Scar Assessment After Breast Reconstruction: Risk Factors for Hypertrophy and Hyperpigmentation in Asian Patients.

BACKGROUND: Breast scars after breast reconstruction can be hypertrophic and/or hyperpigmented, especially in Asian patients, whose skin is thicker and has increased melanin. Few studies have focused on breast scars after breast reconstruction, and the risk factors for an abnormal breast scar remain unknown. METHODS: We examined 257 Asian patients who underwent an immediate 2-stage unilateral implant-based breast reconstruction. Vascularity, hypertrophy, and hyperpigmentation of the patients' breast scars were assessed at 1 year postoperatively. Risk factors for an abnormal scar were analyzed statistically. Analyzed patient factors included age, body mass index, incision site (frontal or lateral), breast size (the weight of the resected specimen), skin necrosis at the initial operation (expander placement), and adjuvant therapy. RESULTS: At 1 year postoperatively, 161 patients (63%) showed normal vascularity, 77 patients (30%) showed mild vascularity, 18 patients (7%) showed moderate vascularity, and 1 patient (0.4%) showed severe vascularity. No patient factors were correlated with vascularity. Thirty-two patients (12%) showed hypertrophy, and the rate of hypertrophy was significantly higher in the patients with a lateral incision (n = 59) compared with those with a frontal incision (n = 198) (28.8% vs 7.6%, P < 0.01). Even in the frontal incision group, a lateral part of the frontal scar was likely to be hypertrophic. Forty-six patients (18%) showed hyperpigmentation, and the rate of hyperpigmentation was significantly higher in the patients with skin necrosis (n = 47) at the initial operation than those without skin necrosis (n = 210) (57.4% vs 9.0%, P < 0.01). Large breast was also a risk factor for hyperpigmentation due to its higher frequency of skin necrosis. CONCLUSIONS: In Asian patients who undergo breast reconstruction, the use of a lateral incision is a risk factor for hypertrophy, and skin necrosis at the initial operation is a risk factor for hyperpigmentation at the breast scar.

Limb-salvage surgery with vascular reconstruction after lower extremity sarcoma resection: A systematic review and meta-analysis.

BACKGROUND: Limb-salvage surgery with vascular reconstruction is the current standard treatment when sarcoma involves major vessels of the lower extremity. However, the low incidence of sarcoma and rarity of limb-salvage surgery are limiting factors for the reliable study of limb-salvage surgery. Therefore, a systematic review was conducted to establish better management of lower extremity sarcoma based on currently available evidence. METHODS: A systematic review and meta-analysis of data on limb-salvage surgery with vascular reconstruction for lower extremity sarcoma were conducted using MEDLINE through PubMed, Scopus, CINARL, and Cochrane Database of Systematic Reviews. Overall limb-salvage rate was the primary outcome, and rates of perioperative complication and arterial patency were secondary outcomes. RESULTS: Among the 271 patients (18 studies) included in this study, 69.4% underwent arterial reconstruction with autologous graft, 22.0% underwent synthetic graft, and 8.6% underwent other reconstructive methods. Pooled overall limb-salvage rate was 89.8% [95% confidence interval (CI), 85.0-93.1%] after a mean follow-up of 19-74.7 months. Pooled overall perioperative complication and arterial patency rates were 49.5% (95% CI, 42.8-56.2%) and 85.4% (95% CI, 79.5-89.9%), respectively. CONCLUSIONS: Current evidence suggests that limb-salvage surgery with vascular reconstruction has a high limb-salvage rate; however, the high perioperative complication rate remains problematic. Early and appropriate interventions are required to optimize the complications of limb-salvage surgery.

Sclerotherapy for Venous Malformations of the Pharynx or the Tongue Base Without Tracheostomy: Treatment Protocol With Intubation and Outcomes.

Venous malformations (VMs) occurring in the tongue base or pharynx are rare, but can cause airway obstruction. Considering the potential issues or morbidity related to surgical resection in the tongue or pharynx region, sclerotherapy is often preferred. We perform sclerotherapy for such lesions without conducting tracheotomy, but keep patients intubated for a certain period. Outcomes of sclerotherapy, and benefits and cautions related with our protocol were investigated.Our subjects were 10 cases in 9 patients who underwent sclerotherapy for VMs of the tongue base (6 patients) or pharynx (3 patients) from 2008 to 2017. One patient underwent treatment sessions twice. The sclerosants used were absolute ethanol (ET) (3 cases), 5% ethanolamine oleate (EO) (4 cases), or both ET and 5%EO (3 cases).In 5 of 9 patients, postoperative MRI was performed, which revealed lesion volume reduction by 12% to 47%. The intubation period varied according to the sclerosant used: ET, 5 to 11 days; 5% EO, 2 to 12 days; and combination of ET and 5% EO, 8 days. Postoperative complications included fever of unknown (n = 2), acute psychosis (n = 3), vocal cord paralysis (n = 2), and bradycardia induced from the use of a sedative agent (n = 1). One patient complained of mild transient swallowing difficulty that lasted for a month postoperatively.Although our method mandatorily requires careful postoperative management in an ICU, including sedation with anesthetic agents and artificial respiration by intubation for a certain period of time, no serious complications or post-therapeutic morbidities occurred.

Risk Factors for Macroscopic Haemoglobinuria After Sclerotherapy Using Ethanolamine Oleate for Venous Malformations.

OBJECTIVES: Sclerotherapy is an essential component of the treatment for venous malformations, and ethanolamine oleate (EO) is known as a useful sclerosing agent. However, macroscopic haemoglobinuria (MH) and subsequent renal impairment are severe complications after sclerotherapy using EO. The present study aimed to clarify the MH risk factors for better peri-operative management of venous malformations. METHODS: Data collected during 130 procedures involving 94 patients who were undergoing sclerotherapy using EO for venous malformation were retrospectively analysed. Pre-operative and operative variables, including sex, age, pre-operative body mass index, location, depth, type of lesion, size, number of procedures, type of drainage vein, ratio of sclerosant to air, and injected total dose of 5% EO per body weight (BW), were examined. Univariable analysis and multivariable logistic regression were performed to determine the possible risk factors for MH. RESULTS: Following sclerotherapy, MH occurred in 27.7% of patients, but no patient developed post-operative renal impairment because of aggressive hydration and haptoglobin administration. On univariable analysis, diffuse lesion, lesion size ≥50 cm2, and total injected dose of 5% EO ≥ 0.18 mL/kg were found to be the MH risk factors. Multivariable logistic regression analysis identified a total injected dose of 5% EO ≥ 0.18 mL/kg as the significant independent factor contributing to MH risk. CONCLUSIONS: Macroscopic haemoglobinuria is a reversible complication if immediate and appropriate interventions with aggressive hydration and haptoglobin administration are performed; therefore, it should be closely monitored following sclerotherapy, especially when using 5% EO ≥ 0.18 mL/kg.

Soft Tissue Reconstruction and Facial Reanimation With Bilateral Latissimus Dorsi Flaps After Extensive Resection of Head and Neck Arteriovenous Malformation: A Case Report.

We report a rare case of a 37-year-old man who presented with a huge arteriovenous malformation in the head and neck region. After resection, the 30 × 25 cm defect was reconstructed with a preexpanded musculocutaneous latissimus dorsi flap. The facial nerve had to be sacrificed during the resection, and smile reanimation was restored in a second operation with the contralateral latissimus muscle flap. A 15-cm length of thoracodorsal nerve was dissected and was anastomosed to the contralateral zygomatic branch in a single stage. He recovered well without any significant complications. At 6 years follow-up, there was no further growth of the arteriovenous malformation, and he had a spontaneous smile.

Convolutional neural networks for wound detection: the role of artificial intelligence in wound care.

OBJECTIVE: Telemedicine is an essential support system for clinical settings outside the hospital. Recently, the importance of the model for assessment of telemedicine (MAST) has been emphasised. The development of an eHealth-supported wound assessment system using artificial intelligence is awaited. This study explored whether or not wound segmentation of a diabetic foot ulcer (DFU) and a venous leg ulcer (VLU) by a convolutional neural network (CNN) was possible after being educated using sacral pressure ulcer (PU) data sets, and which CNN architecture was superior at segmentation. METHODS: CNNs with different algorithms and architectures were prepared. The four architectures were SegNet, LinkNet, U-Net and U-Net with the VGG16 Encoder Pre-Trained on ImageNet (Unet_VGG16). Each CNN learned the supervised data of sacral pressure ulcers (PUs). RESULTS: Among the four architectures, the best results were obtained with U-Net. U-Net demonstrated the second-highest accuracy in terms of the area under the curve (0.997) and a high specificity (0.943) and sensitivity (0.993), with the highest values obtained with Unet_VGG16. U-Net was also considered to be the most practical architecture and superior to the others in that the segmentation speed was faster than that of Unet_VGG16. CONCLUSION: The U-Net CNN constructed using appropriately supervised data was capable of segmentation with high accuracy. These findings suggest that eHealth wound assessment using CNNs will be of practical use in the future.

Liposarcoma Preoperatively Diagnosed as Lipoma: 10-Year Experience at a Single Institution.

BACKGROUND: On rare occasions, a lesion preoperatively diagnosed as a lipoma is ultimately diagnosed as a liposarcoma. It is important to differentiate liposarcomas from lipomas preoperatively. OBJECTIVE: To examine characteristic features of liposarcomas preoperatively diagnosed as lipomas. METHODS: Patients (n = 637) who underwent resection of tumors preoperatively diagnosed as lipomas from January 2006 to October 2016 were retrospectively reviewed. RESULTS: Based on pathological examination, 8 of 637 lesions were diagnosed as liposarcomas postoperatively. All the liposarcomas were well-differentiated liposarcomas. The rate of male patients was higher (87.5% vs 38.9%) and the size of tumors was larger (8.75 vs 4.64 cm) in these cases than in accurately diagnosed lipoma cases. On imaging, nonfatty septa were more frequently observed (71.4% vs 20.0%) and were thicker (2.22 vs 1.33 mm) than in true lipoma cases. CONCLUSION: If the patient with a lipomatous tumor is male and the tumor is large, we should consider the possibility of it being a liposarcoma. A thick internal septum in the image findings is a good predictor of malignancy.

A Simple and Reliable Submental Intubation Technique for Maxillofacial Fractures.

In 1986, Altemir first reported the use of submental intubation to avoid tracheotomy in patients with panfacial and midfacial fractures for whom intermaxillary fixation is necessary, but orotracheal and nasotracheal intubations are not recommended. This novel technique allowed intraoperative access to perform dental occlusion and reconstruction of the nasal pyramid in patients with skull base fractures. Herein, we describe a refined technique based on Altemir's original procedure. Seven male patients with panfacial fractures underwent submental intubation using our refined technique. The technique was developed after encountering a technical error with Altemir's original procedure. In this new technique, we employed a 2-0 silk suture guide to allow the passage of both the endotracheal and cuff-inflation tubes through the same tunnel created from the oral cavity to the submental area. The success rate of the refined technique was 100%, and there were no intraoperative or postoperative complications. There was 20 seconds of ventilation outage time in total. Endotracheal and cuff-inflation tubes were easily and quickly passed through the same submental tunnel. Our refined technique is simple, easy, safe, fast, inexpensive, and does not require specific materials. Submental scars were smaller and relatively inconspicuous in this study, compared to those reportedly associated with other modified techniques.

Implantation of Thickened Artificial Bone for Reduction of Dead Space and Prevention of Infection Between Implant and Dura in Secondary Reconstruction of the Skull.

For the treatment of skull defect compensation after neurosurgery, a customized artificial bone is often employed owing to its toughness and the relative ease of producing cosmetically good result. However, implants are vulnerable to infection and removal of implant is sometimes necessary. Several other treatment options such as autologous bone graft or free flap are likely to be considered for the secondary reconstruction to avoid reinfection; however, reimplantation of artificial bone is beneficial for the patients, being not concerned with donor site morbidity. The authors consider one of risk factors of infection of artificial bone as dead space between the implant and dura. To attain reduction of the dead space, we have employed thickened artificial bone.Between 2010 and 2014, 6 patients underwent implantation of thickened artificial bone for the secondary reconstruction.First, the infected artificial material was removed with proper debridement. More than 3 months after the closure of the infected wound, tissue expander was inserted beneath the surrounding scalp to ensure the coverage of subsequently implanted artificial bone without skin tension. The thickened artificial bone was designed from the computed tomography findings so as not to leave any dead space between the implant and dura. After optimal expansion of the scalp, the artificial bone was implanted.Postoperative courses were uneventful and the appearance of the cranial vault was satisfactory in all patients.The authors consider the use of the thickened artificial bone is easier and more suitable for patients having a skull defect, particularly in secondary reconstruction.

Drug-Induced Atrial Fibrillation Complicates the Results of Flap Surgery in a Rat Model.

The relationship between atrial fibrillation (AF) and flap survival has not been fully characterized. Therefore, the goal of this study was to investigate the effect of AF on survival areas of pedicled flap and survival rates of free flap in an experimental rat AF model. An aconitine-induced rat AF model was established without intubation anesthesia. Survival areas of the pedicled rectangular epigastric flap were compared between AF rats (n = 7) and control rats (n = 7), and survival rates of the free epigastric flap were compared between AF rats (n = 10) and control rats (n = 10). Animals that died during the study or in which AF was not induced were excluded from study. A total of 64 rats were assessed in this study. Atrial fibrillation was induced with a success rate of 77.8% (21/27) throughout the study. Pedicled flap survival area was significantly higher in controls (75.1 ± 9.0%; n = 7) than that in AF animals (55.7 ± 13.0%; n = 7) (P < 0.01, nonpaired Student t test). Free flap survival rates were 80% in controls and 40% in AF animals (P = 0.07, χ² test). This is the first study to develop an aconitine-induced model of AF in rats. Atrial fibrillation has a detrimental effect on survival areas of the pedicled flap and survival rates of the free flap.

Comparison of Nasal Septum and Ear Cartilage as a Graft for Lower Eyelid Reconstruction.

In lower eyelid reconstruction, several types of grafts from the nasal septum, ear cartilage, buccal mucosa, and hard palate mucosa have been used for an inner layer of the lower eyelid, but there have been no studies comparing these grafts. The authors retrospectively reviewed our cases of lower eyelid reconstruction, and compared chondromucosal grafts from the nasal septum (N = 8) and ear cartilage grafts (N = 10) for an inner layer of the lower eyelid. The authors observed no significant difference in operative time, blood loss, or length of hospital stay between the "nasal septum" and "ear cartilage" groups. The final results were aesthetically and functionally satisfactory in both groups. In the nasal septum group, 1 patient suffered from perforation of the nasal septum and another patient suffered from nasal bleeding postoperatively. There were no donor site complications in the ear cartilage group. These findings indicate that both a chondromucosal graft from the nasal septum and an ear cartilage graft are good grafts for an inner layer of the lower eyelid. Regarding the donor site, however, an ear cartilage graft has the advantage of a lower complication rate.

Examination of tissue oxygen saturation (StO2) changes associated with vascular pedicle occlusion in a rat Island flap model using near-Infrared spectroscopy.

PURPOSE: The purpose of this study was to perform continuous StO(2) monitoring of rat island flaps during pedicle vessel occlusion using near-infrared spectroscopy (NIRS) in order to collect experimental data for StO(2) flap monitoring under optimized conditions. MATERIALS AND METHODS: Twenty rats were used in this study. The 3 × 3 cm(2) epigastric skin island flaps were elevated on either side. The animals were randomly assigned to two groups; an arterial occlusion group (n = 10) and a venous occlusion group (n = 10). The StO(2) values of the flaps were observed for over 30 min for the pedicle artery or venous occlusion, followed by an additional 30 min release. RESULTS: The baseline StO(2) value was 78.4% ± 3.2% in the arterial occlusion group, compared to 78.5% ± 5.8% in the venous occlusion group, with no significant differences (P > 0.05). The StO(2) values decreased immediately after arterial occlusion, whereas a temporal StO(2) increase was initially observed after venous occlusion, followed by a StO(2) decrease. The StO(2) values decreased 27.3% ± 7.1% after arterial occlusion and 28.4% ± 19.1% after venous occlusion at 30 min after pedicle vessel clamping (P > 0.05). The StO(2) values were 0.4% ± 5.8% lower than baseline 30 min after arterial release (P > 0.05), while 18.9% ± 11.3% lower than baseline 30 min after venous release (P < 0.01). CONCLUSION: NIRS can be used to indicate StO(2) changes in flaps with the pedicle vessel occlusion and differentiate between pedicle artery and vein occlusion. Further investigations are needed to obtain definitive evidence associated with predicting the degree of flap viability and determine the practical use of this technique.

Efficacy of serial excisions of melanocytic nevi on the face using a carbon dioxide laser: a cosmetic point of view.

UNLABELLED: In cosmetic clinical practice, many patients express the desire for removal of melanocytic nevi, especially those on the face. The carbon dioxide (CO2) laser currently is the preferred for treatment of such lesions because of less scar formation, less bleeding, and simplicity of the procedure. However, if the diameter of the lesion is greater than 5 mm, many clinicians prefer surgical resection to laser resection because laser resection of relatively large nevi often results in the formation of a conspicuous dimple. The authors developed a serial laser excision method for melanocytic nevi larger than 5 mm, with division of the lesion into multiple segments, which allowed the ablated area to gain optimal granulation and reepithelialization, leading to a satisfactory cosmetic appearance. This novel procedure was performed for 25 patients with melanocytic nevi ranging from 5 to 10 mm in diameter. The lesions were divided into two segments in 21 patients, three segments in 3 patients, and four segments in 1 patient. The divided parts of the lesions were ablated by CO2 laser serially at intervals of 2-4 weeks. All the patients obtained optimal granulation and epithelialization in the treated lesions, and the final appearance was satisfactory. Although the therapeutic period was longer than for a surgical excision or a single laser treatment, the new treatment approach of serial excision by CO2 laser achieved favorable outcomes for the treatment of relatively large nevi 5-10 mm in size. LEVEL OF EVIDENCE V: 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 .

Effectiveness of the proximal medial branch in DIEP flaps for breast reconstruction using Hartrampf zone IV.

BACKGROUND: When performing breast reconstruction using a deep inferior epigastric artery (DIEA) perforator (DIEP) flap, including Hartrampf zone IV, the bipedicled DIEP flap has been argued to be necessary to ensure stable perfusion. However, a proximal medial branch (PMB), which is the most proximal perforator of DIEA, may make it possible to obtain adequate perfusion in a unilateral DIEP flap. This study aimed to clarify the detailed anatomical characteristics of PMB and its potential clinical applications in breast reconstruction. METHODS: This retrospective study was conducted on breast reconstruction using the DIEP flap between May 2020 and July 2023. Data on PMB anatomy were collected from preoperative contrast-enhanced computed tomography angiography, and contralateral perfusion of the flap was estimated using intraoperative indocyanine green angiography. RESULTS: PMB was present in approximately 85% of the cases, arising near the lateral border of the rectus abdominis, branching caudomedially in more than half of the cases, and perforating 2.3 cm laterally and 8.8 cm caudally, on average, from the umbilicus. The average perfusion area of zones II and IV significantly expanded to 96.5% and 74.2%, respectively, when PMB was included in the DIEP flap, and 9 of 22 cases showed contrast extending to the entire zone IV. CONCLUSIONS: The use of the DIEP flap with PMB is a good option for substantial-volume breast reconstruction. When utilizing PMB, it is important to consider its specific anatomy, location of the main perforator, and pedicle length.

Silicone sheet containing all-trans retinoic acid and hydroquinone for the treatment of epidermal melanosis.

BACKGROUND: Although bleaching treatment using all-trans retinoic acid (RA) and hydroquinone (HQ) improves epidermal melanosis, the application of two medications and the irritant dermatitis induced by RA inconvenience patients. To overcome these problems, we developed a silicone sheet containing RA and HQ. OBJECTIVE: To compare the efficacy of a silicone sheet containing RA and HQ with that of conventional bleaching treatment. METHOD: Silicone sheets containing 1% RA and 5% HQ were applied at night during the bleaching phase of 4 weeks, followed by application of sheets containing 5% HQ during the healing phase of 4 weeks. Hemifacial epidermal melanosis, for which the sheets were applied, was compared with a contralateral face which was treated conventionally using RA and HQ. Twenty-four Japanese women who were enrolled in this study and followed up for more than 6 months were analyzed. RESULTS: RA/HQ sheets improved epidermal melanosis, as did the conventional bleaching method, but irritant dermatitis occurred less in patients treated using silicone sheets. CONCLUSION: RA/HQ sheets, which are easily applied to face skin, can improve epidermal melanosis to the same extent as conventional bleaching.

Reinnervation of segmented latissimus dorsi muscle with the distal stump of the thoracodorsal nerve: A preliminary experimental study in rats.

To date, nerve stumps have been dissected at the proximal side of the donor muscle for reinnervation of the muscle in free neurovascular muscle transfer. Herein, we examined the use of the distal thoracodorsal nerve, dissected from the muscle belly at the distal side of the latissimus dorsi muscle, for the reinnervation of muscle. The rat right latissimus dorsi muscle was employed as the model for our study. Twenty Wistar rats were used in this study. A rectangular muscle segment was dissected with the distal stump of dominant thoracodorsal nerve. After rotation of muscle, the distal nerve stump was sutured to a severed proximal recipient thoracodorsal nerve (n = 5). The degree of reinnervation through the distal nerve stump was compared with control groups that received proximal-to-proximal nerve sutures (n = 5), nerves that were not severed (n = 5), and severed nerves that were not sutured (n = 5) using electrophysiological, histological, and muscular volume assessments. Reinnervation of the distal nerve stump was confirmed by the contraction of the muscle following electrical stimulation and electromyography. Crossing of axons into motor endplates was confirmed by histology. Results of these assays were similar to that of the proximal nerve suture group. The volume of muscle in the distal nerve suture group was not significant different from that of the proximal nerve suture group (P = 0.63). It was demonstrated that the distal stump of the thoracodorsal nerve can be used to innervate segmented latissimus dorsi muscle. This novel procedure for the reinnervation of transplanted muscle deserves further investigations.

Clinical factors associated with postoperative complications and the functional outcome in mandibular reconstruction.

BACKGROUND: Few studies have performed a multiple factor analysis to assess the factors associated with successful mandibular reconstructions in a large number of subjects. The purpose of this study is to evaluate the functional outcome in mandibular reconstruction by means logistic regression analysis. METHODS: Since April 2005 to September 2009, 126 patients underwent segmental resection of the mandible for cancer ablation and mandibular reconstruction with free flaps at 6 Japanese institutions. The patients' charts were reviewed retrospectively. Twelve patients were excluded for the reconstruction was with double flaps, or they went under secondary reconstruction. With logistic regression analysis in 114 subjects, we assessed multiple factors influencing postoperative speech intelligibility, feeding ability, and postoperative complications of mandibular reconstruction. RESULTS: The use of a reconstruction plate with a soft-tissue free flap only was showed to have a deleterious effect on postoperative feeding. The strong association in the level of statistical significance between the use of a reconstruction plate with soft-tissue free flaps only and the occurrences of major complications was indicated. It was also statistically revealed that the postoperative presence of opposing teeth contributed to both speech intelligibility and oral intake. CONCLUSIONS: In our research, osteocutaneous flaps were superior to reconstruction plates with soft-tissue free flaps regard to the postoperative feeding ability and major complication rate.

Differential expression of wound fibrotic factors between facial and trunk dermal fibroblasts.

Clinically, wounds on the face tend to heal with less scarring than those on the trunk, but the causes of this difference have not been clarified. Fibroblasts obtained from different parts of the body are known to show different properties. To investigate whether the characteristic properties of facial and trunk wound healing are caused by differences in local fibroblasts, we comparatively analyzed the functional properties of superficial and deep dermal fibroblasts obtained from the facial and trunk skin of seven individuals, with an emphasis on tendency for fibrosis. Proliferation kinetics and mRNA and protein expression of 11 fibrosis-associated factors were investigated. The proliferation kinetics of facial and trunk fibroblasts were identical, but the expression and production levels of profibrotic factors, such as extracellular matrix, transforming growth factor-ß1, and connective tissue growth factor mRNA, were lower in facial fibroblasts when compared with trunk fibroblasts, while the expression of antifibrotic factors, such as collagenase, basic fibroblast growth factor, and hepatocyte growth factor, showed no clear trends. The differences in functional properties of facial and trunk dermal fibroblasts were consistent with the clinical tendencies of healing of facial and trunk wounds. Thus, the differences between facial and trunk scarring are at least partly related to the intrinsic nature of the local dermal fibroblasts.

The aspect ratio of the palpebral fissure as a new blepharoptosis parameter.

Although the margin reflex distance (MRD) is widely used to assess blepharoptosis, it has some drawbacks (e.g. inaccuracy in severe ptosis). A new parameter is desired. We digitally analyzed pre- and post-operative photographs of 95 patients with blepharoptosis. We set a rectangle with the vertical sides at the lateral and medial canthus and the horizontal sides at the highest and lowest points of the eyelids. We calculated the percentage of the vertical side (height) to the horizontal side (width) and defined this value as the vertical percentage of the palpebral fissure. The MRD and the vertical percentage values were strongly correlated (correlation coefficient 0.766). In the 77 bilateral cases, both sides showed significant improvement in vertical percentage (from 28.9 to 37.3%, right) and (28.7 to 36.1%, left). In the 18 unilateral cases, the affected side showed significant improvement in vertical percentage (from 29.6 to 38.7%), while the unaffected side showed no change. In the eight patients who underwent re-operation, the revised side's vertical percentage was not improved after the first operation (from 28.0 to 31.3%), and the revision significantly changed the vertical percentage to 39.0%. In the re-operated patients, the difference between the right and left sides decreased significantly from 6.7 to 1.9% post-revision. The aspect ratio of each palpebral fissure (the percentage of height to width) reflected the progression of blepharoptosis and the post-operative changes. The aspect ratio thus has the potential to be a new parameter for blepharoptosis.