第104回 日本美容外科学会

ヴェリテクリニックのドクターが、第104回 日本美容外科学会(2016年5月17日・18日 ANAインターコンチネンタル東京)で学術発表いたしました。

・開催日時:2016年5月17日(火)~18日(水)
・開催場所:ANAインターコンチネンタル東京
・開催概要:こちら

注目講演【シンポジウム】

5月17日(火) <14:30~15:30> シンポジウム1 SY-1 鼻:鼻中隔延長術 vs 鼻翼形成術

座長: 福田 慶三 / 演者:室 孝明

5月18日(水) <9:45~11:45> シンポジウム4 SY-4 フェイスリフティング:スレッド vs サージェリー

演者:大橋 菜都子

OSAPS 2016 abstract,Taipei May13~15

1. Problems in tip onlay graft combined with septal extension

Keizo Fukuta, M.D. Takaaki Muro, M.D.
Verite Clinic

We reviewed the cases who underwent the septal extension graft combined with tip onlay graft from 2008 to 2011.

We found the onlay graft was unfavorably visible in 30 % among 85 cases with longer than 1 year follow-up.

ince then we carefully used the following technique; 1) suture fixation of tip onlay graft, 2) trimming of sharp edge of the onlay graft, 3) symmetry in shape of tip onlay graft and 4)keeping the caudal edge of extension graft behind the alar cartilages.

We conducted a second review study 2 years later, in which we found visible tip graft in 23 % of 94 cases after 1 year follow-up.

Thinking from a different angle

“We should make tip grafts look natural even if they become visible, yet it is important to avoid sharp edge and malposition.”

It concludes that careful tailoring of the tip graft cannot solve the problem of graft visibility completely.

Our current approach for this problem is to create a favorable contour of the tip graft when it becomes visible.

I used two pieces of narrow cartilage graft, fixing them on each side of alar cartilage.

Or I fixed one piece and then make a dich in the middle.

I reviewed the cases who underwent septal extension and tip onlay graft from 2013 to 2015.

45 cases had postoperative photo of more than 1 year follow-up.

In the 3rd study, I reviewed the cases who underwent septal extension and tip onlay graft from 2013 to 2015. 45 cases had postoperative photo of more than 1 year follow-up. During this period, one of the above mentioned 3 methods was applied.

In conclusion of the 3rd study, the use of anatomical graft reduced the incidence of unfavorable visibility down to 15%.

The V-shaped graft with ear cartilage was considered easy to handle and reliable

2. alar lift for Rhinoplasty

Keizo Fukuta, M.D.
Verite Clinic Tokyo JAPAN
ginza@veriteclinic.com

The columella retrusion is a source of poor relationship between columella and alar base. Another cause is low set alar.

This paper presents my new approach for lifting the alar base. The full thickness incision is made along the alar groove, detaching the alar lobule from the cheek. The alar tissue is excised at the superior margin of the alar lobule. The alar was repositioned superiorly. The skin defect at the bottom on the cheek surface is closed with V-Y advancement.

This technique can reposition the alar superiorly and also reduce the size of alar lobule particularly in a vertical dimension. The scars which develop in the superior margin of the alar lobule and below the alar base are tolerated by the patients. Another potential side effect is widening of the nostril floor.

The presentation shows the surgical technique in video and demonstrates clinical results.

3. Spring Thread for face lift

Keizo Fukuta, M.D.
Verite Clinic

Spring Thread™

1st SurgiConcept, France http://www.1stsurgiconcept.com

Spring ThreadTM is the elastic suspension thread with cogs made of silicone rubber. Each cog is mechanically strong and large enough to provide secure anchorage of subcutaneous fat tissue. The elasticity of the thread can prevent the loss of anchorage even in the facial skin being stretched.

Procedure

Spring thread has cogs arranged in bi-direction manner; I cut a thread in the midpoint to produce from one to two treads with unidirectional cogs.

hrough a 2 to 3 cm long incision in the temporal area, the subcutaneous dissection is performed just below the zygomatic arch.

Sprig threads are introduced into the subcutaneous pocket and inserted in the subcutaneous soft tissue (fat layer) using a special spatula needle pin provided by 1st surgiconcept company.

12 threads or even more are used for one side of cheek. The distal end of thread, which is smooth in surface with no cog, is penetrated at the skin along the lower margin of cheek sagging (jowl deformity).

The thread end is pulled out until the most distal cog arrives at 1cm deep to the skin surface. The threads in the temporal region are placed in a neutral tension.They are then pulled superiorly by 1 cm and fixed to the temporal fascia with nylon suture. The distal and proximal ends of thread are trimmed and temporal skin wound is closed.

I believe traction of threads with full strength in the temporal area is not necessary but can be harmful; excessive pull can not only cause an unnatural appearance but also readily lead to anchor loss. Therefore I suspend the lower cheek tissue in the superior direction by 1 cm.

From my clinical experiences with various cog threads I have found the spring thread can suspend the facial soft tissue with minimal chance of anchor breaking.

Skin incision in the temporal area
 

Subcutaneous    dissection over the zygomatic arch

Insertion of threads in the subcutaneous plane

Suspension of threads and fixed to the temporal fascia

Trimming of exposed ends of threads

Wound closure

 

Mid-30’s patient was treated with upper cheek dissection with thread lift

When a casee with loose redundant skin in the cheek was treated with upper cheek dissection with thread lift, elevation of lower cheek tissue can produce excess skin in the area of dissection, making a hallow and bulge in the lateral cheek

I suggest to extend the dissection into the temporal region, elevate the lower cheek with spring lift and suspend the upper cheek skin superiorly to the temporal fascia.

The temporal suspension creates hollow and bulge in the temporal hair bearing area, which is not visible.

This case with loose skin was treated with upper cheek and temporal dissection with thread lift

6. Letter of thanks

2016-afas Seoul, Korea, 2016/04/15-17

Invited lecture: Custom made nasal implant

The use of a ready-made implant is not able to achieve a good fitting in the undersurface with the dorsum of nasal bone and cartilage. This could be one of the causes for malposition of the implant or visibility of implant contour. This paper presents our current effort to use a custom made silicone nasal implant.

3D skull model is manufactured based on CT-scan in each patient. The contour of the upper and lower lateral cartilage was traced manually on the CT slice data. Thus, the shape of nasal cartilage was incorporated in the 3D skull model. The thickness of the implant is designed base on the life size photo of the patient’s profile view and mid-sagittal image reformatted from the CT data. The implant is made using epoxy resin, which is used for hobby craft on the 3D model according to the planned thickness. It is essential to make the bilateral side gently tapered to avoid any step at the junction between the implant and nasal hard tissue. After hardening of epoxy resin, the model is duplicated with silicone with aid of Keosan Trading company (www.ekeosan.com, South Korea).

The implants we made were not only for nasal dorsa augmentation, but also for the augmentation of nasal dorsum, glabella and forehead. We have also designed a prototype for septal extension with dorsal augmentation.

Our clinical experiences of various types of nasal implants will be demonstrated in details.

malposition of ready made implant

The custom-made silicone implant fits perfectly to the underlying hard tissue

第59回 日本形成外科学会総会 2016/04/13-15

一般演題:鼻孔縁を下げる手術の患者の満足度

目的:正面で鼻の穴を見えなくしたいという希望に対して手術を行った患者の満足度を調査した。

方法:過去5年間に鼻孔縁を下げる目的で手術を行った症例のうち、1ヶ月以上の経過観察ができた症例46例を対象に術前術後の写真と患者の訴えを後ろ向きに調査した。

術内容は鼻中隔延長術とcomposite graftの併用が10例(うち片側手術が4例)、composite graft単独が32例(うち片側が7例)、rim graftと鼻腔のV-Y advancement flapが3例、鼻翼rotation flapが1例であった。

結果:全例において鼻孔縁を下げる結果は確認できた。
中隔延長術とcomposite graftの併用例で術後に不満を訴えた症例はなかった。

Composite graft単独で行った症例のうち、16例とV-Y advancement flapの1例とrotation flapの1例が術後に不満を訴えた。

不満の内容は鼻翼の横幅の拡大が7例、鼻尖が太くなったが6例、移植軟骨による鼻孔縁の凹凸が1例、鼻翼縁の肥厚が1例、composite graftのびく右側への突出が2例、鼻翼下降の不十分が1例であった。

そのうち6例にはcomposite graftを取り除く手術を行った。

考察:鼻孔縁を下げる手術法として、composite graftやrim graftやrotation flapはいずれも適している。

しかし、鼻孔縁が下がることに加え、正面像で鼻翼の外側への張り出しが強くなる、また、鼻尖の幅が太くなるという効果が発生する。

患者がこれら第二の効果を好ましいと受け入れてくれるならばよい。しかし、患者にとって好ましくない場合は鼻孔縁を下げる手術は不満を招くことになる。

過去5年間に鼻孔縁を下げる目的で手術を行った症例のうち、1ヶ月以上の経過観察ができた46例の満足度を調査した
composite graft単独
(うち片側が7例)
32例
composite graftと鼻中隔延長術の併用
(うち片側手術が4例)
10例
rim graftと鼻腔のV-Y advancement flap 2例
rim graftとV-Y flapと鼻中隔延長術の併用 1例
鼻翼rotation flap 1例

結果

全例において鼻孔縁を下げることは確認できた。

片側例(composite単独4例、compositeと延長併用7例)はすべて満足

鼻中隔延長術とcomposite graftの併用例で術後に不満を訴えた症例はなかった。

結果

術後に不満を訴えた症例

・Composite graft単独を両側に行った25例のうち16例

・V-Y advancement flapの3例のうち1例

・rotation flapの1例のうち1例

結果

術後の不満内容

♢ 鼻翼下降の不十分が1例

♦ 不満の内容は鼻翼の横幅の拡大が7例

♦ 鼻尖が太くなったが6例

♦ 移植軟骨による鼻孔縁の凹凸が1例

♦ 鼻翼縁の肥厚が1例

♦ composite graftの鼻腔側への突出が2例

♘ そのうち6例にはcomposite graftを取り除く手術を行った。

まとめ

鼻孔縁を下げる手術法として、composite graftやrim graftやrotation flapはいずれも適している。
鼻尖の幅が太くなる。
正面像で鼻翼の外側への張り出しが強くなり、ブタ鼻が牛の鼻になる・・注意必要

TST 2016, Hua Hin, Thailand 2016/03/16-18

Modification of skin redraping method for medial epicanthoplasty

In OSAPS 2014 in Pattaya,I presented the comparison study of epicanthoplsty between Park’s root Z plasty and Dr.Oh’s skin redraping method.

The study showed that the vertical scar of Z plasty was visible and annoying to not a few patients.

The skin redraping method made a scar in the less visible area than the Z plasty.

The redraping has smaller effect to release the vertical skin tension of the epicanthal fold; therefore, this method tends to create in-fold type of double fold.

The redraping method requires the trimming of lower eyelid skin; this maneuver had a potential risk for unfavorable downward expansion of the caruncle.

Since 2011, I have used modified method of skin redraping.

This procedure utilizes Z plasty presented by Japanese plastic surgeon, Dr. Orito in 1993.

The resultant scar is in L shaped, which is similar to that of skin redraping.

This modified method is more effective to release the vertical tension in the medial canthal region.

The technical details and clinical results will be demonstrated in this paper.

For Z plasty, I make the horizontal incision short, and also shorten the incision on the back side of the fold t. This means that I stop the incision away from the caruncle by at least 1mm, usually 2 to 3 mm, before the caruncle

Basically this technique cuts the fold horizontally in the full thickness fashion. The incision line extends into the lower eyelid. The subcutaneous dissection is performed and a small amount of muscle is excised in the medial corner. The skin is trimmed in the upper part of the fold, just like remove a dog ear. Another trimming is done along the lower eyelid incision. In case of redraping method, I make horizontal incision of the fold shorter to preserve a part of the epicanthal fold.

Summary presented in OSAPS 2014

・The skin redraping method makes a scar in the less visible area than the Z plasty.

・The redraping has smaller effect to release the vertical skin tension ; therefore, there is a chance of creating in-fold line after redraping
・The Z plasty is more reliable for creating out-fold line.

ORITO method is a kind of Z plasty. In order to reduce the mongolian fold conservatively, I make the horizontal dimension of the Z flap shorter.

 

 

Out-fold was planned in 4 cases; 2cases achieved out-fold, 2 cases developed in-fold.

Reconstruction of Mongolian fold for revision epicanthoplasty

The epicanthoplasty is a common procedure in Oriental blepharoplasty.

Over-show of caruncle can cause patients’ dissatisfaction.

This paper presents my clinical experiences of reconstructing the epicanthal fold.

I use two different techniques. One is using Z plasty which is a reverse style of Z epicanthoplasty presented by Park JI.

The other technique utilizes a hinge flap of medial skin and transposition flap from the lower eyelid; this was presented by Japanese plastic surgeon, Dr. Doi.

Z plasty technique creates an epicanthal fold which is limited in size.

I use Z plasty for the patients who request coverage of the exposed caruncle by 1 mm.

For those require larger coverage of caruncle, I use transposition flap since this technique can provide larger tissue to the epicanthal region.

I had an experience of partial flap loss in transposition technique.

It was probably due to jeopardized blood supply to the flap which was elevated based on the scar from the previous epicanthoplasty operation.

I have currently applied delay procedure if the scar crosses the flap.

The surgical technique and clinical outcomes are shown in detail.

3D fold, large size
coverage of caruncle by 2~3 mm at the lower eyelid margin round curve at the infero-medial corner

2016-Hawaii Plastic Surgery Symposium 2016/02/27ー29

Nasal dorsum augmentation

The use of a ready-made implant is not able to achieve a good fitting in the undersurface with the dorsum of nasal bone and cartilage.

This could be one of the causes for malposition of the implant or visibility of implant contour.

This paper presents our current effort to use a custom made silicone nasal implant.

3D skull model is manufactured based on CT-scan in each patient.

The contour of the upper and lower lateral cartilage was traced manually on the CT slice data.

Thus, the shape of nasal cartilage was incorporated in the 3D skull model.

The thickness of the implant is designed base on the life size photo of the patient’s profile view and mid-sagittal image reformatted from the CT data.

The implant is made using epoxy resin, which is used for hobby craft on the 3D model according to the planned thickness.

It is essential to make the bilateral side gently tapered to avoid any step at the junction between the implant and nasal hard tissue.

After hardening of epoxy resin, the model is duplicated with silicone with aid of Keosan Trading company (www.ekeosan.com, South Korea).

The implants we made were not only for nasal dorsa augmentation, but also for the augmentation of nasal dorsum, glabella and forehead.

We have also designed a prototype for septal extension with dorsal augmentation.

Our clinical experiences of various types of nasal implants will be demonstrated in details.


http://panpacific.org/program-2016/

making a life size print of the photo and CT data

design of desired profile on the life size print of the patient photo

nose and extending glabella implant based on 3D printer model


2nd Asian Blepharoplasty Forum ソウル、韓国 2015/11/15

Current trends of beautiful Asian eye in my practice in Japan

Keizo Fukuta, M.D.
Verite Clinic, Tokyo Japan

There are increasing demands of making a drooping eye appearance in my practice. I have used three different procedures; glamorous line plasty, lateral canthoplasty (lateral canthus incision) and lateral canthal tendon reposition. This paper presents the technical details and clinical effects of these three techniques.

The glamorous line plasty advances the CPF and fixes it to the lower margin of tarsal plate in the lower eyelid. This procedure can make the lower eyelid margin lower in position and rounder in curvature.

The lateral canthoplasty makes a horizon full thickness incision of the lateral corner of the orbital fissure. New upper and lower lid skin is sutured to conjunctiva. The clinical reviews showed that lateral increase in horizontal dimension was about 1 mm. The lateral corner of orbital fissure changed from angle to round shape. The ascent incline of lateral half of the lower lid margin became gentle, making the lateral sclera larger.

The lateral canthal tendon reposition releases the orbicularis oculi muscle from the periosteum around the lateral orbital rim. The deep raphe and superficial raphe of the lateral canthal tendon are detached from the orbital rim and fixed to the bone in a lower position with drill holes. The elevated orbicularis oculi muscle is fixed to the periosteum in the lower position. This procedure can shift the lateral corner of the orbital fissure in a lower position. The lateral portion of lower lid margin becomes milder ascent, while the upper lid margin becomes steeper descent. The lateral sclera does not become larger; even it looks smaller after procedure.

Announcement by the slide

effect of lateral canthoplasty

・a little lateral extension of lateral sclera
・downward enlargement of lateral sclera
・an inclination of lateral part of lower eyelid margin becomes gentle.

 

Adverse effect of lateral canthoplasty

  ✓ loss of sharp angle at the lateral corner
  ✓ exposure of conjunctiva


19th International Rhinoplasty Workshop& 2nd Chosun Aging face Symposium ソウル、韓国 2015/10/09-11

history of dorsal implantseptal extension with septal cartilage

 

>> 19th International Rhinoplasty Workshop& 2nd Chosun Aging face Symposium

>>  Spring Thread for face lift

>>  Clinical experiences of glamorous line plasty

Spring Thread for face lift

Spring ThreadTM is the elastic suspension thread with cogs made of silicone rubber. Each cog is mechanically strong and large enough to provide secure anchorage of subcutaneous fat tissue. The elasticity of the thread can prevent the loss of anchorage even in the facial skin being stretched.

Procedure
Spring thread has cogs arranged in bi-direction manner; I cut a thread in the midpoint to produce from one to two treads with unidirectional cogs.

Through a 2 to 3 cm long incision in the temporal area, the subcutaneous dissection is performed just below the zygomatic arch.

Sprig threads are introduced into the subcutaneous pocket and inserted in the subcutaneous soft tissue (fat layer) using a special spatula needle pin provided by 1st surgiconcept company.

12 threads or even more are used for one side of cheek. The distal end of thread, which is smooth in surface with no cog, is penetrated at the skin along the lower margin of cheek sagging (jowl deformity).

The thread end is pulled out until the most distal cog arrives at 1cm deep to the skin surface. The threads in the temporal region are placed in a neutral tension. They are then pulled superiorly by 1 cm and fixed to the temporal fascia with nylon suture. The distal and proximal ends of thread are trimmed and temporal skin wound is closed.

From my clinical experiences with various cog threads I have found the spring thread can suspend the facial soft tissue with minimal chance of anchor breaking.

I believe traction of threads with full strength in the temporal area is not necessary but can be harmful; excessive pull can not only cause an unnatural appearance but also readily lead to anchor loss. Therefore I suspend the lower cheek tissue in the superior direction by 1 cm.

A case with loose redundant skin in the cheekwas treated with upper cheek dissection with thread lift

The elevation of lower cheek tissue has produced excess skin in the area of dissection and made a hallow and bulge

I suggest to extend the dissection into the temporal region, elevate the lower cheek with spring lift and suspend the upper cheek skin superiorly to the temporal fascia

A case with loose skin was treated with upper cheek and temporal dissection with thread lift

>> 19th International Rhinoplasty Workshop& 2nd Chosun Aging face Symposium

>>  Glabella and forehead augmentation in Oriental rhinoplasty

>>  Clinical experiences of glamorous line plasty

Clinical experiences of glamorous line plasty

① large round eye 大而圆
② downward convex curved line of lower eyelid margin
下眼睑边缘鱼白的形状向下向外

This lady is Ayumi Hamazaki, a popular singer in Japan. She was most popular image for my clients before Angela Baby became popular.

The capsuropalpebral fascia is sutured to the lower margin of the tarsal plate at three points 下眼睑的腱膜往睑板的缝合的位置

① mid-pupil 黑眼球的中央

② lateral limb   黑眼球的外侧边缘

③ midpoint between the lateral limb and lateral canthus 黑眼球的外侧边缘到眼外角的中间点

purpose of study

to identify the possible problems after glamorous line plasty, their incidents and solutions

198 cases 2012~2014

retrospective evaluation based on clinical photos

chemosis

  chemosis in 37 % of cases
  chemosis dissolved spontaneously in 3 to 4 weeks

chemosis

  severe or prolonged chemosis in 5 %
  severe chemosis treated with temporary tarsorrhaphy

eyelash entropion

Incident of eyelash entropion

Regardless the bottom point, larger inferior expansion can increase the incidence of entropion

  28 % of the cases underwent reoperation ; adjustment of CPF advancement

It is important to achieve symmetry during the operation.

>> 19th International Rhinoplasty Workshop& 2nd Chosun Aging face Symposium

>>  Glabella and forehead augmentation in Oriental rhinoplasty

>>  Spring Thread for face lift

Letter of thanks

第103回日本美容外科学会 東京 2015/06/06-07

仏教ではむさぼり・怒り・仏の教えに対する無知を三毒と呼びます。怒りの感情は人の幸せな気持ちを破壊し、さらに周囲に拡散する猛毒です。

患者が怒ると我々美容外科医の心は折れます。そして、私たちの中にも怒りの感情が生まれます。患者に対して怒ったときには、すかっとした気持ちになるかもしれませんが、後から大変いやな気持ちになり後悔します。

美容外科医の目標は患者の満足を得ることです。そのためには、患者から怒られない、自分自身も怒らないことが大切です。

今回は、私の臨床経験に加え、先輩同輩の美容外科の先生方からの聞き取り調査を基に、患者はなぜ怒るのだろうか?私はなぜ患者に対して腹を立てるのだろうか?その理由を検討してみました。そして、怒りを収めるために私が高じてきた対策を報告します。

美容外科の先生方からの聞き取り調査

Tクリニック院長:
自分の言うことに従うお金持ちのおば様だけを幸福にするというユダヤ教の神タイプ

Kクリニック院長:
お金よりプライドのために戦う武将タイプ

Gクリニック院長:
怒りの3倍返しのテロリストタイプ

Nクリニック院長:
すべての患者を自分の彼女のように1回優しくしてあげたら、すっと優しくしてあげる愛に生きるタイプ

Iクリニック院長:
若造がまねしても効果が発揮できない、オヤジならではの交渉人タイプ

Rクリニック院長:
日本の甘えの社会構造を脱却し、契約社会に適応したタイプ

ヴェリテクリニック:患者の怒りを回避するため術前にしっかりとした契約書を交わすようにしています。すべての施術に対して詳細な同意書を準備しています。