanthus was performed if there was mild medial blepharochalasia, and (3) excision with triangular back cut was performed if there was moderate-to-severe medial blepharochalasia. The surgical method included (1) skin excision, (2) orbicularis oculi muscle excision, (3) orbicularis oculi muscle closure, and (4) skin closure. The mean postoperative follow-up period was 9 months, and the photographic results were collected retrospectively and evaluated. There were no complications related to surgery in terms of the resulting scar and dysesthesia. The mean operative time was 55 minutes. Patient satisfaction was very high in terms of both aesthetic outcome and comfort. Modified infrabrow excision blepharoplasty can be an easy and satisfactory alternative in a selected group of patients.

Dual-plane epicanthoplasty in Chinese blepharoplasty.

The ethnically characteristic upper eyelids of many Chinese individuals include medial epicanthal folds, substantial fatty tissue, a laxity of pretarsal skin, and a lack of superior palpebral folds. Different epicanthoplasty techniques have been described in the literature. However, postoperative medial canthal scarring remains a concern. This article introduces a novel technique that minimizes the risk of postoperative canthal scarring. Dual-plane epicanthoplasty involves an advanced skin flap and a rotation skin flap, which are, respectively, distributed on the outer skin lining and inner skin lining and belong to the different three-dimensional planes of the epicanthus. The dense connective fibers located between the skin and the orbicularis oculi muscle were completely released. In the final steps, the upper advanced triangle flap was anchored in the direction of the lacrimal caruncle and the lower rotation triangular flap was anchored to the nasal skin. From January 2016 to September 2018, 216 patients were enrolled in the cohort undergoing dual-plane epicanthoplasty, with 172 patients undergoing the concomitant double eyelidplasty. For 206 of the cases, follow-up lasted for over 6months, with a median time of 11months. Except for one patient (0.49%) who may need a revision procedure for a prominent scar, all other patients (99.51%) achieved natural and cosmetically desirable appearances with adequate lacrimal caruncle exposure and minimal postoperative medial canthal scaring. Dual-plane epicanthoplasty, with or without double eyelidplasty, is a novel and effective surgical technique modified for Chinese patients with good esthetic outcomes.

Reconstruction of medial epicanthal fold using v-y advancement and turnover flap

BackgroundSince the 1900s, many methods have been developed to correct the epicanthal fold. Increased use of epicanthoplasty has yielded unsatisfactory results. ObjectivesTo describe a method of epicanthal fold reconstruction using V-Y advancement and turnover flap for clinical application. This method is simpler than conventional surgery. It is easy to perform with excellent esthetic results. MethodsThe authors performed medial epicanthal fold reconstruction in 82 patients (16 males and 66 females) between April 2014 and September 2017. All patients enrolled in this retrospective study underwent surgical procedures at the authors’ institution. Interepicanthal distance was the distance between medial epicanthal folds. It was measured with a surgical ruler. ResultsBefore surgery, mean interepicanthal distance was 35.4 mm. Using our surgical technique, successful outcome was achieved in 79 (96.3%) patients with satisfactory results. The mean distance between the medial epicanthi post-surgery was 38.6 mm, increasing the total length by 3.2 mm without showing any major postsurgical complications. DiscussionEpicanthal fold reconstruction using V-Y advancement and turnover flap is a simple and effective technique that can readily improve the frontal view. It improves periorbital contouring, makes eyes look natural without fully showing the caruncle, and yields excellent esthetic results. In particular, there were no major visible scars following eversion suture.

Combined Transverse Incision and Pouch Incision for the Correction of Medial Epicanthus.

The epicanthal fold is a distinct characteristic of the upper eyelid in many Asians. To achieve satisfactory results, epicanthoplasty is usually performed with double eyelid plasty and blepharoptosis. Although many surgical procedures have been reported for the elimination of epicanthal folds, such as recurrence, copious designs, conspicuous scar, and unnatural palpebral contours are challenges to the surgeon and also make patients worried. From June 2010 to June 2015, epicanthoplasty was performed for 236 Chinese female patients using transverse incision combined with pouch incision. The transverse straight incision was performed in new inner canthus to the original eanthal corner point, after the original inner canthus corner point was reached, the oblique parallel incision was performed along the lower eyelid, so that full subcutaneous separation was obtained on the upper and lower incision, the malpositioned isomerous orbicular muscle and thickened tissue were released and excised, so that the epicanthus skin was naturally restored, and finally the incision was sutured without tension. The extent of postoperative scarring and improvement of the epicanthal fold were evaluated after surgery. The medial canthal distance was measured preoperatively and 12 months postoperatively. The average intercanthal distance decreased significantly from a mean of 41.68 ± 2.57 mm preoperatively to 37.14 ± 1.94 mm 12 months postoperatively (P < 0.05, paired t-test). And all patients were satisfied with the excellent aesthetic results in terms of an open medial canthus without definite recurrence, hypertrophic scarring, and other complications during the 12-month follow-up period. Epicanthoplasty with transverse incision and pouch incision is a simple and effective method for elimination epicanthal folds, resulting in a pleasant visualization, inconspicuous scar. However, its long-term effects require further study.

Biomechanics of double eyelid and clinical application in mild blepharoptosis

Objective To investigate biomechanical properties of double eyelid surgery and its clinical application in upper blepharoplasty. Methods In the mild ptosis correction combined with double eyelid surgery, the main force from levator was assigned to upper tarsus to open eyes. At the same time, not only it could ensure the enough height of palpebral fissure, but also had relatively stable and persistent double eyelid. For those who had sunken upper eyelid, were given fat transposition and/or autologous fat grafting. For those who had medial epicanthal fold, to achieve a pleasing eye appearance, we performed epicanthoplasty. Results After 6 months to 2 years of follow-up, 15 cases had unsatisfactory results and underwent secondary surgery. The revision reason was as follows: 7 patients had asymmetry double eyelid width, 3 patients had insufficient correction for ptosis, 2 patients had shallower and narrower double eyelid line. In 3 cases, the correction of the upper sunken was insufficient. The remaining 164 patients with mild ptosis were well corrected, and the double eyelid was stable and natural, and the results were satisfactory. There were no major complications. Conclusions During mild blepharoptosis correction combined with double eyelid surgery, reasonable treatment of the biomechanical balance has certain clinical significance for avoiding postoperative complications and improving the effect of double eyelid surgery. Key words: Blepharoptosis; Blepharoplasty; Biomechanics; Balance; Eyelid fissure height

The Effective Fixation Level for Cosmetic Lateral Canthoplasty.

In previous reports of lateral canthoplasty, the components of the inferior retinaculum were mostly secured to the lateral orbital rim at a level around the pupil or superior limbus. However, that level is not adjustable in young patients who want to lengthen the short palpebral fissure for cosmetic purposes. Moreover, the anchoring method based on the palpebral portion can also be inconvenient and ineffective. Thus, the authors report an effective fixation level of the lateral orbital rim to lengthen and widen the lateral palpebral fissure. From June 2015 to August 2017, 202 women and 44 men underwent cosmetic lateral canthoplasty (mean age 28.4 ± 2.8 years old). The lower lid component of the lateral retinaculum was identified and selectively released through a small incision at the lateral commissure. Then, the released retinaculum was secured to the periosteum of the inner aspect of the lateral orbital wall. The fixation level corresponded to the most concave portion or immediately below the most concave point (1 to 2 mm below). Cosmetic lateral canthoplasty was successfully performed in all cases. No severe complications were observed. There were some minor complications. In most cases, the lateral palpebral fissure was naturally reshaped into a wider and brighter contour. Almost all of the patients were satisfied with the results of the treatment. The anchoring procedure at the most concave portion of the lateral orbital rim, which corresponds to the level of the inferior edge of the limbus or medial epicanthus, consistently resulted in a brighter and wider shape of the lateral palpebral fissure. Fixation based on the bony portion, compared to palpebral portion, offers several advantages as follows: effective lengthening and widening the lateral palpebral fissure; ease of application; symmetry with consistent final results; and minimal occurrences of overcorrection and undercorrection.

Intraoperative Ventriculostomy Using K Point in Surgical Management of Aneurysmal Subarachnoid Hemorrhage

Intraoperative ventriculostomy in the surgical management of aneurysmal subarachnoid hemorrhage (SAH) is frequently performed to reduce increased intracranial pressure. The previously suggested ventriculostomy points have some limitations because the dura mater must be opened to be accessed and it is difficult to measure the exact entry point in patients with brain edema. We propose a new intraoperative ventriculostomy point (Kpoint) for use in the surgical management of aneurysmal SAH patient with severe brain edema. We performed intraoperative ventriculostomy using the K point on 155 patients with aneurysmal SAH between January 2012 and August 2016. Before opening the dura mater following standard pterional craniotomy, we inserted the ventricular catheter through a small dural incision perpendicular to the middle frontal gyrus toward the ipsilateral medial epicanthus. We simulated the catheter trajectory using a commercial navigation system on 2 patients with brain tumor. Ventriculostomy related hemorrhage occurred in 12 patients (7.7%), but there were no large hemorrhages causing neurologic deterioration or requiring evacuation. No language impairment was observed in these patients. Analysis using the navigation system revealed that the trajectory of K point ventriculostomy avoided critical periventricular brain structures and passed through the space between the genu of the corpus callosum and head of the caudate nucleus. K point ventriculostomy allows for easy access to a target point and protects the brain during opening of the dura mater and drilling of the sphenoid bone.

Autologous Tissue Graft in Revision Medial Epicanthoplasty Using Subciliary Fat and Orbicularis Oculi Muscle.

The medial epicanthal fold is one of the racial anatomic characteristics of Asians. As medial epicanthoplasty has become one of the most common cosmetic surgeries among Asians, the need for revision of overcorrected medial epicanthus also increased. In revision medial epicanthoplasty, an autologous tissue graft to the subcutaneous plane is used to reduce postoperative scar. Medial epicanthoplasty, using V-Y advancement and rotation flap, was performed in 93 patients (revision medial epicanthoplasty with autologous tissue graft, 60 patients; revision medial epicanthoplasty only, 33 patients). A V-Y and rotation flap was designed to cover the overexposed lacrimal lake. A small amount of fat tissue and orbicularis oculi muscle were harvested from the upper eyelid through the double-fold line and grafted to the subcutaneous space of the medial epicanthal area. We evaluated the patients' satisfaction with the overall outcome and scar. The mean intercanthal distance increased from 32.3 mm before surgery to 34.6 mm after surgery. Satisfaction with the scar and overall outcome was higher in the patient group who underwent medial epicanthoplasty with autologous tissue graft. No complication was observed in the autologous tissue graft group, whereas 1 patient who underwent medial epicanthoplasty without autologous tissue graft showed recurrence of the medial epicanthal fold, 5 months after surgery. Medial epicanthoplasty with autologous tissue graft is a simple and reliable method to repair the overcorrected medial epicanthus that can efficiently increase the intercanthal distance and prevent scar contracture.

Ocular involvement in pemphigus vulgaris - a retrospective study of a large Spanish cohort.

Ocular/periocular involvement in pemphigus vulgaris (OPV) has rarely been reported. The objective of the present study was to investigate the pattern of OPV and define the prognostic value of its manifestation. From 1985 to 2014, a total of 167 patients with pemphigus vulgaris (PV) were treated at four tertiary Spanish hospitals. In this retrospective study, we included all patients with OPV. Clinical data and information on associated symptoms were obtained from patients' medical records. Only 24 (14.3%) of all PV patients had ocular lesions. In most cases, -ocular involvement was preceded by PV lesions at various other sites (mean duration: 33.7 months). Ocular PV lesions occurred during flares of mucocutaneous pemphigus, and was never the only mucosal manifestation. The most common clinical signs were conjunctival hyperemia (87.5%), erosions on the eyelids (41.6%) as well as of the palpebral/bulbar conjunctiva (33.3%) and at the medial epicanthus (20.8%). Themost relevant associated symptoms included local pain/stinging (71.4%), irritation (47.6%), photophobia (38.1%), and epiphora (23.9%). Ocular PV improved with systemic and adjuvant topical therapies. Only two patients experienced sequelae. In patients with PV, ocular involvement is an exception. Ocular PV is associated with greater disease activity, and usually follows a benign course. Sites affected are the conjunctiva, the eyelids, or both.

Scarless Epicanthoplasty and Concomitant Double Eyelidplasty in Chinese Eyelids.

The presence of mild or moderate medial epicanthus is typical in Asian patients. Numerous epicanthoplasty techniques have been described previously. However, these methods usually leave obvious scars in the medial canthal area. The aim of this report is to introduce a novel epicanthoplasty technique and a concomitant double eyelidplasty which avoid leaving scars in the medial canthal region. From July 2013 to July 2015, 252 patients received epicanthoplasty and concomitant double eyelidplasty with this new technique. The medial epicanthus was corrected through the medial end of the eyelid crease incision. One hundred eighteen of these patients were followed up for 3-24months (8months in average). The preoperative and postoperative interepicanthal distances were measured at pre, 3 and 6months post-operation. The aesthetic results were evaluated with patient visual analog scale (VAS) scores. The average intercanthal distance significantly decreased 3months after the operation (32.7±2.3mm vs 36.5±2.6mm, p<0.05, paired t test). Little retraction was noticed at 6months after the operation (33.0±2.4 vs 32.7±2.3mm, p<0.05, paired t test). The mean patient VAS score associated with satisfaction of overall outcome was 4.2 at 6months after operation (range 2.5-5.0). This new method provides an effective way to correct the medial epicanthus without leaving any scar in the medial canthal region. Patients with mild to moderate medial epicanthus are good candidates for this procedure. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .