Evaluation and Classification of Supraorbital Nerve Emerging Patterns.

BACKGROUND: Numerous significant variations in the supraorbital nerve (SON) pass through the notches and foramina. During endoscopic forehead lifting, the passage and the location of the nerve against the frontal bone render it susceptible to injury, resulting in diminished or absent sensation in the corresponding location. We attempted to obtain accurate knowledge of the SON emergence routes. METHODS: Data of patients who underwent an endoscopic forehead lift in a plastic surgery clinic between November 2015 and August 2021 were retrospectively analyzed. Deep and superficial branch pathways of SONs were identified and compared according to side and gender. We also classified the nerve patterns into six types. RESULTS: Altogether, 942 patients (1884 SON cases) were evaluated. Out of the patients, 86 patients were male, and 856 were female. The overall mean age was 48.6 (± 13.1) years. In the deep branches, 49% came from the notch, and 51% came from the foramen. In the superficial branches, 67% came from the notch, and 33% of superficial branches came from the foramen. Unlike the deep branch, superficial branches from the notch were significant. Deep and superficial branches of male patients were much more notched than those of female patients. Branches emerged together in 56% and separately in 44% of the cases. CONCLUSION: The absolute number of SON notches was higher than that of SON foramina. This study with the largest number of SON cases will help surgeons understand the variation and course of SON. LEVEL OF EVIDENCE IV: This journal requires that authors 38 assign a level of evidence to each article. For a full 39 description of these Evidence-Based Medicine ratings, 40 please refer to the Table of Contents or the online 41 Instructions to Authors www.springer.com/00266 .

Oral Commissure Lift: A Retrospective Analysis of Complication Rates and Overall Outcomes.

BACKGROUND: Downward-turning oral commissures and sagging mouth corners can present an unfavorable impression. We introduced a new oral commissure lift procedure and investigated its effectiveness and complication rates. METHODS: Patients who underwent oral commissure lift in the plastic surgery clinic between January 2010 and December 2017 were enrolled retrospectively. Pre-and postoperative photographs were evaluated to measure oral commissure angles and analyze surgical complications, including visible scarring, unnatural appearance, and asymmetry. Many patients underwent a oral commissure lift with a simultaneous facelift. To exclude potential bias, we compared angular changes between patients receiving both oral commissure lift and facelift, with those receiving only oral commissure lift. Moreover, oral commissure angles of patients only receiving facelift were also measured. Statistical significance was set at p < 0.05. RESULTS: Oral commissure lift was performed in 51 patients. The mean ages and follow-up periods were 46.7 ± 11.9 years, and 25.2 ± 22.9 months, respectively. The preoperative mean angles of the right and left oral commissures measured - 3.1 ± 4.0° and - 3.4 ± 3.7°, respectively, and postoperative mean angles measured 3.6 ± 3.2° and 3.3 ± 3.5°, respectively. Postoperative changes in oral commissure angles were statistically significant (p < 0.05). The low complication rate included undercorrection in one patient, asymmetry in one patient, and visible scarring in three patients. We found no statistically significant differences in the studies excluding bias. CONCLUSIONS: The new oral commissure lift procedure for correcting sagging oral commissures was simple, safe, and effective with a low complication rate. 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 .

Selective Osteotomies to Correct Deviated Bony Vaults of Asian Noses.

BACKGROUND: Standard osteotomies for the correction of deviated noses are bilateral and comprise a combination of medial and lateral osteotomy procedures. However, their uniform application to the small/delicate Asian bony vault is inappropriate and often results in suboptimal outcomes. OBJECTIVES: This study describes how asymmetric bony pyramids were defined through 3-component analysis, which was then used to inform selective/individualized osteotomies. METHODS: Bony vault deviations were categorized after 3-component analysis in 117 patients seeking correction of a deviated nose. Selective osteotomies were applied accordingly. Pre- and postoperative photographs were compared and rated by 2 independent evaluators. Patients' subjective evaluations were also included. RESULTS: Selective osteotomies were possible in 79 (68%) out of 117 patients. Among the 79 study subjects, outcome ratings were excellent in 37 (47%), acceptable in 25 (32%), unsatisfactory in 8 (10%), and unspecified in 9 (11%). Unspecified cases aside, satisfactory correction was achieved in 88% (62/70 patients). Of the 54 patients who responded to telephone interviews, patient satisfaction was excellent in 43 (80%), improved in 10 (18.2%), and unchanged in 1 (1.8%). Follow-up of the 88% of patients with satisfactory correction showed a stable long-term outcome. CONCLUSIONS: Each bony vault in deviated noses is different, and thus, its correction must be individualized for each patient and for each side. The protocol described herein achieves a controlled correction of deviated bony vault. Restoration of bony pyramid symmetry via current techniques is best suited to short Asian bony vaults, where additional structural needs from routine nasal augmentation/lengthening are required.

Onodi cell mucocele causing isolated trochlear nerve palsy: A case report.

RATIONALE: Acquired vertical diplopia is commonly observed in trochlear nerve palsy, often resulting from blunt head trauma or vascular problems. It is rarely caused by tumorous conditions or space occupying lesion. We report the first case of Onodi cell mucocele causing isolated trochlear nerve palsy. PATIENT CONCERNS: A 62-year-old male noticed a double vision which worsened when looking down. On ophthalmologic examinations, the patient showed no abnormalities in visual acuity, intraocular pressure, and no swelling in optic disc. In ocular motility test, he was notable for 10° left hypertropia in primary position, 6° in right head tilt position, 14° in left head tilt position and this was aggravated in right and down gaze. Ostiomeatal complex CT depicted an expansile soft tissue density completely filling the left Onodi cell. DIAGNOSES: He was diagnosed with a trochlear nerve palsy caused by an isolated mucocele in the left Onodi cell. INTERVENTIONS: Three days after presentation, he underwent endoscopic sinus surgery for marsupialization of the mucocele in the left Onodi cell. OUTCOMES: The mucocele was completely removed through the endoscopic endonasal approach. Within 4 months after surgery, his 4th nerve palsy had gradually and completely improved. LESSONS: Onodi cell mucoceles that cause trochlear nerve palsy are extremely rare. Timely surgical decompression is essential to achieve optimal recovery of the neural function. Combined trochlear nerve palsy should be evaluated when Onodi cell mucocele involves the orbital apex from above.

Hybrid Approach for Asian Rhinoplasty: Open Approach Without Transcolumellar Incision.

The hybrid approach delivers unlimited exposure and technical access, enabling all the procedures of the open approach. In addition, the hybrid approach is flexible in its extent of "dissection/ exposure" It can be more of a classic endonasal or limited access approach in some cases or open structural rhinoplasty and reconstruction in others. The benefits of the nonopen approach deserve equal attention among Asian rhinoplasty surgeons and residents-in-training courses. The difference is not merely that it spares an incision, it is an opportunity to fine-tune minor millimeters of changes in every step of rhinoplasty, a real and significant benefit.

Anterior inferior cerebellar artery infarction presenting with sudden hearing loss and vertigo.

A peripheral origin is typically contemplated in a patient presenting with sudden hearing loss (HL) and dizziness without other neurologic manifestations. Although symptoms of anterior inferior cerebellar artery (AICA) infarction include sudden HL and vertigo, the clinical picture usually shows ipsilateral facial anesthesia or paralysis, Horner's syndrome, contralateral body anesthesia, or cerebellar dysmetria. A 68-year-old female patient developed sudden HL in the right ear and vertigo. A left-beating horizontal torsional nystagmus was observed, and caloric weakness in the right side was noted. Diffusion- and T2-weighted magnetic resonance imaging revealed cerebellar infarction in the right AICA territory. AICA infarction may present without obvious neurologic deficits, and an imaging study is advised in patients at high risk for vascular accidents.

Facial Nerve Supply to the Orbicularis Oculi around the Lower Eyelid: Anatomy and Its Clinical Implications.

BACKGROUND: The motor innervation of the lower orbicularis oculi has not been clearly established. There is a discrepancy between anatomical descriptions and clinical outcomes of the motor innervation of the pretarsal orbicularis oculi muscle. Therefore, the purposes of this study were to identify every motor and sensory nerve of the lower eyelid, and to reveal the detailed motor nerve pathways toward the medial canthal area. METHODS: Fresh cadaver dissections were performed on 50 hemifaces under a surgical microscope. Submuscular and intramuscular nerves of the lower eyelid were identified, and the pathways of facial nerves that ran toward the medial canthus were traced. RESULTS: Vertical submuscular nerves at the lower eyelid originated from the infraorbital foramen, indicating that all were sensory nerves. The zygomatic branch of the facial nerve traveled obliquely through the anterior cheek and supplied the orbicularis oculi of the lower eyelid and the medial portion of the upper eyelid. Its route was defined as a clinically useful line, the medial orbicularis motor line. In addition, the nerve innervating the pretarsal orbicularis oculi arose at the superomedial preseptal area and extended horizontally and laterally. Interestingly, the angular nerve appeared not to innervate the palpebral orbicularis oculi. CONCLUSIONS: In the lower eyelid, the vertical sensory and the oblique motor nerve supplies are independent and clearly distinguished in aspect of their own routes. The medial orbicularis motor line represents the motor route to the medial portion of the orbicularis oculi. These results might provide valuable knowledge about surgical anatomy for safe lower blepharoplasty with or without midface lift.

Identification of occult tumors by whole-specimen mapping in solitary papillary thyroid carcinoma.

We undertook this study to estimate an accurate incidence and spread patterns of occult papillary thyroid carcinoma (PTC) in patients with a preoperative diagnosis of solitary PTC by using whole-specimen mapping of all specimens after a total thyroidectomy. Enrolled prospectively in this whole-thyroid mapping study are 82 consecutive patients who underwent a total thyroidectomy under a preoperative diagnosis of solitary PTC. All thyroidectomy specimens were serially sectioned in 2 mm thickness and whole-thyroid mapping was carried out for additional foci of occult PTC. The frequencies of occult lesions detected in the whole and contralateral lobe were determined, and clinicopathologic factors associated with multifocality were assessed. Whole-thyroid mapping revealed 66 occult PTC lesions missed by preoperative ultrasound in 37 (45.1%) of the 82 patients. The great majority (92.5%) of the occult PTC was smaller than 3 mm in size and 25 patients (30.5%) had contralateral lesions. We found that the male sex was an independent predictor of multifocality (odds ratio (OR), 3.00; 95% CI, 1.11-8.14), adjusting for preoperative findings. Analysis with pathologic parameters showed that the male sex (OR, 5.03; 95% CI, 1.68-15.08) and extrathyroidal extensions (OR, 3.03; 95% CI, 1.03-8.95) were associated with multifocal PTC. However, none of the clinicopathologic factors evaluated predicted contralateral PTC. Our study demonstrates the diagnostic limitations of ultrasound for the detection of multifocal PTC and the need to consider the possibility of occult lesions in the management of solitary PTC, especially in male patients.

Management of post-traumatic combined deviated and saddle nose deformity.

CONCLUSION: Establishing a straight and firm septum supporting the overlying nasal structures is the most important step in correcting the post-traumatic combined deviated and saddle nose. OBJECTIVES: To present a surgical algorithm and key maneuvers that were successfully applied in the correction of post-traumatic combined deviated and saddle nose deformity. METHODS: Twenty-five patients who had undergone primary rhinoplasty for a post-traumatic combined deviated and saddle nose were included. The patterns of deformity, surgical maneuvers, surgical results, and complications were analyzed using retrospective chart review, telephone interview, and preoperative and postoperative photographs. RESULTS: Three distinct groups undergoing different techniques to correct the deformity were noted. Eighteen patients (72%) with intact septal support were treated by straightening the nose and septum followed by simple onlay grafts. Five patients (20%) with loss of septal support needed septal reconstruction. In two patients (8%) showing deviation, generalized saddling, and loss of septal support, a dorsal graft integrated to an extended columellar strut was performed, bypassing the major septal reconstruction. The key maneuvers for correction were dorsal onlay graft (100%), septoplasty (92%), and bilateral osteotomies (84%). No major complications were found. Objective evaluation showed complete correction of the deviation and saddling in 76%.

Nasal tip surgery using a modified septal extension graft by means of extended marginal incision.

BACKGROUND: The columellar strut is considered one of the standard procedures in nasal tip surgery, as it provides a structural foundation for the nasal tip. Although effective for most Caucasians, the columellar strut often results in a suboptimal outcome and does not provide an adequate foundation in Asian tip surgery. For an optimal outcome, the authors propose a different surgical paradigm for Asian tip surgery. METHODS: Using an extended marginal incision, a wide-field endonasal dissection is performed and the distal nasal framework including the alar cartilages and the caudal septum is exposed widely. A septal extension graft is made from a preoperatively designed paper template, with markings for anchoring the alar cartilage and overlapping with the caudal septum. The extension graft is fixed to the caudal septum and the alar cartilages are sutured to the extension graft at the precise position using markings transferred to the extension graft. RESULTS: This procedure was applied in 217 Asian rhinoplasties, with all patients having substantial improvement in their nasal tip shape. The advantages of this technique are numerous and include stable tip support and versatility in nasal tip modification. The same basic techniques and sequence can be applied to correct a wide range of tip deformities found in Asian noses. CONCLUSIONS: The authors' surgical paradigm combining the modified septal extension graft with wide-field endonasal dissections provides a unique opportunity to gain greater control and a more predictable outcome in Asian tip surgery. Stable septal support is crucial to the success of this technique.

The Usefulness of Rectified VEMP.

OBJECTIVES: For a reliable interpretation of left-right difference in Vestibular evoked myogenic potential (VEMP), the amount of sternocleidomastoid muscle (SCM) contraction has to be considered. Therefore, we can ensure that a difference in amplitude between the right and left VEMPs on a patient is due to vestibular abnormality, not due to individual differences of tonic muscle activity, fatigue or improper position. We used rectification to normalize electromyograph (EMG) based on pre-stimulus EMG activity. This study was designed to evaluate and compare the effect of rectification in two conventional ways of SCM contraction. METHODS: Twenty-two normal subjects were included. Two methods were employed for SCM contraction in a subject. First, subjects were made to lie flat on their back, lifting the head off the table and turning to the opposite side. Secondly, subjects push with their jaw against the hand-held inflated cuff to generate cuff pressure of 40 mmHg. From the VEMP graphs, amplitude parameters and inter-aural difference ratio (IADR) were analyzed before and after EMG rectification. RESULTS: Before the rectification, the average IADR of the first method was not statistically different from that of the second method. The average IADRs from each method decreased in a rectified response, showing significant reduction in asymmetry ratio. The lowest average IADR could be obtained with the combination of both the first method and rectification. CONCLUSION: Rectified data show more reliable IADR and may help diagnose some vestibular disorders according to amplitude-associated parameters. The usage of rectification can be maximized with the proper SCM contraction method.