Unstable Expansion: The Development of the Military Medical Evacuation Chain in Korea, 1948-1953.

This research examines the expansion and characteristics of the Korean Army's chain of medical evacuation in 1948-1953. The most important goal of the chain of medical evacuation was to conserve fighting strength, which cannot be achieved only by sending the sick and wounded to the rear for treatment. It was more important to maintain as many mission-capable wounded soldiers on the frontline. Therefore, triage for conserving strength was the priority in the evacuation process, and military doctors conducting triage played a significant role. Focusing on military doctors, this article studies the instability of the Korean Army's medical evacuation chain. Although Korea was liberated from Japanese colonial rule in August 1945, Korea had no army or army medical services. With the support of KMAG, the Korean Army was able to build a nationwide evacuation chain during the Korean War. However, the expansion of the medical evacuation chain resulted in instability. At the heart of the instability was manpower, rather than organization and transportation. Koreans had almost no experience with the military medical services before 1948, and during the Korean War, most doctors, who had been conscripted after the outbreak of the war, were not trained as military doctors. Therefore, the Korean Army had no other choice but to conduct medical evacuations using mobilized civilian doctors who were not sufficiently trained as military doctors. The escalating war revealed the problems of civilian doctors in military uniforms. Unlike the goal of the chain of medical evacuation, they easily evacuated patients and were reluctant to release patients to return to their duties. Korean Army doctors who were not sufficiently trained as military doctors struggled between the goals of military medical services and those of medical care. Consequently, the military doctors and the instability of the medical evacuation chain during the Korean War reflect the fundamental tension between war and medicine.

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.

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.

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.

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.

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.