Analysis of Microvascular Free Flap Failure Focusing on the Microscopic Findings of the Anastomosed Vessels.

Microvascular flap reconstruction is known as successful technique, although vascular thrombosis can cause free flap failure. To analyze the histologic characteristics and causes of free flap failure, this clinical study examined failed free flaps, including the microanastomosed sites. This study included a total of 5 failed flaps, including 3 radial forearm free flaps, 1 latissimus dorsi free flap, and 1 fibular free flap, all performed with microvascular reconstruction surgery from 2009 to 2011 at Seoul National University Dental Hospital. At the resection surgeries of the failed nonviable flaps, histologic specimens including the microanastomosed vessels were acquired. For light microscope observation, the slides were stained with hematoxylin and eosin (HE), and also with Masson trichrome. Selected portions of graft tissue were also observed under transmission electron microscope (TEM). It was found that the cause of flap failure was the occlusion of vessels because of thrombi formation. During the microanastomosis, damage to the vessel endothelium occurred, followed by intimal hyperplasia and medial necrosis at the anastomosed site. In the TEM findings, some smooth muscle cells beneath endothelium were atrophied and degenerated. The formation of thrombi and the degeneration of the smooth muscle cells were coincident with vascular dysfunction of graft vessel. The damaged endothelium and the exposed connective tissue elements might initiate the extrinsic pathway of thrombosis at the microanastomotic site. Therefore, it is suggested that accurate surgical planning, adequate postoperative monitoring, and skillful technique for minimizing vascular injury are required for successful microvascular transfer.

The course of the intercostobrachial nerve in the axillary region and as it is related to transaxillary breast augmentation.

PURPOSE: The aim of this study was to precisely determine the course of the intercostobrachial nerve (ICBN) in the axillary region and as it is related to bony landmarks, and all of this might be of use for transaxillary breast augmentation. METHODS: Thirty hemithoraxes of 15 fresh cadavers of Korean adults were dissected. After removal of the skin, the ICBN from its origin was identified. The point of emergence (EP) and the branching point (BP) were marked on translucent paper. RESULTS: The ICBN appeared at the second intercostal space approximately (mean ± SD; 33.4 ± 12.7) mm lateral to the midclavicular line and 9.8 ± 6.4 mm medial to the lateral border of the pectoralis minor (P minor) muscle. The mean (SD) distance from the lower border of the second rib to the EP was 5.2 ± 2.0 mm. The mean ± SD distance from the upper border of the third rib to the EP was 12.7 ± 3.3 mm. It traveled inferolaterally (mean ± SD) 15.1 ± 10.4 degrees from the horizontal plane) 39.4 ± 19.2 mm to reach to the BP. The BP was located at the second intercostal space approximately (mean ± SD) 59.4 ± 21.2 mm lateral to the midclavicular line and 28.5 ± 18.2 mm lateral to the lateral border of the P minor muscle. The mean ± SD distance from the lower border of the second rib to the BP was 11.3 ± 5.4 mm. The mean ± SD distance from the upper border of the third rib to the BP was 6.3 ± 7.1 mm. At the BP, the ICBN gave off a medial brachial cutaneous nerve, and this coursed superolaterally [mean (mean ± SD, 50.7 ± 15.1 degrees from the horizontal plane) toward the medial surface of the upper arm. The mean ± SD depth of the ICBN from the superficial surface of the pectoralis major and P minor was 22.7 ± 5.7 mm and 15.0 ± 5.2 mm, respectively. CONCLUSION: When performing mammary augmentation, care should be taken not to dissect the undersurface of the P minor at the second intercostal space to avoid injury to the ICBN.

Comparison of facial trauma in late middle age (55-64 years) and old age (older than 65 years).

In this study, we attempted to compare facial trauma of late-middle-age patients (55-64 years, LM group) and old-age patients (>65 years old, OL group). The goal of this study was to evaluate the natural history of facial trauma in geriatric patients.The medical record of patients older than 55 years seeking treatment for facial trauma between March 2006 and February 2009 were reviewed, and parameters were collected. Seven hundred seventy-two patients (553 male, 219 female) were analyzed. There were 438 patients of the LM group (55-64 years old) and 334 patients of the OL group (>65 years old).In men (n = 553), the number of patients within the LM group (n = 336, 60.8%) was greater than the number in the OL group (n = 217, 39.2%). Of the 219 women, the number within the OL group (n = 117, 53.4%) was greater than that within the LM group (n = 102, 46.6%) (P = 0.000, χ). Facial lacerations comprised a significantly higher proportion in the OL group (79.3%) than that in the ML group (70.1%), whereas facial bone fractures were more frequent in the ML group (29.9%) than in the OL group (20.7%), which was significant (P = 0.004, χ). Assault and automobile accidents were significantly more frequent in the ML group (n = 65 [15.1%] and n = 31 [7.2%], respectively) than the OL group (n = 20 [6.0%] and n = 11 [3.3%]), whereas falls and pedestrian accidents were more significantly frequent in the OL group (n = 30 [9.0%] and n = 23 [6.9%], respectively) than in the LM group (n = 30 [7.0%] and n = 19 [4.4%]) (P = 0.000, χ). During the hours of the day, between 4 to 6 PM and 6 to 8 PM, injuries occurred more frequently in the OL group (14.5% and 12.4%, respectively) than in the LM group (10.5% and 11.0%, respectively). At the times of 8 to 10 PM and 10 PM to midnight, however, injuries occurred more frequently in the LM group (17.1%, 12.1%, respectively) than in the OL group (12.1% and 8.2%, respectively) (P = 0.03, χ). Frequency of injuries at home within the OL group (n = 68, 22.2%) was significantly higher than within the LM group (n = 55, 14.4%) (P = 0.001, χ), whereas frequency of injuries at the workplace of the LM group (n = 47, 12.3%) was significantly higher than that of the OL group (n = 16, 5.2%) (P = 0.001, χ). Alcohol ingestion at the time of injury was significantly more frequent in the LM group (n = 146, 34.1%) than in the OL group (n = 57, 17.3%) (P = 0.000, χ). In regard to diabetes, the OL group (35.6%) showed a higher prevalence than that of the LM group (25.4%; odds ratio, 2.65).Prevention of injury is important for elderly patients. It is worthy of notice that more than one fourth (26.8%) were in a drunken state at the time of injury. There were no significant differences in the days of hospitalization or in the interval from injury to operation. However, there were significant differences in the place of the injuries, causes of injuries, and time of injuries, which is important in the prevention of injuries. Attention should be paid to assault and automobile accidents in the LM group and to falls and pedestrian injuries in the OL group. Thus, injury prevention should be prepared for differently for both LM and OL groups.

Particle size, temperature, and released amount of fat for safe periorbital fat grafts.

The aim of this study was to determine the particle size, temperature, and amount of released fat for safe periorbital fat grafts. From 28 patients, fat was suctioned from the abdomen (large particles [LPs]) and from the inner thigh (small particles [SPs]) using a 2.1-mm harvesting cannula with a diameter 3.2 × 1.4-mm hole and a 1-mm hole, respectively. The 10-mL syringes full of fat were then put into a centrifuge for 3 minutes (LP) and 1 minute (SP) at 3000 revolutions/min. Fat was then transferred to a 1-mL syringe with Luer-Lock adapters and a blunt cannula of 0.9-mm diameter. The force needed to push the fat out of the cannula was measured with a force gauge. The force was measured within the different groups according to particle size of the fat, temperature of the fat, and released amount of fat. The force needed to push the SP fat out of the cannula into the air with minimal amount (MA) (0.01-0.02 mL) injected at room temperature (25 °C) (1.75 ± 0.82 N) was significantly greater (P = 0.000 [t test]) than at body temperature (BT, 33 °C) (1.27 ± 0.38 N). At BT, the force needed to push the SP fat into subcutaneous pig tissue (2.30 ± 1.46 N) was significantly lesser (P = 0.000 [t test]) than LP fat (6.54 ± 2.39 N). At BT, the force needed to push the MA of SP fat into pig subcutaneous tissue (1.38 ± 0.26 N) was significantly lesser (P = 0.000 [t test]) than the force needed to push the usual amount (0.03-0.04 mL) of SP fat (3.83 ± 1.78 N). The force needed to push the fat into human lower eyelids at room temperature (4.06 ± 2.26 N) was significantly greater (P = 0.000 [t test]) than at BT (2.11 ± 0.96 N). At BT, the force needed to inject an MA of SP fat into human lower eyelids (1.55 ± 0.83 N) was significantly lesser (P = 0.000 [t test]) than the force needed to inject a usual amount of fat (2.78 ± 1.03 N). We suggest injections of the SP (1-mm hole diameter harvesting cannula) fat with MAs (0.01-0.02 mL) by means of fragmented incremental injections stored at BT (33°C) to reduce the injection pressure.

Facial lacerations in children.

The aim of this study was to evaluate the demographics and treatment of facial lacerations in pediatric patients. A retrospective record-based analysis was administered on 3783 patients (<15 years of age) presenting with facial lacerations from March 2002 to February 2011. Males were injured more frequently across all age groups (65.3%) and especially in the 13- to 15-year-old group (81.3%) (P = 0.012, Pearson χ). Overall, 48.9% of injuries occurred outdoors and 45.1% in homes. Only 6.0% occurred in schools or kindergartens. Injuries that occurred in schools or kindergarten increased with the age groups (from 2.3% for 0- to 3-year-olds to 19.1% for 13- to 15-year-olds). In the age groups younger than 12 years, injury occurred more frequently on the weekend. In the 13-to 15-year-old group, however, injury occurred more frequently on weekdays (odds ratio, 2.46). Injury occurred most frequently at the times of 7 to 9 PM and least frequently from midnight to 6 AM. The most frequent cause of injury in children was by being struck or by bumping something (32.5%), followed by slip-down (31.5%). Accidents involving furniture and stairs accounted for 9% each. Accidents caused by stairs decreased with age (from 10.2% for 0-3 years of age to 5.5% for 13-15 years of age, P = 0.000, Pearson χ). In a little less than half (47.2%) of the cases, parents accompanied their children at the time of injury. In the 13- to 15-year age group, only 17.9% of the children were accompanied by their parents. Foreheads (26.4%) took the brunt of most frequent injuries, followed by the eyelids (20.6%), eyebrows including the glabella (19.7%), and chin injuries (15.7%). Only 58 cases had associated injuries. Among 3783 cases of facial lacerations, 3745 patients did not have facial bone fractures or associated injuries and were managed under local anesthesia or through dressings only. A sound knowledge about the epidemiology of lacerations might be beneficial for the prevention of pediatric facial lacerations, which occurs more frequently than facial fractures. It is noteworthy that slip-down showed a peak in kindergarteners (4-6 years, 36.1%) and then decreased with age. The incidence of slip-down might be reduced if attention is paid when the kindergarteners are walking on steep stairs or steep flights of stairs. Injury at the educational institutions increases with the pupil's age, and therefore safety management in schools is important.

Location and tension of the medial palpebral ligament.

The aim of this study was to elucidate the precise anatomic location and tension of the medial palpebral ligament (MPL). Eleven hemifaces of 10 fresh Korean adult cadavers were used in this study. Nine specimens were used for measurement of dissection and tension, and 2 were used for histologic study. Measurements of tensile strength of each part of the MPL and Horner muscle were performed using a force gauge.The MPL consisted of 2 layers in all specimens dissected. The superficial layer of the palpebral ligament (SMPL) was observed from the anterior lacrimal crest to the upper and lower tarsal plates. The deep layer of the palpebral ligament (DMPL) lay from the anterior lacrimal crest to the posterior lacrimal crest, covering the lacrimal sac. The Horner muscle was observed at the posterior lacrimal crest just lateral to the attachment of the DMPL and ran laterally to the tarsal plate deep to the SMPL. The SMPL began at 4.5 ± 2.3 mm lateral to the nasomaxillary suture line to the upper and lower tarsal plates. Its transverse length was 9.6 ± 1.5 mm, and vertical width was 2.4 ± 0.7 mm, and its thickness was 4.5 ± 2.3 mm. The transverse length of the DMPL was 3.7 ± 0.4 mm, and its vertical width was 2.9 ± 1.3 mm, with a thickness of 0.3 ± 0.1 mm. The transverse length of the Horner muscle was 7.6 ± 1.9 mm, and its vertical width was 4.06 ± 1.5 mm, with a thickness of 0.4 ± 0.1 mm. The tensile strength of the SMPL was 13.4 ± 3.2 N, that of the DMPL was 4.1 ± 1.7 N, and that for Horner muscle was 9.0 ± 3.1 N. The tensile strength of the SMPL was significantly higher than that of the DMPL (P = 0.003).We reconfirmed that the MPL consisted of 2 layers: superficial layer and deep layer. Our results might be of use in surgeries of the medial canthi.

Anatomy and tensile strength of the abdominal head of the pectoralis major muscle in relation to transaxillary breast augmentation.

BACKGROUND: This study aimed to elucidate the anatomy of the abdominal head of the pectoralis major (AHPM) in relation to transaxillary breast augmentation (TBA). METHODS: In 20 hemithoraxes of fresh Korean cadavers, the width, thickness, and location of the origin of the AHPM were measured in relation to the seventh rib-costal cartilage junction. A force gauge was used to measure the force needed to detach the AHPM from its origin. In another four breasts, an implant pocket was made first, followed by observation of the AHPM. In 92 patients who underwent surgery, the AHPM was observed at its origin during performance of endoscopic TBA. RESULTS: The AHPM was observed in 23 (96%) of 24 hemithoraxes dissected. The AHPM was observed in 170 (92.4%) of 184 breasts subjected to surgery. The AHPM originated from the rectus fascia at the sixth (60%) and seventh (35%) costochondral junctions. The width of the AHPM was 23.5±5.2 mm at its origin, 15.2±3.9 mm at midbelly, and 7.3±4.3 mm at insertion. The thickness of the AHPM at its origin was 1.6±0.5 mm. The force needed to detach AHPM from its origin was 23.5±12.0 N. In two cadavers of mock surgery, the AHPM could limit the boundary of the implant pocket after division of the costal origins. After division of the AHPM, the free inferior space was obtained. CONCLUSION: In submuscular or dual-plane breast augmentation, the AHPM should be cut to place the implant in the correct desired position. LEVEL OF EVIDENCE III: 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 .

Diplopia and enophthalmos in blowout fractures.

The aim of this study was to compare the changes of diplopia and enophthalmos in patients with blowout fractures. Three hundred sixty-two patients who presented with blowout fractures between March 2006 and February 2011 were analyzed. The sequential time changes of diplopia and enophthalmos were measured in the operated group and the observed group according to (1) the duration of preoperative observation (early: within 7 days, late: 8-14 days, delayed: >15 days); (2) the defect size (minimal: <1 cm(2), small: 1.1-2.0 cm, medium: 2.1-3.0 cm(2), large: >3.0 cm(2)); and (3) the age of the patients (<20, 21-40, 41-60, >61 years).Among the 362 patients, 242 (66.9%) had an operation, and 120 (33.1%) did not. The duration of preoperative observation did not affect the postoperative diplopia or enophthalmos. There were significant differences of enophthalmos among the operated groups with a different defect size at the preoperative period (P = 0.036 [Pearson χ(2)]). There were significant differences of diplopia among the operated groups with different defect sizes at the 6 months' follow-up period (P = 0.014 [Pearson χ(2)]). The diplopia in the older age group (>60 years) was significantly greater than that of the other 3 groups at 6 months (P = 0.023) and at 12 months (P = 0.023, [Pearson χ(2)]).We think surgery should be delayed until the swelling is decreased unless the medial rectus muscle is incarcerated. We also think that the defect size is not an important factor for whether to perform surgery. We think that the reason for the greater diplopia in the older age group is that the adaptation of binocular convergence is decreased in the older age group.

Tension and distortion of the upper double eyelid by a nonincision method.

The aim of this study was to compare the suture tension and the extent of distortion according to the continuous and interrupted suture methods. An in vitro eyelid model of 10-cm length and 5 layers was made with a 3-layer skin pad for the skin, muscle, and aponeurosis and silicone sheet and sponge for the tarsal plate and conjunctiva. The thickness of the model was 11.8 mm. All interrupted sutures were used in Khoo's method, the buried method, and Mikamo's method, and a continuous suture was applied in the 2-loop en bloc method, the subconjunctival buried method, and Maruo's method. The thickness of the eyelid was measured with a custom-made micrometer that had tacks attached on a measuring bar. The tension was measured with a force-gauge. The distortion in the interrupted suture methods was 15.2% ± 3.4% of the original thickness, and it was significantly greater than the 3.3% ± 2.8% of the original thickness in the continuous suture methods (P = 0.000, t- test). In the interrupted suture methods, Khoo's method showed the greatest rate of distortion (16.9% ± 4.5%), and this was followed by Mikamo's technique (14.5% ± 2.5%) and the buried suture method (13.6% ± 1.4%). For the continuous suture methods, the 2-loop en bloc method showed the least tension (0.33 ± 0.05 N), and this was followed by Maruo's method (0.41 ± 0.07 N) and the subconjunctival buried suture method (0.45 ± 0.07 N). The tension of the suture at each loop was significantly greater (P = 0.000, t-test) in the interrupted suture methods (0.52 ± 0.07 N) than that in the continuous suture methods (0.41 ± 0.08 N). For the interrupted suture methods, Khoo's methods showed the greatest rate of tension (0.54 ± 0.06 N) compared with the buried suture technique (0.51 ± 0.08 N) and Mikamo's technique (0.48 ± 0.07 N). For the continuous suture methods, the 2-loop en bloc method showed the least tension (0.33 ± 0.05 N), followed by Maruo's method (0.41 ± 0.07 N) and the subconjunctival buried suture method (0.45 ± 0.07 N). We contend that a continuous suture method causes minimum notching, whereas an interrupted suture method causes less incidence of double-fold fading.

Levator sheath revisited.

The aim of this study was to reconfirm the detailed histologic structure of the levator aponeurosis and superior transverse ligament, which were first described by Whitnall. Twenty-eight upper eyelids from 28 Korean adult cadavers (mean age, 79.5 [SD, 11.3] years; 16 males and 12 females) were used. Sagittal sections on the midpupillary line were made, and 10-µm-thick sections were prepared. Twenty-five were stained with Masson trichrome, and 16 were prepared for immunohistochemical staining for smooth muscle fibers using mouse monoclonal anti-smooth muscle Ab. The levator palpebrae superioris muscle was covered with its fascial sheath along its course. The superficial part of the fascia sheath that covered the upper aspect of the levator palpebrae superioris just behind the aponeurosis was condensed to form a definite ligamentous band. In front of this ligamentous condensation, the sheath becomes abruptly so thin that it appears to end in a free border, but it could be traced forward as a very delicate layer up to the supratarsal border. The orbital septum consisted of 2 layers. The whitish outer (superficial) layer descends to interdigitate with the levator aponeurosis with loose connective tissue, and then it disperses inferiorly. The inner (deep) layer initially follows the superficial one, and then it reflects at the levator aponeurosis and continues posteriorly with the levator sheath. In most of the specimens, the levator aponeurosis consisted of a single layer in 27 (96.4%) of 28 eyelids. Only 1 eyelid has been observed to show a double-layered levator aponeurosis (3.6%). Some immunostained smooth muscle fibers in the lower side of the levator aponeurosis ran along its entire course. We reconfirmed the levator sheath covering the levator aponeurosis, and it continued anteriorly with the inner layer of the orbital septum, as Whitnall described. This information will be helpful when performing upper eyelid surgeries.

Location of the vascular arcade superficial and deep to the Muller muscle related to blepharoptosis surgery.

The aim of this study is to elucidate the location of the vascular arcades of the Muller muscle as it is related to blepharoptosis surgery. A total of 28 eyelids of 14 patients were observed. In 4 hemifaces of 2 fresh Korean adult cadavers, injection of red latex and dissection were performed via a cutaneous and conjunctival approach. Measurements were performed for determination of distances from the upper margin of the tarsal plate to the visible vascular arcades. Two parallel vascular arcades were observed through the conjunctiva. The distance from the upper margin of the tarsal plate to the visible vascular arcade was 6.86 ± 0.53 mm (lower arcade) and 11.71 ± 0.73 mm (upper arcade), respectively. Using the skin approach, an upper vascular arcade was observed between the levator aponeurosis and the Muller muscle. Using the conjunctival approach, a lower vascular arcade was observed between the conjunctival epithelium and the Muller muscle. We hope that these two vascular arcades can be regarded as landmarks for placating the Muller muscle in blepharoptosis surgery.

Medial pretarsal fat compartment as related to upper eyelid surgery.

The aim of this study was to elucidate the precise topographical anatomy and histology of the pretarsal fat as related to upper eyelid surgery. Twelve eyelids of 6 Korean adult cadavers were used (mean age, 78 [SD, 15] years; age range, 55-93 years; 3 men and 3 women). Ten eyelids were dissected, and 2 were prepared for histologic study. One hundred eyelids from 100 Korean adults were operated (mean age, 30.2 [SD, 10.6] years; age range, 16-70 years; 11 men and 89 women). The location and the shape of the fat compartment on the tarsal plate were measured in reference to the medial canthus and the vertical line of the medial papillary border. The medial pretarsal fat compartment (MPFC) was found in all the cadavers that were dissected and in all the patients who were operated on. The MPFC was located at the medial two fifths of the tarsal plate. The lateral border of the MPFC was 0.94 ± 0.22 mm lateral to the medial pupillary border. Type R (round shape) was most frequent (70.0%), followed by type I (inverted triangular shape: 18.3%) and type T (triangular shape: 11.7%). The MPFC was elevated in 60.0%, and it was flat in 40.0%. When performing suture fixation during upper eyelid surgery, the MPFC might be a prominent landmark because it exists in all the patients, and it is in a constant location.

Degree of swelling of the medial rectus muscle on CT images to differentiate old from new medial orbital wall fracture.

The aims of this study were to compare the degree of swelling of the medial rectus muscle (MR) in a recent fracture group, an old fracture group, and a normal group and to use this to differentiate old medial orbital wall fracture from recent fracture.We made measurements of the computed tomography images of 43 patients with a recent medial orbital wall fracture (the recent fracture group), 46 patients with depression of the medial wall and who were without a recent trauma history (the old fracture group), and 86 patients who were without any facial injury (the normal group). On the axial view, the width of the MR was measured bilaterally, and the width ratio to the contralateral side was calculated. On the coronal view, the height of the MR was measured bilaterally, and the height ratio to the contralateral side was calculated. The width-to-height ratio was also measured on the involved side.The width ratio of the recent fracture group was 1.42 ± 0.31, and it was significantly higher than that of the old fracture group (1.25 ± 0.15) or the normal group (1.00 ± 0.09). The width ratio of the old fracture group was also significantly higher than that of the normal group. The height ratio of the normal group (1.00 ± 0.04) was significantly higher than that of the recent fracture group (0.91 ± 0.15) or the old fracture group (0.86 ± 0.07). The height ratio of the recent fracture group was also significantly higher than that of the old fracture group (P = 0.043). The width-height ratio of the recent fracture group (0.63 ± 0.23) was significantly higher than that of the old fracture group (0.55 ± 0.09) or the normal group (0.37 ± 0.05). The height-to-width ratio of the old fracture group was also significantly higher than that of the normal group.We think the width ratio of the MR of the injured side to the MR of the contralateral side can be the better parameter to differentiate a recent fracture from an old fracture.

Perforating frontal branch of the superficial temporal artery as related to subcutaneous forehead lift.

The aim of this study was to elucidate the precise anatomy of the perforating branch of the superficial temporal artery in relation to subcutaneous forehead lift (SFL).Ten hemifaces of 6 fresh adult Korean cadavers were used in this study. In 4 hemifaces, following injection of red latex, dissection was performed. In 2 hemifaces, following injection of methylene blue solution into the perforator, the area of discoloration was observed. An artery perforating the frontalis muscle into skin of the forehead was identified in 18 foreheads of 9 patients who underwent SFL. Measurements were taken of the external diameter and the location of the perforator.Perforating branches originating from the frontal branch of the superficial temporal artery, perforating the frontalis muscle into skin of the forehead, were observed in all 10 of the dissected hemifaces. Thereafter, it was referred to as the perforating frontal artery (PFA). Skin of the ipsilateral mid-forehead was discolored by methylene blue solution. Most of the PFA (83%) was included in a circle having a radius of 8.9 mm. The center of the circle was located 40.5 mm from the midline on the x axis and 53.6 mm from the supraorbital rim (on the y axis). The center of the circle was located at 89.8% of the length of the midline to the lateral canthus (x axis) and 79.1% of the length of the supraorbital rim to the hairline (y axis).Plastic surgeons can use the PFA in order to achieve sufficient circulation of the skin flap. When surgeons are required to sacrifice the PFA in order to achieve flap mobilization, they can safely cauterize the PFA after isolation without causing accidental burn injury to the skin flap. In addition, the PFA might be useful in creation of local or distant flaps for reconstruction of the forehead or scalp.

Location of the mandibular branch of the facial nerve according to the neck position.

The aim of this study was to elucidate the exact location of the mandibular branch of the facial nerve according to different neck positions. Twenty-two hemifaces of 11 fresh human cadavers were used (age range, 53-89 y; mean age, 72.3 ± 10.5 y; 8 men and 3 women). Working through skin windows, the distance from the mandibular border to the mandibular branch of the facial nerve (border-nerve distance or BND) was measured at 3 points: (1) the mandible angle (gonion or Go point), (2) the point where the mandibular branch of the facial nerve crosses the facial artery (FA point), and (3) the one-fourth point from the gonion to the menton (1/4 point). Threads were hung on the skin windows along the mandibular border. With the neck in the neutral position and then full flexion (15 degrees), extension (15 degrees), and left and right rotations (30 degrees), the distance of the mandibular branch from the thread of the mandibular border was measured using calipers. In the neutral position, the mandibular branch was 3.50 ± 2.82 mm above the mandibular border at the Go point, 5.34 ± 2.98 mm above the mandibular border at the FA point, and 5.28 ± 1.86 mm above the mandibular border at the 1/4 point. At all 3 points, flexion or extension of the neck did not significantly move the mandibular branch. At the Go point and FA point, there was no significant difference between the ipsilateral rotation position and the contralateral rotation. Yet at the 1/4 point, the BND decreased (4.32 ± 2.60 mm) with the neck in ipsilateral rotation and the BND increased (5.97 ± 2.62 mm) with the neck in contralateral rotation. There was a significant difference between the ipsilateral rotation position and the contralateral rotation position (P = 0.020, t-test). Surgeons should keep in mind that at the 1/4 point, the mandibular branch of the facial nerve moves downward 1.10 ± 1.42 mm with the neck in ipsilateral rotation and moves upward 0.49 ± 1.84 mm with the neck in contralateral rotation.

Factors influencing the acceptance of toenail-to-fingernail transfer.

The aim of this study is to determine the factors influencing the acceptance of toenail-to-fingernail transfer. A total of 240 patients were divided into four groups according to severity of nail injury. Half (expensed informed [EI] group) were informed about the expenses (about $9,000) before the interview; the other half were not informed (the expense not-informed [ENI] group). The participants were asked to answer yes or no to the question "If you lose your fingernail and it can be reconstructed by transferring your toenail like this figure, will you undergo surgery? If you want it or not, please choose the reason for your choice." In the EI group, 68.3% accepted the surgery. In the ENI group, 85.0% accepted the surgery. There was a significant difference between the EI and ENI groups (p = 0.002). In the EI group, the age of the surgery acceptance group (36.9 ± 11.8) was significantly lower (p = 0.004) than that of the surgery rejection group (44.5 ± 15.5). The young age group wished to accept the surgery irrespective of the expenses, yet the old age group hesitated to have surgery when informed about the expenses. We think the risk acceptance for toenail-to-fingernail transfer mostly depends upon the expense.

Research progress of bile biomarkers and their immunoregulatory role in biliary tract cancers.

Biliary tract cancers (BTCs), including cholangiocarcinoma and gallbladder carcinoma, originate from the biliary epithelium and have a poor prognosis. Surgery is the only choice for cure in the early stage of disease. However, most patients are diagnosed in the advanced stage and lose the chance for surgery. Early diagnosis could significantly improve the prognosis of patients. Bile has complex components and is in direct contact with biliary tract tumors. Bile components are closely related to the occurrence and development of biliary tract tumors and may be applied as biomarkers for BTCs. Meanwhile, arising evidence has confirmed the immunoregulatory role of bile components. In this review, we aim to summarize and discuss the relationship between bile components and biliary tract cancers and their ability as biomarkers for BTCs, highlighting the role of bile components in regulating immune response, and their promising application prospects.

Muscle fiber types of human orbicularis oculi muscle.

The aim of this study was to elucidate the muscle type of the preseptal, pretarsal, and ciliary parts of the orbicularis oculi muscle in humans using immunostaining. The eyelids of 5 Korean adult cadavers were used (3 male and 2 female cadavers; age range, 50-85 years). A 1:1000 mouse monoclonal anti-skeletal myosin antibody solution (fast, M4276; Sigma, St Louis, MO) was used for immunostaining. On sagittal sections, preseptal, upper pretarsal, midpretarsal, lower pretarsal, and ciliary (muscle of Riolan) parts were selected, and 0.38 × 0.038-mm rectangular areas (0.1444 mm) were photographed. The number and size of the muscle fibers in each part of the orbicularis oculi muscle were evaluated by the image analyzer program and calculated per unit area (1 mm).On the whole, fast fibers (mean, 87.8% ± 3.7%; range, 85.6%-91.7%) occupied a significantly larger portion of the muscle (P = 0.000 [t-test]) than nonfast fibers (mean, 12.2% ± 3.7%; range, 8.3%-14.4%). Among the 3 areas (preseptal, pretarsal, and ciliary parts), the ciliary part had a significantly (P = 0.019 [Scheffé]) higher portion (91.7%) of fast fibers than the pretarsal part (86.6%). The diameter of the fast fibers (mean, 17.7 ± 2.6 µm) was significantly greater (P = 0.000 [t-test]) than the nonfast fibers (mean, 13.0 ± 2.1 µm).Our results showed that the eyelid has a higher proportion of fast muscle fibers than the mouth (pars peripheralis, 73% fast fibers; and pars marginalis, 66% fast fibers). Thus, closing of the eyelids is faster than closing of the mouth; however, the duration or power associated with closing of the mouth is stronger than closing of the eyelids.

Width of the levator aponeurosis is broader than the tarsal plate.

The aim of this study was to compare the width of the levator aponeurosis and tarsal plate in different levels grossly and histologically. Twelve eyelids of 6 Korean adult cadavers were used. Ten eyelids were dissected, and 2 were prepared for histologic study. Widths of the tarsal plate at its lower border, midheight, and upper border were 21.8 ± 1.8, 16.2 ± 1.6, and 8.3 ± 1.0 mm, respectively. The widths of the levator aponeurosis at the lower border, midheight, and upper border of the tarsal plate were 32.0 ± 2.2, 29.2 ± 3.5, and 27.2 ± 3.9 mm, respectively. Its width was 19.9 ± 4.3 mm at the anterior border of the superior transverse ligament. The width of the levator aponeurosis was broader than tarsal plate at all 3 levels. The medial brims of the levator aponeurosis at the lower border, midheight, and upper border of the tarsal plate were 3.6 ± 1.1, 5.1 ± 1.0, and 6.2 ± 1.1 mm, respectively. The lateral brims of the levator aponeurosis at the lower border, midheight, and upper border of the tarsal plate were 6.6 ± 0.9, 7.9 ± 2.6, and 12.7 ± 3.7 mm, respectively. The width of the levator aponeurosis is broader than the tarsal plate at all levels. This result might be useful in upper-eyelid surgery.

The anatomy of the palpebral branch of the infraorbital artery relating to midface lift.

The aim of this study was to elucidate a branch of the infraorbital artery (IOA) crossing the arcus marginalis into the orbit that might be vulnerable during a procedure of midface lift or fat sliding or a transposition in lower blepharoplasty.Eleven orbits of 6 Korean cadavers were dissected after injecting red latex into the external carotid artery. The IOA and nerve were identified. A branch of the IOA running upward was traced. In 28 cases of blow-out fracture, a branch of the IOA crossing the arcus marginalis into the orbit was identified, and the location was measured from each medial and lateral canthus.The palpebral branch of the IOA (PIOA) emerged from the infraorbital foramen and ran superior and lateral to the orbital septum. After passing through the orbital septum near the arcus marginalis, PIOA was distributed to the orbital fat. The palpebral branch of the IOA was identified in 21 (75.0%) of 28 fractured orbits. Twenty orbits had 1 PIOA, and 1 orbit had 2 PIOAs. The location of PIOA from the medial canthus (49.0%) was approximately half of the eye width in average. Most of the PIOAs (91%, 20 of 22 arteries found) were included in the range of 40% to 80% of the eye width from the medial canthus.Knowledge of the anatomic course of the PIOA crossing the arcus marginalis is conducive to cauterizing the vessels, as needed, in the subciliary or transconjunctival approach for lower blepharoplasty.