西岡 宏

BACKGROUND: Lymphatic vessels support wound recovery and absorb excess fluid. Blepharoplasty involves excess tissue excision, and this study investigated the relationship between lymph vessel density in excised tissue and the postoperative course. METHODS: Forty eyelids from 21 patients with blepharoptosis who underwent blepharoplasty were included. Each resected excess tissue sample was divided into 4 parts by 3 parasagittal cuts-medial, central, and lateral. The area percentages occupied by lymphatic vessels and elastic fibers in the inner tissue between skin and muscle, exposed by these cuts, were determined histologically. The wound-healing process was assessed at 2 weeks and 1, 3, and 6 months postoperatively, using a visual analog scale (VAS) to estimate edema and the Vancouver Scar Scale (VSS) for scar assessment. RESULTS: With increasing age, the area percentage of lymphatic vessels declined significantly (r = -0.581, p < 0.001), while an increase in solar elastosis was observed. The percentage of lymphatic vessels was highest on the medial side of the eyelid (p < 0.05), where their relative distribution to the "shallow layer" close to the skin was also the highest (p < 0.01). Independent of age, the VSS values at 2 weeks and 1 month postoperatively were significantly lower in patients with a higher area percentage of lymphatic vessels (2 weeks: p < 0.05; 1 month: p < 0.01). CONCLUSIONS: In patients undergoing blepharoplasty, the percentage of lymphatic vessels in the upper eyelid tissue decreased with advancing age. Higher proportions of lymphatic vessels were associated with improved wound-healing outcomes.

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.

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.

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.

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.

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.

PURPOSE: A drain tube is commonly inserted during breast reconstruction surgery. This leads to a scar in addition to the scar on the breast. This study was performed to investigate how patients feel about the drain scar and to clarify its ideal location. METHODS: A questionnaire survey about the drain scar was distributed to 38 consecutive breast reconstruction patients and a total of 104 female doctors and nurses engaged in breast reconstruction. The drain scars were evaluated using the Japan Scar Workshop (JSW) Scar Scale. RESULTS: A total of 32% of the patients expressed some anxiety about the drain scar. Patients who were anxious about the drain scar had higher scores on the JSW Scar Scale than those who were not anxious. Younger doctors and nurses preferred the drain scar to be on the side of the chest, while older doctors and nurses preferred the drain scars to be at the axilla. CONCLUSIONS: About a third of the patients had some anxiety associated with their drain scar after breast reconstruction surgery, and this anxiety level was correlated with objective assessment of the scar. Thus, more patient involvement or the provision of more information regarding drain placement is required.

Background: Blepharoptosis operations are performed under local anaesthesia, and it is necessary to determine the location where the levator aponeurosis is fixed to the tarsus by checking opening and closing of the eyelids during surgery. Changes in posture during the operation affect the facial condition in various ways. This study was performed to clarify the differences in palpebral fissure height according to intraoperative head position. Methods: Sixty subjects (48 women and 12 men aged 20-76 years) were enrolled in the study. The palpebral fissure height of the dominant eye was measured in the head-neutral position and 30° head-down position. Results: The total fissure height in the 30° head-down position was lower than that in the head-neutral position. Conclusions: The head-down position affects the patient's fissure height and may mislead the operator. Blepharoptosis operation under local anaesthesia should be performed with the patient in the head-neutral position.

Several operative techniques for inframammary fold (IMF) reconstruction have been described and have resolved the shortcomings of conventional methods. However, there are still difficulties with IMF reconstruction, that is, performance through small mastectomy scars, creation of a smooth IMF curve, transfer of external IMF markings to the interior chest wall, or determining correct IMF without an implant in place. We have used a type of anchor suture with a completely percutaneous approach, the vertical pendulum suture (VP suture), to reconstruct the IMF easily in implant-based breast reconstruction.The VP suture requires a pair of skin incisions a few millimeters in length (incisions A and B). The needle passes through the subcutaneous tissue from incision A, the chest wall, again through the subcutaneous tissue, and exits from incision B. Then, the needle passes through the edge of the dermis from incision B, the superficial layer of the subcutaneous tissue, again through the other edge of the dermis, and exits from incision A. The knot is tied and buried in the subcutaneous tissue. The whole technique can be performed percutaneously without visualizing the inside of the pocket. A retrospective case series study of photographs and chart review was conducted for all cases of unilateral implant-based breast reconstruction performed from December 2016 to December 2017 at Ina Central Hospital, Ina, Japan.Nine consecutive patients underwent unilateral implant-based breast reconstruction. Five patients treated using the VP suture were included in this study. All 5 patients showed good esthetic results over the follow-up period (average, 11 months). Scalloped appearance was observed in all patients, but flattened spontaneously and disappeared within 3 months postoperatively. There were no complications, such as hematoma, infection, skin necrosis, pneumothorax, seroma, scar contracture, or implant injury.The VP suture is completely percutaneous, parallel to the IMF, and is easy to perform at any time during surgery regardless of whether the implant is in place or not. IMF reconstruction is facilitated by freeing the surgeon from the need to visualize the inside of the pocket.

BACKGROUND: Nasal fracture is the most common type of facial fracture treated by plastic surgeons. Here, we clarify the postoperative deformities that frequently remain after closed reduction of fresh nasal bone fracture by three-dimensional computed tomography (3D-CT). METHODS: Hundred consecutive cases of fresh nasal bone fracture in patients treated between May 2010 and January 2016 were examined. After closed reduction, the overall appearance of the arch formed by the nasal bone and maxillary process was evaluated as 'Excellent', 'Good' or 'Fair'. Patients were also asked about their overall satisfaction with the operation, and the responses were classified as 'Satisfied', 'Neutral' or 'Dissatisfied'. RESULTS: Eighty-six patients underwent 3D-CT examination both at the time of the initial consultation and 3 months after the operation. The results were 'Excellent' in 69 patients and 'Good' in 17 patients, with none of the patients having only 'Fair' results. Convex bone deformities on one side were seen in all six bilateral type fractures evaluated as 'Good'. All patients classified as 'Excellent' reported being 'Satisfied' with the results, but some patients classified as 'Good' gave a 'Neutral' evaluation regarding their satisfaction. CONCLUSIONS: The residual deformities seen in bilateral type fractures were most notable, and they were all convex bone deformities on one side. Plastic surgeons should use ultrasonography or other reliable new methods in addition to visual inspection during the operation to successfully treat the region of the convex fracture.

症例1は75歳男性で、下口唇粘膜部の色素斑が徐々に拡大し、易出血性となった。右上下口唇に、約2cm大の黒色色素斑を認め、下口唇口角寄りに浸潤のある局面を認めた。局所所見、ダーモスコピー所見より、下口唇粘膜部原発の悪性黒色腫と診断した。右下口唇悪性黒色腫の診断で腫瘍を切除した。上口唇赤唇部は、悪性黒色腫の辺縁が明らかでなかったため、口腔前庭粘膜弁の進展皮弁にて再建した。術後化学療法を行った。術後5年以上経過しているが、腫瘍の再発はなく、患者は整容的にも満足している。症例2は78歳男性で、左口角の結節および色素斑を自覚した。左口角部に7mm大の黒色結節を認める。その周囲の口唇粘膜、左頬粘膜に黒色色素斑を認めた。局所所見、ダーモスコピー所見より、悪性黒色腫と診断した。左顎下部に弾性硬、可動性不良なリンパ節腫大を触知した。左口角悪性黒色腫の診断で、全身麻酔下にて腫瘍を切除した。口腔内粘膜は皮膚、粘膜と同程度の組織欠損となった。上口唇赤唇部はキューピッド弓を温存し赤唇進展皮弁にて再建した。現在、術後6ヵ月経過しているが、開閉口障害はなく、感覚異常もない。顔面形態に患者本人は満足している。

80歳男。仙骨部褥瘡に対して外科的デブリードマンを行い、術中出血は少量であったが、翌日から体位変換などの軽度な刺激によって創部から出血するようになった。これに伴い貧血が進行したため、対症的に濃厚赤血球と新鮮凍結血漿の輸血を行った。その結果、貧血は改善傾向を示したが、出血は続き、凝固系検査でAPTTの延長を認めた。APTTの延長が凝固因子欠乏症によるのか、あるいは自己抗体の存在によるのかを鑑別するためAPTTクロスミキシング試験を行ったところ、正常血漿を加えても凝固時間の補正が不十分でインヒビターパターンを呈した。凝固異常の原因を検索すると、第VIII因子活性が著明に低下しており、同因子に対する自己抗体が検出された。抗核抗体が80倍であったが、フォンウィルブランド因子抗原やカルジオリピン抗体は検出されず、後天性血友病と診断した。ステロイド治療を行い、APTT値、出血傾向とも改善した。