Long-term outcomes of neuroendoscopic cyst partial resection combined with stereotactic radiotherapy for craniopharyngioma.

PURPOSE: The aim of this study was to evaluate the treatment outcomes of neuroendoscopic cyst partial resection (ECPR) combined with stereotactic radiotherapy (SRT) for cystic craniopharyngiomas. METHODS: In this retrospective study, 22 craniopharyngioma patients undergoing ECPR combined with SRT were included. This combination therapy was indicated for suprasellar cystic craniopharyngiomas in patients whose pituitary function was preserved but would be difficult to preserve in direct surgery. The outcomes of combination therapy, including tumor control and postoperative visual and pituitary functions, were investigated. RESULTS: ECPR was safely performed, and cyst shrinkage was accomplished in all cases. After ECPR, visual function improved in 12 of 13 patients (92%) with visual field disturbance and did not deteriorate in any patients. Pituitary function was preserved in 14 patients (64%) and deteriorated in eight patients (36%) after ECPR. As a complication of ECPR, meningitis occurred because of a wound infection in one patient. In 18 of 22 patients (82%), the tumor was controlled without further treatment 19 - 87 months (median, 33 months) after SRT. Hypopituitarism was an adverse event after SRT in two of the 18 patients who achieved tumor control. Four patients (18%) had enlarged cysts after SRT. Postoperative pituitary function was significantly more likely to deteriorate in cases of extensive detachment from the ventricular wall, and retreatment was significantly more common in cases with hypothalamic extension. CONCLUSION: Although limited to some cases, ECPR combined with SRT is a less invasive and useful therapeutic option for suprasellar cystic craniopharyngiomas. However, its long-term prognosis requires further evaluation.

Craniofacial Fracture with Superior Orbital Fissure Syndrome Resulting in Pupil-sparing Oculomotor Nerve Palsy.

Superior orbital fissure syndrome (SOFS) is a rare complication of craniofacial fracture, caused by damage to cranial nerves Ⅲ, Ⅳ, Ⅴ, and Ⅵ, which typically is associated with ophthalmoplegia, blepharoptosis, pupil dilatation and fixation, and upper eyelid and forehead hypesthesia. However, we here describe a very unusual case of craniofacial fracture with SOFS in the absence of pupil symptoms, involving a patient who was injured when he fell while riding his bicycle. Upon medical examination, we observed mild blepharoptosis and ophthalmoplegia of the right eye without pupillary symptoms. Computed tomography (CT) revealed basal skull and zygomatic fractures. After the patient had been treated conservatively for his skull base fracture, facial bone reduction was performed at our hospital. Because ophthalmoplegia and blepharoptosis remained after the surgery, we checked the preoperative CT images again and discovered stenosis of the superior orbital fissure. Postoperative CT revealed a widening of the superior orbital fissure after the facial bone reduction, and therefore, the patient was given steroid treatment without additional surgery. At 6 months postoperatively, the cranial nerves had completely recovered. Our finding emphasizes that, in contrast to common theory, trauma-induced SOFS can result in pupil-sparing oculomotor nerve palsy.

[Recent Progress in Treatments of Pituitary Neuroendocrine Tumors(Pituitary Tumors)].

In the World Health Organization 2022 classification, a nomenclature change from pituitary adenoma to pituitary neuroendocrine tumor(PitNET)was introduced to indicate rare but potentially malignant behavior. No grading system is available for PitNETs; therefore, the establishment of a system that corresponds to their clinical behavior is an urgent issue. Presently, this change has no direct influence on therapeutic strategies. Recently, the therapeutic outcomes of most patients with PitNETs have significantly improved owing to marked advancements in both surgical and medical treatments. The former includes the evolution of endoscopic surgery and technical refinements, whereas the latter includes the introduction of new effective drugs and increased knowledge and experience regarding their use, leading to personalized and/or precision medicine. Consequently, the treatment goals have advanced, encompassing endocrinological remission, successful management of comorbidities, increased health-related quality of life, and a normalized mortality rate. However, management of some aggressive and metastatic PitNETs remains difficult. Although temozolomide(TMZ)is considered a promising sole therapeutic option, recent reports have shown that TMZ does not provide long-term control in many cases. A multidisciplinary approach is necessary for the reliable prediction and successful management of aggressive tumors.

Influences of hair dyeing on the distribution shapes of zolpidem and methoxyphenamine in hair.

In order to investigate the influences of hair dyeing on the distribution shapes of drugs in hair, different hair dyeing processes ("semi-permanent coloring without bleaching" and "permanent coloring with bleaching") were performed in vitro on black hair specimens collected from two subjects (Asians) who took a single dose of zolpidem (ZP, 10 mg of ZP tartrate) or methoxyphenamine (MOP, 50 mg of MOP hydrochloride). Under the following three different dyeing conditions, (1) semi-permanent coloring, (2) permanent coloring (once), (3) permanent coloring (twice), drug distributions in single hair specimens were investigated using a 2-mm segmental analysis by liquid chromatography-tandem mass spectrometry. Distribution shapes of drugs changed significantly only under the permanent coloring (twice) condition, resulting in reduced peak concentration and extended distribution width. There was, however, no significant difference in the amounts of drugs in hair between non-treated and dyed specimens, suggesting the drugs hardly leaked out of hair or were only slightly degraded during dyeing. In addition, while assuming contact with aqueous environment such as daily hair washing after dyeing, dyed hair specimens were individually immersed in ultrapure water for 20 hours, then the outflow of drugs in ultrapure water as well as the distribution shapes of drugs remaining in hair were determined. The drug outflow after permanent coloring (once and twice) was significantly larger than those after semi-permanent coloring, and the outflow ratios, [outflow]/([outflow] + [amount remaining in hair]), ranged over 9.8-24% (n = 3) for ZP and 68-71% (n = 3) for MOP after permanent coloring (once), and 54-72% (n = 3) for ZP and 86-91% (n = 3) for MOP after permanent coloring (twice). The distribution shapes of drugs after 20 h of immersion tended to flatten as outflow ratios increased, resulting in no change in the shapes after semi-permanent coloring, and complete collapse of their shapes after permanent coloring (twice). Thus, the present results indicated that hair dyeing involving bleaching and subsequent contact with aqueous environment after dyeing could significantly influence distribution shapes of drugs in hair.

What are the Factors That Induce Paradoxical Hypertrichosis After Laser Hair Removal?

BACKGROUND: Laser hair removal (LHR) is one of the most requested cosmetic procedures worldwide. A rare side effect is the appearance of excess hair around previously treated areas, known as paradoxical hypertrichosis. OBJECTIVES: The aim of this study was to retrospectively identify the cause of this side effect. METHODS: This study included all patients who underwent LHR at our center between November 2018 and November 2020. Alexandrite laser hair removal (HR) or diode laser super hair removal (SHR) was performed in 70% and 30% of cases, respectively. Clinical features and daily habits of patients with and without postlaser hypertrichosis were compared. RESULTS: Of the 7381 patients who received LHR, 25 patients (0.34%) demonstrated an increase in hair growth compared to baseline. Of these 25 patients, 24 had been treated with alexandrite laser HR (P < .01). The most common site was the upper arm, followed by the periareolar area. Daily sun protection was associated with a significantly lower incidence of hypertrichosis (P < .05), as was confirmed and shown to be independent of Fitzpatrick skin type by binary logistic regression analysis (odds ratio = 0.41, P < .05). CONCLUSIONS: In our clinic, we observed paradoxical hypertrichosis after laser hair removal in a small minority of cases, as described by others. We did not observe differences in incidence related to skin type, but daily sun protection and LHR with diode laser SHR were associated with significant reductions in incidence rates. In addition to previously reported common sites, we also identified the periareolar area as a high-risk region.

The outcomes of a standardized protocol for extracorporeal mechanical circulatory support selection-left ventricular challenge protocol.

There are no criteria for surgical mechanical circulatory system (MCS) selection for acute heart failure. Since 2021, we have utilized cardiopulmonary bypass system to assess patients' heart and lung condition to inform surgical MCS selection. we aimed to retrospectively analyze the outcomes of treatments administered using our protocol. We analyzed the data of 19 patients who underwent surgical MCS implantation. We compared patients' characteristics across the biventricular-assist device (BiVAD), central Y-Y extracorporeal membrane oxygenation (ECMO), central ECMO, and left VAD (LVAD) systems. Patients' diagnoses included fulminant myocarditis (47.4%), dilated cardiomyopathy (21.1%), acute myocardial infarction (15.8%), infarction from aortic dissection (5.3%), doxorubicin-related cardiomyopathy (5.3%), and tachycardia-induced myocarditis (5.3%). Eight patients (42.1%) underwent LVAD implantation, 1 (5.2%) underwent central ECMO, 4 (21.1%) underwent BiVAD implantation, and 6 (31.6%) underwent central Y-Y ECMO. 48 h after surgery, both the pulmonary arterial and right atrial pressures were effectively controlled, with median values being 19.0 mmHg and 9.0 mmHg, respectively. No patients transitioned from LVAD to BiVAD in the delayed period. Cerebrovascular events occurred in 21.1%. Successful weaning was achieved in 11 patients (57.9%), and 5 patients (26.3%) were converted to durable LVAD. Two-year cumulative survival was 84.2%. Our protocol showed good results for device selection in patients with heart failure, and device selection according to this protocol enabled good control of the pulmonary and systemic circulations.

A Prospective, Multicenter, Observational Study of Surgical vs Nonsurgical Management for Pituitary Apoplexy.

CONTEXT: Pituitary apoplexy (PA) has been traditionally considered a neurosurgical emergency, yet retrospective single-institution studies suggest similar outcomes among patients managed medically. OBJECTIVE: We established a multicenter, international prospective registry to compare presentation and outcomes in PA patients treated with surgery or medical management alone. METHODS: A centralized database captured demographics, comorbidities, clinical presentation, visual findings, hormonal status, and imaging features at admission. Treatment was determined independently by each site. Key outcomes included visual, oculomotor, and hormonal recovery, complications, and hospital length of stay. Outcomes were also compared based on time from symptom onset to surgery, and from admission or transfer to the treating center. Statistical testing compared treatment groups based on 2-sided hypotheses and P less than .05. RESULTS: A total of 100 consecutive PA patients from 12 hospitals were enrolled, and 97 (67 surgical and 30 medical) were evaluable. Demographics, clinical features, presenting symptoms, hormonal deficits, and imaging findings were similar between groups. Severe temporal visual field deficit was more common in surgical patients. At 3 and 6 months, hormonal, visual, and oculomotor outcomes were similar. Stratifying based on severity of visual fields demonstrated no difference in any outcome at 3 months. Timing of surgery did not affect outcomes. CONCLUSION: We found that medical and surgical management of PA yield similar 3-month outcomes. Although patients undergoing surgery had more severe visual field deficits, we could not clearly demonstrate that surgery led to better outcomes. Even without surgery, apoplectic tumor volumes regress substantially within 2 to 3 months, indicating that surgery is not always needed to reduce mass effect.

Clinical Factors Affecting Daily Dosage of Desmopressin Orally Disintegrating Tablets in Arginine Vasopressin Deficiency.

CONTEXT: Desmopressin orally disintegrating tablets (ODTs) are widely used to treat arginine vasopressin deficiency (AVP-D). However, limited information is available on the dosage regimen; the dosage for each patient is selected based on their response to the initiation dose. OBJECTIVE: To investigate the relationships between clinical characteristics and the daily dose of ODTs and to identify factors that affect ODT dosages. METHODS: This retrospective study included 209 adult patients with AVP-D. Patients were administered ODTs sublingually and instructed to restrict eating and drinking for 30 minutes after taking ODTs using a patient leaflet. ODT dose titration was conducted during hospitalization with close monitoring of urine output, body weight, and serum sodium levels. Multivariable linear regression models were applied to identify clinical factors associated with the daily dose of ODTs at discharge. We also evaluated the dosage at 1 year in 134 patients who were followed up in our hospital. RESULTS: The median daily dose of ODTs at discharge was 90 µg (IQR 60-120 µg). Multivariable linear regression models identified sex, age, and estimated creatinine clearance (eCCr) as significant factors associated with the daily dose of ODTs, with eCCr having the strongest effect. After excluding patients recovering from AVP-D, 71% of those followed up at our hospital took the same daily dose at 1 year after discharge. CONCLUSION: To achieve the safe and stable treatment of AVP-D, the daily dose of ODT needs to be selected based on a patient's sex, age, and eCCr under appropriate sublingual administration by patient education.

[Histological Classification and Diagnosis of Sellar/Parasellar Tumors].

In the 5th edition of the WHO classification of pituitary tumors, there are several significant changes:(1)the nomenclature has evolved from "pituitary adenoma" to "pituitary neuroendocrine tumor"(PitNET);(2)PitNETs are now categorized in detail based on tumor lineage, cell type, and related characteristics;(3)the routine use of pituitary transcription factor(PIT1, TPIT, SF1)immunohistochemistry for PitNET classification;(4)there is a distinction between two types of craniopharyngioma(CP), adamantinomatous CP and papillary CP, characterized by CTNNB1(ß-catenin)and BRAF mutations, respectively;(5)the integration of four subtypes of posterior lobe(neurohypophysial)tumors, known as the family of pituicyte tumors that express TTF1, is emphasized. Regarding tumor proliferation markers, the assessment of the Ki-67 proliferation index remains important, although no specific cutoff value was provided. Certain PitNET subtypes have been recognized as clinically more aggressive, referred to as high-risk PitNETs. However, it is worth noting that the classification does not introduce a new grading system for PitNETs.

Ipsilateral Visual Loss Caused by Optic Nerve Compression between a Tuberculum Sellae Meningioma and the Internal Carotid Artery.

We report a rare case of ipsilateral visual loss caused by compression of the optic nerve between a tuberculum sellae meningioma (TSM) and the internal carotid artery (ICA). The patient was a 70-year-old female who presented with a 2-year history of left visual disturbance with a TSM on magnetic resonance imaging. No tumor infiltration to the optic canal was identified in the preoperative images. Extended endoscopic transsphenoidal surgery was performed and showed no infiltration to the optic canal. The tumor was removed completely, and optic nerve compression was found between the TSM and atherosclerotic ICA. This report shows an atypical case in which compression of the optic nerve between a TSM and the ICA caused ipsilateral visual loss despite no infiltration to the optic canal.

[WHO Histological Classification of Pituitary Tumors].

The major changes in the upcoming 5th edition of the "2022 WHO Classification of Endocrine and Neuroendocrine Tumors" include:(1)evolution of the nomenclature: from pituitary adenoma to pituitary neuroendocrine tumour(PitNET),(2)detailed subtyping of a PitNET based on the tumor lineage, cell type, and related characteristics,(3)endorsement of the routine use of immunohistochemistry for pituitary transcription factors(PIT1, TPIT, SF1, GATA3, and ER-alpha),(4)introduction of some additional clinicopathologically distinct PitNET subtypes,(5)introduction of the term "metastatic PitNET" to replace the previous terminology "pituitary carcinoma," and(6)unifying posterior lobe tumors, the family of pituicyte tumors that invariably express TTF1, et al. Currently, no widely agreed grading or staging systems for PitNETs exist. Prognosis varies by tumor subtype and certain tumor subtypes are recognized as more aggressive(high-risk PitNETs)than others. Potentially aggressive PitNETs should be identified on an individual basis upon considering the tumor subtype, proliferative potential, and tumor invasion assessment.

Immunohistochemical and ultrastructural review of six cases previously diagnosed as null cell PitNETs.

Pituitary neuroendocrine tumors (PitNETs) lacking lineage affiliation are termed "null cell" PitNETs (NCTs). NCTs are characterized as being immunonegative for pituitary hormones as well as transcription factors. We analyzed the ultrastructure and immunohistochemistry of six hormone-negative and transcription factor (TPIT, PIT1, SF1)-negative PitNETs, with less than 1% immunoreactive cells. Histologically, three cases presented a perivascular pattern and pseudorosettes; the other three showed a solid pattern with oncocytic changes. Electron microscopic examination revealed poorly differentiated tumor cells with sparsely scattered secretory granules and intracellular organelles in all null cell tumors when compared with hormone-positive PitNETs. Two cases harbored a honeycomb Golgi (HG) structure, and three oncocytic tumors showed mitochondrial accumulation. The two HG cases were immunopositive for newly obtained TPIT (CL6251) and showed some adrenocorticotropic hormone-positive cells, while the remaining four were diffusely immunopositive for GATA3, with two SF1-positive cases identified in subsequent immunostaining. Thus, these six cases may be classified as two sparsely granulated corticotroph PitNETs, two gonadotroph PitNETs with SF1 re-staining, and two likely gonadotroph PitNETs with GATA3 immunostaining. No "true NCT" was detected among 1071 PitNETs, demonstrating the importance of precise diagnosis following the most recent criteria to improve therapeutic success.

Aggressive pituitary tumors (PitNETs).

The majority of anterior pituitary tumors behave benignly, that is, they grow slowly and do not metastasize, and were therefore called adenomas. However, they would frequently invade adjacent structures, leading to recurrence. One of the misleading assumptions in their previous classification was the simplistic distinction made between adenoma and carcinoma. In the upcoming WHO 2022 classification, a new terminology will be introduced: pituitary neuroendocrine tumor (PitNET) which is consistent with that used for other neuroendocrine neoplasms. In general, aggressive PitNETs are invasive and proliferative tumors with frequent recurrences, resistant to conventional treatments, and yet virtually without metastases. At present, no single morphological or histological marker has been shown as yet to reliably predict their aggressive behavior. In terms of treatment, temozolomide (TMZ) had been considered promising and the sole therapeutic option for aggressive and malignant PitNETs following failure of standard therapies. However, recent reports have disclosed that TMZ does not provide long-term control of many aggressive PitNETs. A further multidisciplinary approach is necessary for both reliable prediction and successful management of aggressive PitNETs.

Corrigendum: Guidance for the treatment of adult growth hormone deficiency with somapacitan, a long-acting growth hormone preparation.

[This corrects the article DOI: 10.3389/fendo.2022.1040046.].

Human and rat microsomal metabolites of N-tert-butoxycarbonylmethamphetamine and its urinary metabolites in rat.

PURPOSE: N-tert-Butoxycarbonylmethamphetamine (BocMA), a masked derivative of methamphetamine (MA), converts into MA under acidic condition and potentially acts as a precursor to MA following ingestion. To investigate the metabolism and excretion of BocMA, metabolism tests were conducted using human liver microsomes (HLM), rat liver microsomes (RLM) and rat. METHODS: BocMA metabolites were analyzed after 1000-ng/mL BocMA incubation with microsomes for 3, 8, 13, 20, 30, and 60 min. Rats were administered intraperitoneal injections (20 mg/kg) of BocMA and their urine was collected in intervals for 72 h. Metabolites were detected by liquid chromatography-tandem mass spectrometry with five authentic standards. RESULTS: Several metabolites including 4-hydroxy-BocMA, N-tert-butoxycarbonylephedrine and N-tert-butoxycarbonyl-cathinone were detected for HLM and RLM. In the administration test, three glucuronides of hydroxylated metabolites were detected. The total recovery values of BocMA and the metabolites during the first 72 h accounted for only 0.3% of the administered dose. Throughout the microsomal and administration experiments, MAs were not detected. CONCLUSION: Hydroxylation, carbonylation and N-demethylation were proposed as metabolic pathways. However, BocMA and phase I metabolites were hardly detected in urine. This study provides useful information to interpret the possibility of BocMA intake as the cause of MA detection in biological sample.

Proteogenomic landscape and clinical characterization of GH-producing pituitary adenomas/somatotroph pituitary neuroendocrine tumors.

The clinical characteristics of growth hormone (GH)-producing pituitary adenomas/somatotroph pituitary neuroendocrine tumors (GHomas/somatotroph PitNETs) vary across patients. In this study, we aimed to integrate the genetic alterations, protein expression profiles, transcriptomes, and clinical characteristics of GHomas/somatotroph PitNETs to identify molecules associated with acromegaly characteristics. Targeted capture sequencing and copy number analysis of 36 genes and nontargeted proteomics analysis were performed on fresh-frozen samples from 121 sporadic GHomas/somatotroph PitNETs. Targeted capture sequencing revealed GNAS as the only driver gene, as previously reported. Classification by consensus clustering using both RNA sequencing and proteomics revealed many similarities between the proteome and the transcriptome. Gene ontology analysis was performed for differentially expressed proteins between wild-type and mutant GNAS samples identified by nontargeted proteomics and involved in G protein-coupled receptor (GPCR) pathways. The results suggested that GNAS mutations impact endocrinological features in acromegaly through GPCR pathway induction. ATP2A2 and ARID5B correlated with the GH change rate in the octreotide loading test, and WWC3, SERINC1, and ZFAND3 correlated with the tumor volume change rate after somatostatin analog treatment. These results identified a biological connection between GNAS mutations and the clinical and biochemical characteristics of acromegaly, revealing molecules associated with acromegaly that may affect medical treatment efficacy.

"Predicting Facial Changes After Blepharoplasty".

INTRODUCTION: The primary goal of blepharoplasty for blepharoptosis and blepharochalasis is to elevate the upper eyelid to restore a full field of vision, although many surgeons also aim to provide a better aesthetic outcome. Several facial configuration changes may occur following blepharoplasty. This study examined the effectiveness of vessel clips to preoperatively predict facial configuration alterations. METHODS: We retrospectively enrolled 93 consecutive patients who underwent blepharoplasty correction for blepharoptosis and blepharochalasis with eyebrow elevation. Frontal portrait images were taken at the initial examination without load, preoperatively with vessel clips, and without load at 6 months postoperatively for evaluations of eyebrow height, forehead wrinkle length, and procerus area wrinkle length. Subjective outcomes were also surveyed by questionnaires and interviews at 6 months post-surgically. RESULTS: No significant differences were detected between preoperative measurements with vessel clips and recordings at 6 months postoperatively. Significant correlations were identified among the addition/reduction values for preoperative and postoperative measurements (eyebrow height and forehead wrinkle length: r=0.402, p<0.001; eyebrow height and procerus area wrinkle length: r=-0.327, p<0.01; forehead wrinkle length and procerus area wrinkle length: r=-0.488, p<0.001). Women more frequently described notable changes in wrinkles than men. CONCLUSIONS: Postoperative facial change outcomes for blepharoplasty may be predicted using the simple but effective vessel clip test. A better understanding of surgical results can relieve patient anxiety and contribute to increased satisfaction.

Recurrent Bleeding after Head Trauma Caused by Acquired Factor XIII Deficiency.

Factor XIII (FXIII) is the final factor in the coagulation cascade. FXIII plays a critical role in clot stabilization by cross-linking fibrin and making the clot denser and stiffer. FXIII plays crucial roles in platelet clot retraction, wound healing, and tissue repair. When FXIII is deficient, unusual bleeding that persists for several days, delayed healing, and morbid granulation may occur. We present a case of acquired FXIII deficiency presenting as recurrent bleeding after head trauma. A 66-year-old man fell from a ladder and sustained a head injury. The patient had a history of postremission acute myeloid leukemia and Stanford type B aortic dissection and was on three antihypertensives but no antiplatelets or anticoagulants. Approximately 1 month postinjury, the patient suddenly experienced repeated bleeding and hematoma. Routine coagulation tests were normal; therefore, we suspected another type of coagulation disorder. Low FXIII activity was identified 39 days postinjury. We immediately administered concentrated human coagulation FXIII (Fibrogammin P). The patient's head contusion was completely healed by day 55 postinjury. Acquired FXIII deficiency should be considered when routine coagulation test results are normal. Plastic surgeons who treat injuries routinely must be cognizant of FXIII deficiency because the condition can be life-threatening and early detection is important. Whenever the process of wound healing is unusual or hematoma and bleeding recur unexpectedly with no clear explanation-despite suitable treatments-FXIII deficiency should be suspected and, if present, must be appropriately treated without delay.

Morphological Changes in Faces Depending on Posture.

Facial surgeries are usually performed with the patient in the supine position; however, it is crucial to predict postoperative results in the upright position. This study aimed to clarify the posture-related morphological changes in the facial soft tissue regarding age and sex, using physical measurements to obtain results in specific linear metric measurements of standard facial features. One hundred healthy volunteers were divided into four groups based on age and sex (25 young men, 25 young women, 25 old men, 25 old women). For all participants, 18 measuring points were marked on the skin along with 18 paired linear measurements, and the angle was measured using a digital sliding caliper and angle meter in both upright and supine positions. In all four groups, the intercanthal width (en-en), binocular width (ex-ex), length of the eye fissure (en-ex), length of the nasal bridge (n-prn), width of the nose (al-al), height of the lower face (sn-gn), vermilion height of the lower lip (sto-li), height of the lower lip (sto-sl), width of the philtrum (cphi-cphi), width of the mouth (ch-ch), and nasolabial angle (NLA) were significantly larger in the supine position than in the upright position. The increase was larger in the older age groups than in the younger age groups. Moreover, the increase was larger in old men than in old women. During facial surgery involving these areas, surgeons should consider the patient's age and sex and understand what facial figuration change would occur depending on posture and change their preoperative design or make minor adjustments during operation in the supine position to increase patient satisfaction.