2 correction of bulbous tip; management of skin envelop

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

Polly beak deformity is post-rhinoplasty deformity associated with fullness in the supratip.

Two categories of a Polly beak deformity are generally described; cartilaginous source and soft tissue source.

The letter category is more common in Orientals and more difficult to correct.

The nasal skin in many of Oriental patients is thick and inelastic, providing poor redraping after reduction rhinoplasty such as correction of bulbous tip.

Excess of thick skin and soft tissue develops at the supratip region.

We have used direct skin excision in a spindle shape overt the supratip bulkiness.

This simple procedure can remove the excess soft tissue and convert the bulging dorsal contour to straight line.

Only problem concerned after this method is a postoperative scar on the nasal dorsum.

10 Japanese patients were treated with the direct excision.

The scar became inconspicuous in 3 cases without further treatment and in 7 cases after CO2 laser abrasion.

The correction of bulbous tip, making the tip narrow and sharp, is a common request for Oriental rhinoplasty.

The correction can be done using endo-nasal incision by removing subcutaneous fat tissue from the regions over the lateral crura of alar cartilage and between the bilateral middle crura and approximation of cephalic marign of bilateral lateral crura.

Why does Polly beak deformity occur? When we perform the defatting and cartilage suture, we expect that the skin should redrape nicely over the modified cartilagenous structure.

In case the skin is soft and pliable, it will do so.

However, those who ask for bulbous tip correction, their skin tends to be thick and hard. The nice redraping does not take place.

Therefore, the dead space from wide subcutaneous dissection can not be eliminated, causing scar tissue formation.

Excess amount of skin will bulge out when it is squeezed in the midline.

A case with Polly beak deformity after having undergone the correction of bulbous tip.

Here in my imagination, I extend a dorsal contour line in straight.

This line helps me to find the caudal end and cephalic end of the excess bulge.

I draw a straight line from the cephalic end point to the caudal end point on the profile.

I draw another line on the other side.

When we look from the front, those straight lines are not really straight but slightly curved.

We can actually see a marking of spindle shape.

I excised full thickness skin of the spindle mark and closed the defect in two layers.

These are the patient before surgery.

This is the result 6 months after skin excision.

The bulging of the supratip region became flat, even concave. The scar is inconspicuous.

In summary, spindle skin excision is very effective to correct Polly beak deformity.

Although this procedure leaves a scar, the scar is well accepted by patients.

Actually the scar was almost invisible in some cases.

This procedure was found useful not only for postoperative Polly beak deformity but also for primary bulbous tip.

The amount of skin excision should be conservative in width, otherwise it will result in concave contour or dog ear deformity.

美容外科のきずあとベストプラクティスのパネルディスカッション

発表内容の詳細 : 「許されるきずあとと許されないきずあと 」

われわれ形成外科医は皮膚にできたきずあとが消えないことを知っています。

そして、きずあとを作ることは悪であるという思いに囚われています。そのため、きずあとが隠れるように切開線の選択に悩みます。

例えば、上瞼のたるみをとるために上眼瞼リフトという手術をする場合、傷をどこまで延ばしていいものか悩みます。

形成外科のトレーニングをした医師なら、眉毛の下に隠れる範囲にとどめるべきだと考えます。

眉毛からはみださないように皮膚を切り取るだけでは、目頭や目尻のたるみが残ってしまうことがあります。

目頭側のたるみを十分に取らないと、目尻がつり上がった目になります。反対に目尻のたるみを取り残すと、タレ目になります。

術者がきずあとは悪であると思いに囚われて、切開を十分延ばさなかったために、患者さんは恐ろしいつり目になったといって苦しむ結果になります。

眉毛からはみ出したきずあとは時間がたって赤みが消えれば、目立たなくなります。

もちろんきずあとが消えることはありませんが、ほとんどのきずあとは患者さんに受け入れていただけます。

美容外科は切開を加えて形を整える手術治療であり、きずあとができても容姿が変わればいいと患者さんは理解しているように思います。

しかし、中には 美容外科の手術の後で、きずあとに不満を訴える患者さんがいらっしゃいます。

手術の結果、明らかにきれいになった、若くなった、ある程度希望していた結果になった場合には、患者さんは傷跡を許してくれます。

しかし、手術を受けたのに全然変わらなかった、希望する形と全く違う結果になった、手術の後かえって醜くなったとか老けたという場合には、患者さんはきずあとを許してくれません。

たとえ、手術でできたきずあとが他人からみてほとんど分からないほどきれいに治っていても、そのきずあとを許せないようです。

許せないどころか、きずあとを憎むようになります。

そんな悲しい結果にならないために、われわれ美容外科医は患者さんの希望する結果が出るように手術をしなければなりません。

わたしは美容外科医として、患者さんを傷つけ、患者さんによって救われ、患者さんによって育てられているとつくづく思います。

【許されるきずあとと許されないきずあと 】発表風景

【パネルディスカッション】

招待講演-invitation lecture

1.Upper blepharoplasty for bulky eyelid

2.Glamorous line procedure; Anchoring of capsuropalpebral fascia to make a round shape lower eyelid

発表内容の詳細

Upper blepharoplasty for bulky eyelid

The standard procedure of upper blepharoplasty involves skin incision at the planned double fold line, excision of excess skin if necessary, and removal of orbital fat.

Excision of orbital fat is helpful to create a sharp double fold.

The patient presents with excess hanging skin over the eyelashes.

Although hanging skin gives bulky looking to the upper eyelid, she does not have a lot of volume in the eyelid.

These two cases indicate that the excision of orbital fat is not enough to correct bulky eyelid.

MRI images show the orbit of a normal Japanese person in eye closed position and eye opened position.

These diagrams are made from MRI images.

The orbital fat lying behind the septum (membranous structure in light blue color) is not really thick when the eye is closed.

There are other fat tissues (the preseptal fat and ROOF) in front of septum.

Although the preseptal fat, ROOF and also orbicularis oculi muscle are thin structure with eye closed, they are squeezed and provide a bulk to the upper eyelid when the eye is opened.

The fullness is made by the presence of orbital fat, preseptal fat and ROOF.

The orbicularis oculi muscle is partly related to the thickness just above the double fold.

Upper blepharoplasty for bulky eyelid should involve the excision of excess skin, excision of orbital fat, preseptal fat and ROOF and excision of about 10 mm wide orbicularis oculi muscle band just above the double fold.

Cases treated with skin excision, removal of orbital fat, preseptal fat and ROOF, and excision of orbicularis oculi muscle.

These clinical cases strongly suggest that it is effective to excise the preseptal fat, ROOF and orbicularis oculi muscle in addition to orbital fat for the correction of bulky upper eyelid

Glamorous line procedure; Anchoring of capsuropalpebral fascia to make a round shape lower eyelid

Long false eyelashes near the lateral corner help to enhance the lateral extension of eye.

Mascara and wide eyeliner near the lateral corner as well as false eyelashes on the lower eyelid help to enhance the lower extension of eye.

Those who wear eye make-up in this fashion wish to have almond shaped eye, down slanting eye, droopy eye and eye with long slit at the outer corner.

Operation of lateral canthoplasty

A case treated with lateral canthoplasty

Lateral canthoplasty is the procedure to provide lateral elongation at the lateral corner and downward enlargement of lower lateral portion of the orbital fissure.

The lateral sclera show will become larger after lateral canthoplasty.

Glamorous line procedure can give the lower eyelid margin more round convex curvature.

The location of the lowest point should be determined according to the desire of each patient.

The transconjunctival incision is made at the lower margin of the tarsal plate.

The orbital septum is cut at the superior margin and exposed orbital fat is retracted downward to reveal capsuropalpebral fascia (CPF).

The CPF is advanced and fixed to the tarsal plate at three points; at the level of pupil, at the lateral limb and further lateral between the limb and lateral corner of the orbital fissure.

The three sutures are tied temporarily and the position and shape of the lower eyelid margin are estimated.

The anchoring points on CPF have to be adjusted to achieve desired position and shape of the lower eyelid.

After the desired shape is obtained, excess amount of conjunctiva is excised.

A Case presented with a history of over-done lateral canthoplasty was treated with glamorous line procedure.

A case underwent glamorous line procedure and also Muller tucking with stitch method and stitch double fold procedure.

A case treated with glamorous line procedure and hyaluronic acid injection to enhance pretarsal band.

The glamorous line procedure makes the posterior lamella shorter, producing excess of anterior lamella, which may cause entropion.

If entropion occurs after glamorous line procedure, it should be treated with simple excision of excess skin 1mopnth after primary surgery.

Although I am not sure whether eye with long slit at the outer corner, down slanting eye, droopy eye, or eye with downward convexity of lower eyelid margin can create sexy, sweet and cute looking, I am sure the following finds.

Lateral canthoplasty

	● elongation of lateral slit ● preoperation

CPF anchor

	● increased downward convexity of lower eyelid margin ● skin trimming to correct entropion in 10%

一般演題「予定外重瞼線の治療」

発表演題 : General subject

■The role of glabella augmentation for Oriental rhinoplasty

■The purpose of lower blepharoplasty

Announcement contents :

The role of glabella augmentation for Oriental rhinoplasty

The most common demand in rhinoplasty for Orientals is augmentation of the dorsum. Insertion of a silicone implant has been widely used for this purpose.

The dorsal augmentation increases the height of the dorsal line.

At the same time, it shifts the nasion to more cephalic position.

This means the dorsal augmentation alone can make the nose look longer.

Thus, the dorsal augmentation may create an impression of nose being too long for those who have low dorsum with the nasion in an adequate or cephalic position.

As I mentioned before, the dorsal augmentation move the nasion to the cephalic direction.

In contrast, the augmentation of the glabella can shift the nasion caudally. This paper presents our experience with use of glabella augmentation.

The upper margin of the implant should be wider than the lower margin The width of the lower margin of the glabella implant is to be the same as that of the dorsal line.

The width of the upper margin is 2 cm in most of cases but can vary from 1.5 cm to 4 cm depending on request.

We have used a PTFE implant, which is inserted via endonasal approach or open rhinoplasty approach.

The folded implant is inserted into the subperiosteal pocket and unfolded using guided percutaneous sutures. The splint is applied for 1 week.

The augmentation of the glabella and nasal dorsum was combined in most of cases.

The combination of the dorsal augmentation and glabella augmentation resulted in enhancement of the nasal ridge from the eye brow to the nasal tip in the front view.

On the profile, the nasion was maintained at the level between the upper eyelid margin and pupil.

It is important to take into account the projection of the glabella and nasal root and the position of the nasion in case of augmentation rhinoplasty.

The glabella augmentation enhances the dorsal highlight of the nose, making the nose look long in the front view.

The glabella augmentation prevents the augmentation rhinoplasty from making the nose look too long.

The details of announcement contents :

The purpose of lower blepharoplasty

The aging signs of lower eyelid are skin wrinkles including fine wrinkles and pleates-like wrinkles and festoon, eye bag and nasojugal groove.

The purpose of the study was to clarify effects of the lower blepharoplasty to correct those aging deformities.

I have performed two different procedure for lower belpharoplasty.

In order to avoid postoperative scleral show, the surgeons (Stuzin JM Plast Reconstr Surg1998, Ramirez OM Aesthetic Surg J 2000, Hwang K Annals Plast Surg 2001) thought it be important to preserve the orbicularis oculi muscle intact.

Therefore, I used transconjunctival approach to remove the fat and I dissected the skin only above the muscle.

I plicated the orbicularis muscle near the lateral canthus without any cut in the muscle.

In this way, I kept the orbicularis oculi muscle intact.

This technique was performed in 10 cases in 2005.

Another technique I used was elevation of skin-muscle flap.

The dissection was perfomed under the msucle in front of the septum.

I cut the septum along the inferior orbital rim.

The herniated fat was then excised and the septum and remaining fat was transposed downward to cover the inferior orbital rim.

This procedure is called septal reset reported by Dr. Hamara.

The orbicularis muscle flap is sutured to the lateral orbital rim for suspension.

This procedures were used in 36 cases in 2005 and 2006.

The surgical outcomes were assessed in terms of wrinkles, eye-bag and nasojugal groove.

The evaluation was made particularly to answer the following 3 questions.

Is the skin flap technique more effective to improve skin wrinkles?

Is skin flap with transconjunctival fat resection useful to prevent ectropion or lower scleral show?

Is skin muscle flap with fat reposition more effective to correct the nasojugal groove?

In skin flap group, the wrinkles which were seen in the excised skin disspaered.

Fine wrinkles in the remaining skin showed no change.

Pleates-like wrinkles which develop due to hanging and folding of excess skin just like festoon was improved.

Eye-bag becomes smaller.

When we see the nasojugal groove in relation to the cheek projection, the nasojugal groove become deeper but improved in appearance.

This patient underwent skin flap technique.

Although no incision was made in the muscle, she developed lower scleral show.

Wrinkles show great improvement.

In the skin-muscle flap group, Festoon has improved.

The pretarsal bands are built up.

Eye-bag is reduced and nasojugal groove becomes shallow and smooth.

Only the wrinkles which were excised with skin disappeared.

Fine wrinkle remained.

Eye-bag was succesfully reduced and nasojugal groove became shallow.

The eyelid-cheek junction became smooth.

Before the surgery, the eye-bag was larger in the left side.

The bulging of right side was not remarkable.

I excised the orbital fat only in the left side and performed fat and septum reposition in both sides.

After surgery, eye-bag of both sides shows improvement.

The left side showed deeper hollow; however, the patient like the left side better than the right side.

Later she asked me to remove fat from the right side but it has not been done yet.

As you see, fine wrinkles remain. Wrinkles in the lateral region are cleared.

The nasojugal groove looks shallow and smoothed off.

The both techniques were found capable to correct the festoon, but neither of them was effective to improve fine wrinkles.

It was found that the nasojugal groove became shallower in the skin-muscle group.

The depth of the groove became even deeper in the skin flap group.

This difference was subtle clinically.

Both groups showed improvement of nasojugal groove and reduction of eye bag.

The lower sclera show developed in 3 cases of skin flap group and 2 cases of skin-muscle flap.

In addition, skin muscle flap with muscle suspension was more useful to create the pre-tarsal band (smiling band) and reduction of vertical dimension of the lower eyelid in the lateral portion.

第92回弁護士の基礎医学講座、大阪 2009/10/24

講座内容: 「形成外科と美容外科の総論」「形成外科」「美容外科」

第92回弁護士の基礎医学講座、福岡 2009/7/11

講座内容: 「形成外科と美容外科の総論」「形成外科」「美容外科」

一般演題：かぶった鼻孔縁（hanging nostril）の修正術

　　　

シンポジウム：「鼻尖・鼻翼形成の標準術式とトピックス」
鼻尖形成術は未だ神仏頼み

　

発表内容詳細 : かぶった鼻孔縁（hanging nostril）の修正術

■ ヴェリテクリニック
福田慶三、中西雄二、尾山修一

【目的】

鼻孔縁のラインは通常上に凸のカーブである。これが下に凸のカーブになると、鼻翼の縦幅が長くなり、鼻が重たい印象になる。

これを修正するために鼻孔縁を直接切除する方法を行ってきた。その術式と結果を報告する。

【方法】

側面から観察して、希望する鼻孔縁のカーブを鼻翼の外側に描く。この外側に描いたのと同じ高さになるように鼻翼の鼻腔側にも線を描く。外側と鼻腔側の線で囲まれた範囲の鼻孔縁の組織を楔状にメスで切除する。

創は７－０ナイロンで細かく一層縫合し、４日後に抜糸する。

【結果】

鼻孔縁を直接切除することにより、hanging nostrilは計画したとおりに修正される。鼻孔縁にできた手術瘢痕は正面や側面では全く目立たない。

下から観察しても、ほとんど目立たないこと症例もあるが、瘢痕が線状に陥凹しているものがあった。

楔状切除を１０㎜ほどに深く行った症例では、創縁の血行が悪く、皮膚壊死や創離開を認めた。

５㎜の深さで切除した症例では創治癒に問題はなかった。

鼻翼の厚みの改善は実感できなかった。

【考察】

hanging nostrilを修正するために鼻翼の鼻腔側皮膚を切除する方法があるが、それに比べて、鼻孔縁を直接楔状切除する方法は結果が予測しやすい。

鼻尖形成術は未だ神仏頼み

鼻尖の手術に対する希望は、鼻先を細くしたい、鼻先を小さくしたい、丸い輪郭をスマートにしたい、鼻先を高くしたい、鼻の穴を隠したいといったものが多い。

これらの希望に対して、鼻尖の皮下脂肪組織の切除、左右の大鼻翼軟骨の縫合、鼻中隔軟骨延長術、鼻尖に軟骨のonlay graftといった手術を行っている

このように、各症例に対して限られた術式を組み合わせて行っている。しかし、これを鼻尖形成の標準術式とはとても呼べないとわたしは思う

症例毎に大鼻翼軟骨は大きさや形が異なる。内側脚と中間脚と外側脚の割合も異なれば、角度も異なる。

たとえ、軟骨を理想の形に形成できても、その上にかぶる皮膚の厚みと硬さが異なる。そのため、鼻尖がどんな形になるのかを術前に予想することははなはだ難しく、術中でも鼻尖の形を調整できない。

たとえば、比較的予想の付きやすい側面の輪郭において、予定したtip defining pointを作成するように鼻尖の軟骨を形成しても、軟部組織がtip defining pointを決定してしまうことが少なくない。

ましてや、正面像での鼻尖形態を計画して作成するなんてことは神業である。

現時点では、毎回鼻尖の手術をした後、どのような結果になるのかは神仏頼みだと思って手術を行っている。

　

今回は鼻尖の形を思うがままにできないわたしの苦しみを報告する。

第1回低侵襲形成美容外科学会、ソウル、韓国 2009/09/4-6

1st International Congress of Minimal Invasive Plastic Surgery-seoul-2009/09/4-6

General subject :

Stitch method for correction of acquired blepharo-ptosis

Spindle skin excision to correct Polly beak deformity in rhinoplasty

Education lecture :

Treatment of retaining ligament, SMAS and fat tissue in facelift

Announcement contents :

1. Stitch method for correction of acquired blepharo-ptosis

: Keizo Fukuta, M.D.

Verite Clinic, Tokyo Japan

This paper presents the use of stitch technique to correct acquired blepharo-ptosis without any incision.

7-0 nylon suture is buried under the conjunctiva between the upper margin of tarsus and the upper sulcus in a triangular fashion.

The ligation of the suture shortened the conjunctiva and Muller muscle longitudinally.

The vertical distance of the conjunctiva to be plicated is 14 mm in many of cases, but needs be changed for each case.

Although long term result is still unclarified, follow-up of some of my cases has revealed the lasting of ptosis correction for 3 years.

This procedure was found useful to correct asymmetry of ptosis after levator aponeurosis repair via incisional approach.

The swelling after the stitch ptosis correction is mild in most of cases.

Other possible complications are ecchymosis, asymmetry over-correction or under-correction.

The width of double fold became narrower after the ptosis repair.

Stitch upper blepharoplasty was therefore performed depending of the patients’ request simultaneously or subsequently.

2. Spindle skin excision to correct Polly beak deformity
    in rhinoplasty

Polly beak deformity is post-rhinoplasty deformity associated with fullness in the supratip.

Two categories of a Polly beak deformity are generally described; cartilaginous source and soft tissue source.

The letter category is more common in Orientals and more difficult to correct.

The nasal skin in many of Oriental patients is thick and inelastic, providing poor redraping after reduction rhinoplasty such as correction of bulbous tip.

Excess of thick skin and soft tissue develops at the supratip region.

I have used direct skin excision in a spindle shape overt the Polly beak deformity.

This simple procedure can remove the excess soft tissue and convert the bulging dorsal contour to straight line.

Only problem concerned after this method is a postoperative scar on the nasal dorsum.

7 Japanese patients were treated with the direct excision.

The scar became inconspicuous in 2 cases without further treatment and in 5 cases after CO2 laser abrasion.

The correction of bulbous tip, making the tip narrow and sharp, is a common request for Oriental rhinoplasty.

The correction can be done using endo-nasal incision by removing subcutaneous fat tissue over the lateral crura of alar cartilage and intra and inter domal suture.

Why does Polly beak deformity occur?

When we perform the defatting and cartilage suture, we expect that the skin should redrape nicely over the modified cartilagenous structure.

In case the skin is soft and pliable, it will do so.

However, those who ask for bulbous tip correction, their skin tends to be thick and hard.

The nice redraping does not take place.

Therefore, the dead space from wide subcutaneous dissection can not be eliminated, causing scar tissue formation.

Excess amount of skin will bulge out when it is squeezed in the midline.

A case with Polly beak deformity after having undergone the correction of bulbous tip.

Here in my imagination, I extend a dorsal contour line in straight.

This line helps me to find the caudal end and cephalic end of the excess bulge.

Now I draw a straight line from the cephalic end point to the caudal end point on the profile.

I draw another line on the other side.

When we look from the front, those straight lines are not really straight but slightly curved.

We can actually see a marking of spindle shape.

I excised full thickness skin of the spindle mark and closed the defect in two layers.

These are the patient before surgery.

This is the result 6 months after skin excision.

The bulging of the supratip region became flat, even concave. The scar is inconspicuous.

In summary, spindle skin excision is very effective to correct Polly beak deformity.

Although this procedure leaves a scar, the scar is well accepted by patients.

Actually the scar was almost invisible in some cases.

This procedure was found useful not only for postoperative Polly beak deformity but also for primary bulky tip.

The amount of skin excision should be conservative in width, otherwise it will result in concave contour or dog ear deformity.

3. Treatment of retaining ligament, SMAS and fat tissue in facelift

The retaining ligaments suspend the facial skin to the underlying deep structure.

As aging, the soft tissue (skin and subcutaneous fat) looses the firmness.

The skin between the masseteric retaining ligament and mandibular retaining ligament show the sag over the mandibular ligaments due to gravity in the upright position.

This sagging deformity is recognized as jawl.

A long skin incision is made along the temporal hairline, the side burn, natural crease in front of the ear, the ear lobe, postauricular groove and occipital hairline.

The lateral margin of platysma and muscular portion of SMAS is located at 3 cm from the ear lobe.

The subcutaneous dissection is made up to 4 cm from the ear lobe.

The SMAS is incised at the lateral margin of the platysma which is at 3 cm from the ear lobe.

The deep dissection is carried out under the SMAS and platysma and continued up to beyond the anterior margin of the masseteric muscle where the masseteric ligaments are present.

This sub SMAS dissection can release all the masseteric ligament s and zygomatic ligaments from the SMAS, which allow us to pull the medial portion of the skin and SMAS with traction of the SMAS flap.

The intraoperative photo showing the 1cm long SMAS cuff attached to the skin flap and wide sub-SMAS pocket.

The suspension of the short SMAS flap to the mastoid fascia and relatively immobile SMAS over the parotid gland.

In case of no significant neck sagging, the facelift with a short scar is feasible.

This procedure eliminates an incision along the occipital hairline.

Instead of using the temporal hairline incision, an incision is made in the hair-baring skin the temporal area.

A 42 year old female presented with mild jawl deformity and heavy look in the upper eyelid.

For her preoperative planning, traction of skin in front of the ear with fingers demonstrates the possible result from the short scar facelift.

The simulation shows budging in the lateral cheek in spite of the strong pull.

In order to make smaller the bulge which will remain after facelift alone, the combination of liposuction with facelift is useful.

The middle picture shows the simulation of facelift with temporal lift, which make the lateral canthus look sharper.

The patient denied to have temporal lift.

The right picture demonstrates possible result from lateral brow lift.

6 months after the short scar facelift with liposuction in the lateral cheek and lateral brow lift with close approach.

62 year-old female presented with jawl, marionette line, nasolabial fold and loss of soft tissue fullness.

The middle picture shows simulation of facelift for the lateral cheek.

The right picture shows simulation of facelift and temporal lift which provide the lateral canthal region and lower eyelid with pull in the super-lateral direction.

The patient chose to have temporal lift with pulled appearance of the lateral canthus.

The green marking demonstrates the area for which lipofilling is planned.

One year after facelift and temporal lift with lipo-injection.