Evaluation of Blepharoptosis in Patients With Refractory Blepharospasm by VISA-Video Recordings, Idiosyncratic Expressions, Sensory Tricks, and Ancillary Procedures.

BACKGROUND: How to evaluate blepharoptosis concomitantly presented with refractory and uncontrollable blepharospasm? To date, there is a paucity of publications on the ideal evaluation methods. An innovative method-video recordings, idiosyncratic facial expressions, sensory tricks, and ancillary procedures (VISA)-is developed for preoperative evaluation, and the surgical outcomes are demonstrated. METHODS: A retrospective study using VISA for blepharoptosis evaluation was conducted on 51 patients with refractory blepharospasm. Based on the evaluation, patients underwent blepharoptosis correction simultaneously besides the selective myectomy and myotomy in situ of the eyelid protractors for blepharospasm. Preoperative and postoperative palpebral fissure height, margin reflex distance 1, ptosis severity, and levator function were assessed to identify the effectiveness of VISA. All the procedures were performed by the senior author C.-S.L. RESULTS: There were 42 patients diagnosed with essential blepharospasm and 9 patients with Meige syndrome. Forty-one patients (82/102 eyelids [80.4%]) had concomitant blepharoptosis and blepharospasm. Ptosis severity was mild in 21 eyelids (25.6%), moderate in 12 eyelids (14.6%), and severe in 49 eyelids (59.8%). Preoperative/postoperative (6 months) values of palpebral fissure height, margin reflex distance 1, and levator function were 4.70 ± 2.45 mm/8.35 ± 1.33 mm (P < 0.05), -0.30 ± 3.19 mm/3.73 ± 1.05 mm (P < 0.05), and 13.07 ± 2.56 mm/13.68 ± 2.34 mm (P < 0.05), respectively. Undercorrection and revision rate reported 9.8% and 3.7%, individually. CONCLUSIONS: VISA approach overcomes the difficulty of blepharoptosis assessment in patients with refractory blepharospasm. It provides useful preoperative information required for adequate blepharoptosis correction in blepharospasm surgery and yielded desirable outcomes.

Selective Myectomy and Myotomy In Situ for the Management of Refractory Blepharospasm in Meige Syndrome.

BACKGROUND: Meige syndrome is characterized by involuntary blepharospasm and varied subphenotypes of oromandibular tonic-clonic muscle contraction. Despite botulinum toxin (BTx) being the mainstay of treatment for Meige syndrome, a small subset of patients remain refractory to its effects because the disease is a form of functional blindness. An integrative surgical procedure combining selective myectomy and myotomy in situ of eyelid protractors, blepharoptosis correction, and tightening of the lower eyelid laxity was first applied to treat refractory blepharospasm in patients with Meige syndrome. MATERIALS AND METHODS: This study is a retrospective review conducted on 24 patients with refractory Meige syndrome between 2013 and 2020. Besides selective myectomy and myotomy in situ of eyelid protractors, levator plication and lateral tarsoplasty or canthopexy was performed for blepharoptosis correction and lower eyelid tightening, respectively. Patient demographics, associated diseases, medical treatment history, associated surgical procedures, final aesthetic outcomes, and therapeutic effects as reflected by changes in function disability score and Botox (BTx) treatment were thoroughly recorded and analyzed. RESULTS: The mean age of the patients was 65.2 ± 8.9 years. Twenty-one patients (87.5%) received blepharoptosis correction by levator plication with an average of 11.2 ± 2.9 mm in length. Lateral tarsoplasty was performed in 16 patients (66.7%) by pentagonal tarsal resection with an average of 3.9 ± 0.8 mm in width. Five patients (20.8%) received lateral canthopexy. Among the total of 96 operated eyelids, scar revision with fat graft was performed in 3 eyelids (3.1%). The average amount of BTx treatment decreased from 49.2 ± 12.8 U once every 2.7 ± 0.8 months before surgery to 35.4 ± 7.8 U once every 3.8 ± 0.7 months after surgery. Function disability score improved from 76.7 ± 17.5% preoperatively to 15.6 ± 9.9% postoperatively ( P < 0.001). Only 3 upper eyelids (3.1%) received scar revision and fat grafting due to minor postoperative contour depression. All patients expressed high satisfaction with both functional and aesthetic outcomes (Likert scale 4.5 ± 0.5). CONCLUSIONS: Selective myectomy and myotomy in situ of eyelid protractors combining blepharoplasty correction and lower eyelid tightening can produce long-lasting functional and aesthetic results with minimal complication in patients with refractory Meige syndrome.

Lateral Tarsoplasty for Managing Ectropion and Laxity of the Lower Eyelid.

BACKGROUND: The most challenging complication associated with lower blepharoplasty is ectropion, and the traditional lateral canthopexy or canthoplasty procedure may carry the risk of eyelid malposition or subsequent chemosis. We propose lateral tarsoplasty with a detailed description of the techniques to treat and even prevent ectropion by not involving the medial or lateral canthal ligament so as to avoid complications. MATERIALS AND METHODS: Lower eyelid laxity was analyzed with the snap-back test and distraction test before surgery. Approximately 5 mm medial to the lateral canthus, lateral tarsoplasty is performed through a full-thickness pentagonal tarsal-conjunctival resection according to the "overlapping test" for an accurate measurement of the amount of the tarsus to be resected. Seventy-two eyelids that received either ectropion correction or prevention with lateral tarsoplasty over an 8-year period at a single institution were collected and analyzed for this retrospective review. RESULTS: Lateral tarsoplasty was performed in 39 patients with a mean age of 63.8 years. Thirteen patients with 20 eyelids presented for ectropion correction, in whom 5 to 10 mm of tarsus was resected, 6.0 mm in average. The other 26 patients with 52 eyelids presented for ectropion prevention, in whom 3 to 7 mm of tarsus was resected, 4.1 mm in average. Apart from temporary mild chemosis, all patients experienced highly satisfactory results without any ectropion or malposition of the involved lower eyelids after a follow-up of 8.1 months in average. CONCLUSIONS: For patients with moderate and severe laxity of lower eyelids, lateral tarsoplasty without involvement of the lateral canthal ligament proves to be an effective way to treat and prevent lower eyelid ectropion.

Personal Approach to Optimizing Inframammary Fold Incision for Asian Augmentation Mammoplasty.

BACKGROUND: The rates of aesthetic breast augmentation have risen substantially in Asia. Outcomes of various breast augmentation approaches in Asia have not been comprehensively studied. In the past, the inframammary approach to breast augmentation was not popular because of conspicuous scarring. In this article, the authors review academic articles related to the use of an inframammary incision for breast augmentation in Asian women and present our recommendations for the available techniques. METHODS: A literature search was performed for articles published after 2015 on Asian women with augmentation mammoplasty describing techniques, incision sites, outcomes, and complications. The search was performed using the MEDLINE, Embase, and Cochrane databases. We also included our own technique to demonstrate the outcome of augmentation mammoplasty through inframammary incision. RESULTS: Eight articles satisfied our inclusion criteria. Evidence indicates that with proper preoperative design and surgical techniques, scarring resulting from the inframammary approach is not inferior to that resulting from the transaxillary approach in Asian patients. Long-term satisfaction with the inframammary approach to breast augmentation is high in Asian patients.Eight articles reported the outcomes of 1168 women receiving breast augmentation. Inframammary incisions were used in 45.29% of patients (529 patients). After the 2015 publication of Zelken's review paper on Asian breast augmentation, the rate of inframammary incisions increased from 3.1% to 45.29%. CONCLUSIONS: With precise design of the new inframammary fold, accurate wound suture fixation, and postoperative scar care, the inframammary approach to breast augmentation offers optimal operative visualization, reduced pain, fewer complications, and desirable esthetic outcomes even in Asian patients. This study demonstrates that the percentage of inframammary fold approach of Asian esthetic mammoplasty grows rapidly after 2015.

The Function-Preserving Frontalis Orbicularis Oculi Muscle Flap for the Correction of Severe Blepharoptosis With Poor Levator Function.

BACKGROUND: Severe blepharoptosis with poor levator function (LF) has traditionally been managed with exogenous frontalis suspension but complications such as lagophthalmos, infection, and rejection are often reported. OBJECTIVES: The aim of this study was to design a function-preserving frontalis orbicularis oculi muscle (FOOM) flap to correct severe blepharoptosis with poor LF. The long-term surgical outcome of the technique was assessed. METHODS: This retrospective study included only adult patients with severe blepharoptosis and poor LF, all of whom had their surgery performed by the senior surgeon over a 6-year period. Clinical assessment of LF, palpebral fissure height (PFH), marginal reflex distance 1 (MRD1), duration of follow-up, and postoperative complications were recorded. RESULTS: A total of 34 patients and 59 eyelids were recorded during a mean follow-up period of 17.7 months. Postoperative evaluation yielded mean [standard deviation] improvements of PFH gain of 5.62 [1.61] mm (P < 0.001), and MRD1 and PFH increases of 4.03 [0.82] mm (P < 0.001) and 8.94 [0.81] mm (P < 0.001), respectively. All patients demonstrated normalization of orbicularis function: no lagophthalmos was observed at the 8-month postoperative follow-up. Recurrence of ptosis was recorded in 4 eyelids (6.78%). Revisions were performed in 2 eyelids (3.39%). No infection or granuloma was noted. CONCLUSIONS: The function-preserving FOOM flap is a useful vector for frontalis suspension. Not only does it effectively address lagophthalmos as well as other complications, but it provides aesthetically pleasing outcomes in patients with severe blepharoptosis and poor LF.

Myotomy In Situ for Essential Blepharospasm Refractory to Botulinum Toxin.

BACKGROUND: Full myectomy is recommended for benign essential blepharospasm (BEB) refractory to botulinum toxin (BT) treatment, but long-term swelling, scar contracture, hollow appearance, and unnatural contour of the eyelids are common postoperative complications. We present myotomy in situ to minimize these adverse outcomes. METHODS: The redundant eyelid skin with its underlying muscle is resected first, and myotomy in situ is performed by completely cutting the residual orbicularis oculi muscles into multiple cubes and down to the subcutaneous layer, and then cutting the procerus and corrugator muscles down to the periosteum. Patient demographics, medical treatment history, BT injection history, blepharoptosis correction techniques, associated surgical procedures, and aesthetic outcomes were analyzed. Preoperative and postoperative BT injection dosage and frequency, as well as modified disability scores, were compared using paired Student t tests. RESULTS: Twenty-five patients underwent this technique. Their average ± SD age was 64.4 ± 8.9 years, with average postoperative follow-up occurring 17.0 ± 8.0 months. Associated diseases included blepharoptosis (88%) and apraxia of lid opening (44%). There were no postoperative hematoma, seroma, scar contracture, and depressed hollow eyelid contours. Preoperative to postoperative assessments revealed improvements in mean BT injection interval (10.4 ± 2.1 to 14.6 ± 2.9 weeks, P < 0.001), BT injection dosage (44.4 ± 13.3 to 28.1 ± 6.7 units, P < 0.001), and modified disability score (15.3 ± 3.0 to 2.8 ± 2.2, P < 0.001). All patients were highly satisfied with functional and aesthetic surgical outcomes (4.5 ± 0.6 on Likert scale). CONCLUSIONS: Myotomy in situ is effective for patients with BEB who are refractory to BT treatment, with therapeutic benefits similar to that of full myectomy with the ability to maintain favorable cosmetic results. Relative high incidence of blepharoptosis and apraxia of lid opening in patients with refractory BEB was reported. Simultaneous correction of the ptosis can further optimize outcomes.

Severe Ocular Complications After Blepharoptosis Correction in the Oculopharyngeal Muscular Dystrophy Patient: Literature Review and Case Presentation.

BACKGROUND: Blepharoptosis correction in oculopharyngeal muscular dystrophy (OPMD) patients may result in severe ocular complications owing to lagophthalmos and ophthalmoplegia. Managing the acute episode to prevent further aggravation of the keratopathy or blindness is of paramount importance. METHODS: A review of the literature for severe chemosis, keratopathy, and corneal ulceration in the patient population was performed using the PubMed database, with key words including ptosis surgery, ptosis correction, ptosis repair, and oculopharyngeal muscular dystrophy. A retrospective review of all patients with blepharoptosis from a single surgeon from September 2009 and May 2017 was performed, selecting those with OPMD who underwent blepharoptosis correction. RESULTS: Our literature review revealed a total of 15 articles after excluding repeated articles and selecting those meeting our inclusion criteria. A total of 232 OPMD patients underwent blepharoptosis correction. Severe ocular complications were noted in 7 patients, with treatment unspecified. For 9 years, 2 OPMD patients at our institute underwent blepharoptosis correction, with one developing severe acute keratitis, chemosis, and corneal ulceration due to lagophthalmos and ophthalmoplegia. Use of the temporary drawstring tarsorrhaphy and topical eye drop treatment for 2 weeks led to resolution of corneal ulcerations without necessitating further intervention. CONCLUSIONS: Severe ocular complications may occur after blepharoptosis correction in OPMD patients, potentially owing to lagophthalmos and ophthalmoplegia. Temporary drawstring tarsorrhaphy is an effective option to treat these adverse outcomes.

Disparity of perspectives between teachers and learners on perioperative teaching and learning.

BACKGROUND: To build a consensus about learning objectives in the operating room, the aim of the study was to evaluate both surgical teacher and learner perspectives on perioperative teaching and learning in Taiwan. METHODS: Twelve main technical and non-technical learning objectives in the operating room were evaluated by learners and surgical teachers in Kaohsiung Medical University Hospital. The learners included postgraduate year (PGY) 1-3 residents (junior learner, JL) and PGY 4-7 residents (senior learner, SL). The definition of learning preferences were recommended learning objectives, and learning load was defined as demands of learning preferences. During the survey, surgical teachers evaluated the learning preferences for the learner, and learners evaluated their learning preferences. The learners also evaluated the learning preferences that the surgical teachers should teach. RESULTS: Response rate of the questionnaire was 65.4%. A total of 31 learners and 39 surgical teachers completed the survey. The consensus was that the need to increase the learning loads and ethical issues were the learning preferences for SL, and indications, details of procedure, and teamwork were important to both JL and SL. The teachers intended to set specific learning objectives for different learner levels, including (i) indications, details of procedure, teamwork, and postoperative care for both JL and SL; (ii) preoperative preparation, surgical anatomy, and instrument handling for JL (P = 0.022, 0.021 and 0.006); and (iii) surgical technique, independent practice, clinical reasoning, complications, and ethical issues for SL (P = 0.010, < 0.001, < 0.001, 0.001, 0.011). Resident perspective on learning objectives differed between JL and SL, and there was discrepancy between resident's learning as perceived by teachers, particularly in the JL. CONCLUSIONS: Our study revealed significant disparity of perspectives between teachers and learners on perioperative teaching and learning. Surgical teachers should set specific learning objectives for different learner levels, since junior and senior residents have different learning preferences even though both scrub in the same case. Effective communication between teachers and learners has the potential to improve learning experience and create a positive environment in the operating room.

Differential Response of Non-cancerous and Malignant Breast Cancer Cells to Conditioned Medium of Adipose tissue-derived Stromal Cells (ASCs).

Background: The application of adipose tissue-derived stromal cells (ASCs) in regenerative medicine has become a growing trend due to its abundance and differentiation potentials. However, several breast cancer studies indicated that ASCs promote tumor progression, therefore, the use of ASCs for reconstruction after oncological surgery poses potential risks. In this study, we aimed to examine whether cancerous or non-cancerous breast cells will exhibit different responses to ASC-derived CM. Methods: ASCs were isolated from residuals of subcutaneous adipose tissue obtained from patients undergoing surgery. Cancerous MCF-7, MDA-MB231, and MDA-MB468 cell lines and one non-cancerous M10/H184B5F5 cell line were cultured with variant concentrations of ASC-derived conditioned medium (CM) for analysis. Results: ASC-derived CM significantly reduced cell viability by triggering apoptosis in MCF-7, MDA-MB231, and MDA-MB468 cell lines. ATM-Chk2-dependent DNA damage response was activated early in cancer cells when exposed to ASC-derived CM. By contrast, prompted cell proliferation instead of cell death was detected in M10/H184B5F5 cells under the treatment of lower CM concentration. Even when exposed to the highest concentration of CM, only cell cycle arrest accompanied by a weak DNA damage response were detected in M10/H184B5F5 cells, no cell deaths were observed. Conclusions: Overall, this study demonstrated that cancerous and non-cancerous breast cells respond differently to ASC-derived CM. ASC-derived CM triggered significant cell death in breast cancer cell lines, however non-cancerous breast cells exhibited dissimilar response to ASC-derived CM.

Triamcinolone Acetonide Suppresses Keloid Formation Through Enhancing Apoptosis in a Nude Mouse Model.

BACKGROUND: Current understanding of steroid treatments for keloids is in regards to modulation of inflammation, proliferation, and apoptosis, with no in vivo study on the latter. Using a nude mouse model, we investigated whether triamcinolone acetonide (TA) injections induce keloids regression through enhancing apoptosis. MATERIALS AND METHODS: Thirty-six keloid specimens (1 × 1 cm) were harvested from 6 patients and separated into sets of 2 from the same patient: no treatment and intralesional TA injection (0.4 mg/mL/kg) at 8 weeks of postimplantation. One set was implanted in each of 18 randomly selected nude mice, which were separated into 3 groups based on time of keloid harvesting after treatment: group A, 2 weeks; group B, 8 weeks; and group C, 14 weeks. Each group had 1 set of specimen from each patient. Histological staining was performed with hematoxylin and eosin stain. Immunohistochemistry staining was performed for human-prolyl 4-hydroxylase (hPH4) and caspase 3 protein, along with terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay. RESULTS: All keloid specimens survived, with no noted overgrowth. Hematoxylin and eosin staining revealed dense extracellular matrix and viable fibroblasts, and hPH4 immunohistochemistry revealed strong expression, demonstrating keloid viability. Caspase 3 protein and TUNEL expressions were significantly increased in the treatment versus control groups, demonstrating that TA injections induced apoptosis. CONCLUSIONS: Triamcinolone acetonide intralesional injections significantly increased apoptosis in keloids, represented by increased caspase 3 protein and TUNEL expressions, supporting that steroids suppress keloids in part owing to enhancement of apoptosis.

The Epidemiology and Clinical Features of Blepharoptosis in Taiwanese Population.

BACKGROUND: Blepharoptosis describes a condition of low-lying upper eyelid that may affect individuals of all ages under various etiologies. It may be of congenital or acquired form by the timing of onset or be divided into myogenic, neurogenic, aponeurotic, or mechanical types according to the mechanism. Our goal was to report the characteristics of age-specific blepharoptosis and to analyze the association between levator function (LF) and ptosis severity of each ptosis subtype. MATERIALS AND METHODS: The retrospective, single-center, cross-sectional study consisted of patients diagnosed with blepharoptosis in the plastic surgery practice at a medical center between September 2009 and May 2017. We reported patients' age at presentation, sex, laterality of ptosis, etiology, classification, and evaluation of ptosis including levator function and ptosis severity. RESULTS: During a nine-year span of study, a total of 1975 eyelids of 1164 Taiwanese patients aged between 2 and 88 years were enrolled in the research (mean = 57.73 ± 13.41 years). The female-to-male ratio was 2.72 (95% confidence interval [CI]: p < 0.0001). Acquired blepharoptosis and bilateral blepharoptosis were more frequently observed (55.85%, p < 0.0001 and 69.67%, p < 0.0001, respectively). In age-specific relative incidence of blepharoptosis, myogenic ptosis was the majority in patients younger than 40 years. Early onset of aponeurotic ptosis was observed in young contact lenses wearers. Aponeurotic blepharoptosis was the predominant type of ptosis in the senior population older than 40 years (p < 0.0001). Among the subtypes, mechanical ptosis had the most preserved LF (p < 0.0001). LF and MRD1 had statistically positive correlations in all subtypes of blepharoptosis, in which neurogenic ptosis demonstrated the severest levator dysfunction for each millimeter in MRD1 reduction. CONCLUSIONS: Of the 1164 Taiwanese patients, blepharoptosis had a higher propensity for female gender and the age between the second to fourth decades. Bilateral involvement of blepharoptosis with acquired type was frequently diagnosed. Myogenic ptosis had a preponderance in age younger than 40 years, while aponeurotic ptosis usually affects senile population. Many mild degree myogenic ptosis was simultaneously recognized in young-aged adults seeking aesthetic double eyelid surgery. Early onset of acquired aponeurotic ptosis was also observed in contact lens wearers given the trend of decorative contact lens use. Levator dysfunction was implicated in the pathology of not only myogenic ptosis but aponeurotic, mechanical, and neurogenic ptosis. Moreover, levator function of neurogenic ptosis was most severely impacted in each MRD1 reduction among all subtypes of blepharoptosis. LEVEL OF EVIDENCE IV: 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 .

Three Simple Steps for Refining Transcutaneous Lower Blepharoplasty for Aging Eyelids: The Indispensability of Micro-Autologous Fat Transplantation.

BACKGROUND: Lower blepharoplasty has been used for rejuvenating lower eyelids, and diverse modifications have been used to treat conjunct deformities at the tear trough/lid-cheek junction. Strategies for recontouring prominent tear trough/lid-cheek junctions, including orbital fat manipulation, have been reported with good results in the literature. Micro-autologous fat transplantation (MAFT) is a previously unevaluated, potentially advantageous approach to blending the prominent tear trough/lid-cheek junction. OBJECTIVES: We determined the long-term results after 3-step transcutaneous lower blepharoplasty with MAFT for patients with aging eyelids and prominent tear trough/lid-cheek junctions. METHODS: We evaluated 205 patients with aging lower eyelids who underwent transcutaneous lower blepharoplasty with MAFT between October 2010 and September 2016. The 3-step procedure involved a subciliary elliptical skin excision, resection of 3 orbital fat compartments, and MAFT for the tear trough/lid-cheek junction employing a MAFT-GUN under intravenous anesthesia. RESULTS: The mean patient age was 52 years (range, 34-78 years). The mean operating time was 61 minutes. The mean fat volumes delivered to the tear trough/lid-cheek junctions were 2.80 mL and 2.76 mL for the left and right sides, respectively. The average weights of the 3 resected orbital fat compartments were 0.58 g for the left side and 0.56 g for the right side. Patients showed significant improvement and maintenance at an average follow-up of 60.2 months (range, 18-90 months). CONCLUSIONS: Three-step transcutaneous lower blepharoplasty with MAFT is an effective, reliable, and promising method with high patient satisfaction and minimal risk of complications. Long-term results demonstrated its utility for aging lower eyelid treatment.

Platelet-Rich Plasma Injection in Burn Scar Areas Alleviates Neuropathic Scar Pain.

Objective: No effective treatments have yet been developed for burn-induced neuropathic pain. Platelet-rich plasma (PRP) has been reported to ameliorate various types of inflammation pain. However, the effect of PRP on burn-induced neuropathic pain is unclear. Methods: Burn-induced neuropathic pain Sprague-Dawley rat model was confirmed using a mechanical response test 4 weeks after the burn injuries were sustained, following which PRP was injected in the scar area. The rats were divided into four groups (n = 6) as following: Group A, Sham; Group B, Sham + PRP; Group C, Burn; and Group D, Burn + PRP. Four weeks after the PRP injection, the animals were subjected to behavior tests and then sacrificed; specimens were collected for inflammation tests, Masson's trichrome stain and chromosome 10 (PTEN) in the injured skin; and PTEN, phosphorylated mammalian target of rapamycin (p-mTOR), p38, nuclear factor κB (NFκB), chemokine (CC motif) ligand 2 (CCL2), and CCL2 cognate receptor (CCR2) in spinal cord dorsal horns through immunohistochemistry and immunofluorescence staining. Results: PRP significantly alleviated allodynia in burn-induced neuropathic pain 4 weeks after treatment, and PTEN expression in the skin and spinal cord were significantly increased in group D compared with the group C. p-PTEN, p-mTOR, and CCL2 expression in neuron cells; p-p38 and p-NFκB expression in microglia; and p-JNK and p-NFκB activation in spinal astrocytes decreased significantly in the group D compared with the group C. Conclusions: PRP is effective in treating burn-induced neuropathic pain and may be used in clinical practice.

Floppy Eyelid Syndrome: An Unfamiliar Entity for Plastic Surgeons.

BACKGROUND: Floppy eyelid syndrome (FES) is typically characterized by chronic eye irritation and an increased laxity of the upper eyelid that can be easily everted by applying minimal upward traction. However, it is a clinical entity that is less known to most plastic surgeons. Blepharoptosis is one of the most common features, which links to FES, for which a thorough differential diagnosis has become important in directing proper medical treatment. PURPOSE: This review aims to discuss current understanding about FES in a broader spectrum, encompassing the clinical features and evaluation of FES, the underlying etiologies, systemic associations, and surgical procedures for upper eyelid tightening. METHODS: The literature search was conducted in Endnote interface using the keyword "floppy eyelid" through March 2017. All search abstracts were reviewed without language restriction. Citations of identifiable articles were also examined. RESULTS: Despite the exact definition of FES remains ambiguous, patients with FES often demonstrate unresolvable blepharoptosis, dermatochalasis, eyelash ptosis, entropion, or ectropion of the lower eyelid. The pathological course of FES can be worrisome because it is often associated with both ocular and systemic morbidities, most notably papillary conjunctivitis, keratoconus, and obstructive sleep apnea (OSA). Decades of research into the pathogenesis has lent further recognition linking the eyelid floppiness with a loss of elastic fibers, an increased expression of matrix metalloproteinases, and possible collagen gene mutations. Surgery is usually prompted if conservative measures give limited responses. High surgical success rates with different follow-up time have been reported. CONCLUSIONS: For plastic surgeons, early recognition of FES is important because of its chronic, distressing course and the associated morbidities. We believe that surgical intervention is the most effective treatment of choice. The indication for embarking on surgery is based on the clinical severity of the condition. A variety of blepharoplasty techniques for FES have been proposed, including full-thickness wedge excision of the tarsus, medial and lateral canthal ligament ligation, conchal cartilage graft, lateral tarsal strip with flap, and lateral tarsorrhaphy. Most of the procedures have provided excellent visual and aesthetic outcomes; therefore, early surgical intervention is encouraged if early diagnosis can be made.

Combined Use of Liposuction and Arthroscopic Shaving for Delayed Debulking of Free Flaps in Head and Neck Reconstruction.

BACKGROUND: Bulky appearance after free flap reconstruction in patients with head and neck cancer is common and requires revision to achieve improved final outcomes. Although different delayed debulking methods have been reported, the procedure can be technically difficult in patients with severe scaring after adjuvant radiotherapy. The present study proposes a combined method of liposuction and arthroscopic shaving for delayed contouring of free flaps in head and neck reconstruction. METHODS: In this study, 12 patients with head and neck cancer who had bulky flaps after cancer ablation surgery and immediate free anterolateral thigh flap reconstruction were included. These patients underwent delayed debulking through the combined arthroscopic shaving and liposuction method at least 3 months after the initial reconstruction or the completion of adjuvant radiotherapy (if required). Age, sex, cancer stages, the presence or absence of adjuvant radiotherapy, the interval between the initial free flap reconstruction and the debulking procedure, complications, and subjective satisfaction ratings were recorded 1 and 6 months after the revision surgery. RESULTS: All patients were men, with an average age of 56.3 years (43-69 years), and 9 (75%) patients underwent adjuvant radiotherapy. Partial flap loss was not observed in the study patients, and subjective satisfaction ratings improved after the debulking procedure. CONCLUSIONS: The combined liposuction and arthroscopic shaving method can facilitate the debulking and contouring procedures in patients with head and neck cancer after free flap reconstruction. With appropriate timing, the combined procedure can be simple and safe, even in patients with severe scaring after adjuvant radiotherapy.

Correction: Chang, C.-H.; et al. Secreted Protein Acidic and Rich in Cysteine (SPARC) Enhances Cell Proliferation, Migration, and Epithelial Mesenchymal Transition, and SPARC Expression Is Associated with Tumor Grade in Head and Neck Cancer. Int. J. Mol. Sci. 2017, 18, 1556.

We would like to submit the correction to our published paper [1]. [...].

Micro-Autologous Fat Transplantation for Treating a Gummy Smile.

BACKGROUND: A gummy smile is treated using many techniques, including botulinum toxin injection and various surgical interventions. Micro-autologous fat transplantation (MAFT) is a potentially advantageous alternative approach that has not been previously evaluated. OBJECTIVES: This study sought to determine the long-term results of MAFT in patients with a gummy smile. METHODS: Seven patients with gummy smiles were evaluated for MAFT treatment between October 2015 and April 2017. Centrifuged purified fat was micro-transplanted into the nasolabial groove, ergotrid, and upper lip areas using the MAFT-GUN while the patients were under total intravenous anesthesia. RESULTS: The mean age of the 7 patients was 31 years (range, 23-40 years). The mean operating time for MAFT was 52 minutes (range, 40-72 minutes), and the mean volume of fat delivered to the nasolabial groove, ergotrid, and upper lip was 16.1 mL. The mean decreases of gingival display in the right canine incisor, left canine incisor, right canine, and left canine teeth were 4.9, 4.6, 3.8, and 4.4 mm, respectively. The smiles of the 7 patients showed significant improvement at an average follow-up time of 12.9 months. CONCLUSIONS: Gummy smile treatment using MAFT is an effective, reliable, and relatively simple method, with high patient satisfaction and minimal risk of complications.

Analysis of Levator Function and Ptosis Severity in Involutional Blepharoptosis.

BACKGROUND: Involutional blepharoptosis is the most common type of acquired blepharoptosis. The etiology is believed to be the degeneration of the levator aponeurosis, and levator superioris muscle function was believed to be normal. However, there are a few studies analyzing levator function (LF) in involutional blepharoptosis. Our study aimed to access the LF abnormality in involutional blepharoptosis and analyze the correlation between LF and ptosis severity in involutional blepharoptosis in Taiwan. METHODS: We reviewed the medical records of patients who underwent ptosis correction surgery between October 2011 and December 2015 after receiving a diagnosis of involutional blepharoptosis. This study examined patient sex and age, preoperative LF, margin reflex distance of the upper eyelid (MRD1), and ptosis severity. Linear regression was performed for statistical analysis. Levator muscle specimen was sent for pathologic examination. RESULTS: We analyzed 231 eyelids of 126 patients. Average MRD1 was 0.43 ± 2.15 mm. Average LF was 14.30 ± 2.51 mm. Overall, 77.1% (178/231) of involutional blepharoptotic eyelids had normal LF (more than 12 mm). Forty-three (18.6%) of 231 were good (10-12 mm), and 10 (4.3%) of 231 were fair (6-9 mm). No patients with poor levator function (≤5 mm) were observed in our case series. A positive correlation between LF and MRD1 was observed after statistical analysis. On average, a 0.6-mm reduction in LF was observed for each 1.0-mm decrease in MRD1. Fat infiltration in levator muscle is observed both grossly and microscopically in most cases with varied degrees. CONCLUSIONS: Levator function and MRD1 were positively correlated in patients with involutional blepharoptosis. In our study, 77.1% (178/231) of eyelids had normal levator function, which meant there was 23.0% (53/231) of eyelids had abnormal LF, in contrast to current literature. Fat infiltration was common in our series. In Asian involutional blepharoptosis, LF was not always excellent and it had positive correlation with ptosis severity.

Simultaneous double free radial forearm flaps combined with coronoidectomy and myotomy to release bilateral severe trismus: A case report.

Oral cancers associated with submucosal fibrosis-induced trismus are common. They may affect the patients' quality of life, cause nutritional deficits, and interfere with postoperative cancer surveillance. In such cases, locating desirable recipient vessels in the head and neck can be difficult. This report presents a 47-year-old man with severe trismus caused by recurrent head and neck cancer, who had received multiple free-flap reconstructions after cancer ablation. Reconstruction was successfully achieved for the bilateral defects and releasing the trismus by using simultaneous double free radial forearm flaps as a chained flow-through pattern with one residual recipient vessel combined with the bilateral myotomy of the medial pterygoid and masseter muscles, and coronoidectomy. Both flaps survived without any postoperative complication. The maximal mouth opening measured by interincisal distance was 38 mm intraoperative and 32 mm during the 3-year follow-up period. This approach may be an effective option for releasing trismus when recipient vessels are lacking.

Long-Term Outcome of Microautologous Fat Transplantation to Correct Temporal Depression.

OBJECTIVE: Sunken temporal fossa appears oftentimes in Asians and resembles bad fortune that people wish to change. Numerous techniques and materials have been applied clinically for augmenting the sunken temporal fossa with variable results. The microautologous fat transplantation (MAFT) technique proposed by Lin et al in 2006 has demonstrated favorable results in facial rejuvenation. In the present study, the authors applied the MAFT technique with an innovative instrument in sunken temporal fossa and reported its results. METHODS: Microautologous fat transplantation was performed on 208 patients during the 4-year period starting in January 2010. Fat was harvested by liposuction, processed and refined by centrifugation at 1200 g for 3 minutes. Then purified fat was microtransplanted to the temporal fossa with the assistance of an instrument, MAFT-Gun. The patients were followed up regularly and photographs were taken for comparison. RESULTS: On average, the MAFT procedure took 48 minutes to complete. The average delivered fat was 6.8 ±â€Š0.2 mL/6.5 ±â€Š0.3 mL for the right/left side. The average follow-up period was 18 months. No complication including skin necrosis, vascular compromise, nodulation, fibrosis, and asymmetry was noted. The patient-rated satisfaction 5-point Likert scale demonstrated that 81.3% of all patients had favorable results (38.5% very satisfied and 42.8% satisfied). CONCLUSIONS: The concept and technique of MAFT along with the micro- and precise controlling instrument enabled surgeons to perform fat grafting accurately and consistently. In comparison with other strategies for volume restoration, the MAFT procedure demonstrated the patients' high satisfaction with the long-term results. Therefore, the potential of MAFT as an alternative strategy in sunken temporal fossa in Asians was emphasized.