Pretreatment assessment for botulinum toxin and filler injection

서구일 ( Kyle Koo-il Seo ) 대한피부과학회 2016 대한피부과학회 학술발표대회집 Vol.68 No.2

During the patient consultation, items to be evaluated can be separated into the following categories: subjective, objective, sociocultural, financial and previous history of cosmetic procedures. True ‘custom-tailored’ treatment is only possible when the treatment plan fully takes into account the results of a comprehensive evaluation covering various aspects along with an understanding of individual characteristics. Since beauty is a subjective concept, it is important to know which points a patient is primarily concerned about. Patients are usually not satisfied unless they receive the improvements they want even if their needs are met in other areas. Once you feel that you have truly grasped a patient’s needs, you should evaluate their expected results in the next step. If the expectation level is too high, it will be extremely difficult to satisfy a patient despite what you feel may be a successful outcome. The objective evaluation is a summary of the patient’s physiological characteristics such as age, gender, facial shapes and facial aging features: wrinkle characteristics, follicular pores, depression, sagging, skin thickness, elasticity, et al. Botulinum toxin type A(BoNT-A) dose and injection sites vary by age and gender. Accurately grasping your patients’ problems is the first step towards the effective treatment of any disease and cosmetic treatment is no exception. Once you have gathered information about patients’ characteristics and general aging state, it is important to assess the appropriate indications and potential adverse effects of treating them with BoNT-A and fillers. For example, fillers are required as a supplement to BoNT-A for deep wrinkles in the glabellar area and fractional lasers for infraorbital lines. Patients with ptosis may experience difficulties to open their eyes after injection of BoNT-A into forehead unless dose of BoNT-A is lowered. Developing an acute sense of ‘doctor’s insight’ to grasp patients’ problems before treatment is essential for providing successful care. It is helpful to develop meticulous observation skills for examining patients from the forehead to the neck when they are at rest and while giving forced facial expressions. As prolonged staring at patient’s face may be a bit uncomfortable, ‘diagnosis with mirror’, allowing patients to observe themselves through a mirror is a good alternative for doctors to find their problems. ‘Mirror diagnosis’ is not only helpful for catching problems in detail, but also allows patients to find new problems that may have been unnoticed previously, which motivates patients to receive treatments for new problems. It is also important to observe patients’ facial expressions during consultations, including their involuntary habits. It can be helpful to naturally observe all of a patient’s habitual movements such as lifting of the eyebrows, twitching of the nose, glabellar frowning, applying force to the anterior jaw, peculiar expressions accompanied by tics, and to also watch for periorbital lines and nasolabial folds that appear while smiling or speaking and the shape of lines around the lips. Among sociocultural aspects, it is helpful to know the profession, marital status, nationality and ethnicity of your patients. You should also determine to what extent bruising or edema may interfere with their daily lives in case they occur. For male CEOs in their 60s, the procedure should be without social down time. As people of different races and ethnicities have their own preferred facial shapes and treatment goals, treatments should be adjusted as necessary according to these factors. For example, BoNT-A treatment for masseter hypertrophy is not popular in western countries since most Caucasians do not care much about square jaw with mandibular angles and masseter hypertrophy. Volumization using filler for sunken lower cheek which is popular in Asians is not performed since Caucasians prefer sunken cheeks. It is important to check your patients’ previous history of cosmetic treatments such as the removal of infraorbital lines, nose surgery, fat transplantation, BoNT-A injections and filler injections. With regards to fillers, it is helpful to know which products were used and how satisfied they were with the treatment. If a patient has received prior treatments with BoNT-A, it is important to find out if they had experienced any adverse effects after the injections, particularly eyebrow drooping or change of facial expressions. Finally, financial situation is one of the most important, yet often overlooked, aspects of a patient evaluation. Budgetary constraint is an important factor in customer purchase decisions. Most patients need to weigh up the cost and benefits of a given treatment. If there is true financial burden, it is better to initially recommend the best cost-benefit options with the most noticeable results in order of priority. It is with this in mind that practitioners assist patients prioritize the necessary treatments they need to receive. For example, upon assessing a patients’ face, I would suggest they start with treatment of the glabellar wrinkle and anterior malar depression as their first priority. I would then suggest they could do with a nose filler and chin augmentation later to add more definition to the face, but for now their priority should be the glabellar wrinkle and malar depression treatments for the younger appearance. Or it can be a good idea to drop patients who come in with unrealistically low cost estimations. Patients who are under cost pressure tend to have disproportionately higher expectations about the results, and will most likely end up being an unhappy customer.

봉소염의 임상적 고찰

서구일(Koo Il Seo),박향준(Hyang Joon Park),조광현(Kwang Hyun Cho),윤재일(Jai Il Youn),이유신(Yoo Shin Lee) 대한피부과학회 1992 대한피부과학회지 Vol.30 No.5

We reviewed the 43 medical records of patients with cellulitis or erysipelas who had been admitted at the depar1ment of dermatology of Seoul National University Hospital and followed them up for mean 21.6 months. The results were as follows. 1. The sex ratio of patients with cellulitis was 1:1.4 and the average age was 49 years. 2. The lower extremity as the most frequently invloved site of cellulitis with the frequency of 58.1% (25 cases), with the head and neck being involved in 16 cases(37.2%) and trunk and upper extremity in 1 case each(2.3% ). 3. The portals of infecticin were suspected in 33 cases(76% ), where tinea pedis was detect,ed in 18 cases(41.9%), previous skin infeection 10 cases(23.3%) and trauma in 9 cases(20.9%). 4. Initial systemic symptoms were fever(76.7%), chill(65.1%) and headache(37.2%). Erythema(100%), local heating(90,7%), tenderness(88.4%), swelling(86.0%), ulcer(16.3%), bulla(14.0%), lymphangitis(9.2%) and lymphadenit,is(9.2%) were found in the skin lesions. 5. The laboratory findings revealed leukocytosis in 35.7%, elevaed ESR in 86.8% positive 6. ASO titer in 63.0% and positive CRP in 80%, Microorganism. were detected in only 1 of 15 blood cultures, in 2 of 4 bulla fluid cultures and in 7 of 9 bus cultures. There was no growth of causative microorganisms in 3 tissue cultures and 9 saline needle aspiration cultures. Penicillin was used as primary antibiotics in 19 cases, which changed to another antibiotics due to lack of improvement in 3 cases and cefazolin was used in 21 cases, which changed in 2 cases due to the same reason. 7. Average admission priod was 11 days(range from 3 to 20 days) and 30.2% of patients wit.h cellulitis experienced recurrence, but 48% on low extrernity in contrast with 6.7% on head and neck. (Kor J Dermatol 1992;30(5):618-624)

족부백선 환자의 군화 및 양말에서의 진균 검출에 관한 연구

서구일 ( Koo Il Seo ) 국군의무사령부 1997 대한군진의학학술지 Vol.28 No.1

군 장병에게서 흔히 발생하는 피부과 질환의 진단 및 치료에 대한 군의사관후보생들의 지식 평가

서구일 ( Koo Il Seo ) 국군의무사령부 1998 대한군진의학학술지 Vol.29 No.1

다발성 피부전이를 보인 신경아세포종

서구일(Koo Il Seo),정승용(Seung Yong Jung),김규한(Kyu Han Kim),윤재일(Jai Il Youn),이유신(Yoo Shin Lee),안효섭(Hyo Seop Ahn) 대한피부과학회 1993 대한피부과학회지 Vol.31 No.2

We report a case of neuroblastoma with multiple skin metastases as a chief complaint in a 2-month-old girl. the skin lesions were rnultiple, pea-sized, bluish, nontender, moable subcutaneous nodules on abdomen, back and scalp. Histopathology showed small round or poly gonal tumor cells which have deeply stained, basophilic, hyperchromatic nuclei with some mitoses. Th.se tumor cells showed clumping tendency which is one of early menifestations of rosette formation. Immunohistochemically positive reaction was demonstrated by anti-NSE(neuron specific enolase) antilody but negative reaction by anti-NFP (neurofilament proteiin ) antibody. She has been succesfully treated with combined chemotherapy for 10 months without relapse. (Kor J Dermatol 1993; 31 (2): 264-268)

군대에서 발생한 봉소염 환자의 임상 양상에 관한 연구

서구일(Koo Il Seo),조광현(Kwang Hyun Cho),김계정(Kea Jeung Kim),은희철(Hee Chul Eun) 대한피부과학회 1999 대한피부과학회지 Vol.37 No.9

N/A Background : Cellulitis is one of the most common infectious skin diseases in primary care units of military service in which personal hygiene could be easily neglected under special circumstances such as outdoor training. Objective : This study was designed to elucidate the probable causes of the high incidence rate of cellulitis in military service. Methods : We prospectively evaluated the clinical findings of 59 patients with cellulitis who were hospitalized in the medical detachment of the 1st Infantry Division of the ROK Army from May, 1995 to April, 1996. Results : The mean age of patients was 21(19-25). Analysing the rank of the patients, the number of recruits was 3(5%), private 26(44%), private first class 17(29%), corporal 11(19%), and sergeant 2(3%). Seventy eight percent of them were included in ranks below corporal. The recurrence rate of cellulitis during the 2 1/2 year follow-up period was only 4%. Skin lesions noted were erythema(100%), tendemess(98%), swelling(98%), local heating(97%), lymphadenopathy(73%), pus(63%), fluctuation(32%), ulcer(27%), lymphangitis(14%), bullae(8%), etc. The most common route of infection was the previous wounds(46%) which allows a portal for inbasion of microorganisms. Tinea pedis was also found to be in 39% of patients with cellulitis of the lower leg. The pus culture performed on 7 patients who had not been responsive to primary antibiotics resulted in 6 positive cases of Staphylococcus aureus. Conclusion : Considering the ranks of the patients and the routes of infection, we found that the incidence of cellulitis in the military service of the ROK Army could be reduced if more attention would be paid to preventive counterplans for secondary infection and tinea pedis. (Korean J Dermatol 1999;37(9) : 1305∼1309)

Hyperhidrosis: Optimized toxin injection technique

서구일 ( Kyle Koo-il Seo ) 대한피부과학회 2017 대한피부과학회 학술발표대회집 Vol.69 No.1

피부과를 전공하지 않은 의사들의 흔한 피부질환에 대한 의학 지식 평가

서구일(Koo-Il Seo),고우석(Woo-Seok Koh),은희철(Hee Chul Eun) 한국의학교육학회 1999 Korean journal of medical education Vol.11 No.1

의과대학 교육목표로 많은 수의 대학이 일차진료를 담당하는 의사의 양성을 표방하고 있다1. 피부과교육 역시 한국의과대학장협의회에서 정한 의과대학 학습목표 중 피부과학 학습목적으로 ‘피부의 정상 및 병적 상태를 이해하여 흔한 피부질환의 진단과 치료에 응용한다’고 기술되어 있으나7 피부과를 전공하지 않은 의사들이 일반인에서 유병률이 높은 피부질환에 대해서도 제대로 진단을 못 내리거나 치료를 못해 곤혹스러운 경우가 많은 것이 현실이다. 본 연구는 흔한 피부질환의 진단 및 치료에 대한 피부과를 전공하지 않은 일반 의사들의 지식을 평가하여 우리 나라 피부과 임상교육의 취약한 부분을 보충할 수 있는 자료로 삼고자 공중보건의와 군의사관후보생을 대상으로 설문조사 및 흔한 피부질환에 대한 지식 평가와 임상 슬라이드 시험을 시행하였다. 교육부문에 관한 설문조사 결과에서 피부과를 전공하지 않은 의사들이 피부질환을 진단할 때 84%가 어려움을 느낀다고 응답하였으며 그 원인으로서 일반의를 위한 교재의 부족과 미흡한 의과대학 피부과 교육을 지적하였다. 치료부문의 경우 국소 스테로이드 연고의 적응증,여드름 치료, 족부백선의 치료, 두드러기 치료, 옴치료 등에 대해서는 50% 내외만이 정답을 맞추어 흔한 피부질환의 치료도 제대로 알지 못하는 문제점을 보여주었다. 그룹별로 평균 점수를 살펴보면 학부만 졸업한 일반의 군이 전문의 군에 비해 통계적으로 유의하게 낮게 나왔는데 평가 문항이 치료약제 위주이므로 의과대학을 갓 졸업한 의사보다 직접 치료 경험이 많은 전문의 군이 좋은 점수를 보여주었다고 생각된다. 전문의 군에서 전공과목별 점수 차이를 보면 가정의학과와 비뇨기과 두 군만이 유의하게 높은 점수를 보여주었다. 진단 부문에서 전형적인 임상양상을 보여준 질환은 높은 점수를 나타낸 반면 본 평가문항의 둔부에 발생한 완선과 안면백선과 같이 조금 변형된 임상양상을 보이는 경우는 진단률이 현격히 떨어졌다. 즉 흔히 알고 있는 질환이라 할지라도 비전형적인 임상양상에 대해서는 일반의들의 진단이 쉽지 않음을 알 수 있었다. 어루러기와 농가진같이 1차 의료기관에서 흔히 볼 수 있는 피부질환들 역시 평균에도 못 미치는 상대적으로 낮은 진단률을 보여 주었는데 이것은 의과대학 피부과 교육에서 흔한 질환에대해 상대적으로 소홀히 교육받았다는 증거이기도 하며 아마도 3차 의료기관인 대학 병원에 이러한 유병률이 높은 피부 질환자가 상대적으로 적기 때문에 임상 실습의 기회가 적은데서 기인한다고도 생각한다. 전공과목에 따른 진단률의 차이를 조사한 결과 가정의학과만 유의하게 높은 진단률을 보였주었는데 이것은 의과대학 졸업 후의 수련과정 중 피부과 임상 실습 교육을 다시 받는 가정의학과 수련과정의 특성 때문으로 생각된다. 반면 치료부문의 평가에서 가정의학과와 함께 높은 점수를 보여준 비뇨기과 군은 진단부문에서는 다른 전문의 군과 차이가 없는 것으로 나타나 피부과 임상 실습 교육의 중요성을 재삼 확인할 수 있었다. 이상의 결과를 종합해보면 피부과 전문의가 아닌 의사들이 일반인에서 유병률이 높은 피부질환에 대해서도 제대로 진단을 못 내리거나 진단은 내려도 치료를 잘 모르는 경우가 많은 것으로 나타났다. 이를 보완하기 위해서는 의과대학 피부과 교육에서 희귀하고 학문적 관심이 많은 질환들에 중점을 둘게 아니라 유병률이 높은 흔한 질환들을 중심으로 전형적인 양상 뿐아니라 변형된 양상에 대해서도 교육을 해야 하며 실제 진단과 치료에 도움이 되는 내용이 강조되어야 할 것이다. 또한 대학병원에서의 실습만을 고집할 것이 아니라 1차 의료기관과 연계해서 지역사회에 흔한 질환에 대해 어느 정도의 경험을 가질 수 있도록 배려해야 된다고 생각한다. 본 조사 결과에서는 가정의 뿐아니라 일차 진료를 맡게될 내과나 소아과 전문의들도 레지던트 교육과정에 흔한 피부질환에 대한 추가적인 임상 교육이 필요하다고 판단된다. Proper education about dermatology in medical college would have physicians appropriately diagnose and treat common dermatoses without referring patients to dermatologists. However, physicians who are not dermatologists have difficulty in diagnosing and treating common dermatoses. We have made up a questionnaire about treatment and a slide test for clinical diagnosis of common dermatoses in order to evaluate the knowledge of physicians about common dermatoses, which reflects indirectly the current status of medical education of dermatology in Korea and can be used as a basic data for modifying directions for education in medical college. Total 654 physicians answered the questionnaire, including 125 just graduated general physicians, 111 general physicians who had just finished internship and 418 medical specialists. 11 data from dermatologists were analyzed as a control for evaluation. The result showed that 84%(545) of them have difficulty in diagnosing dermatologic diseases. The probable causes answered by them are lack of easy illustrative textbook for general physician(48%), inadequate education of dermatology in their medical colleges(27%) and so on. In the field of therapy in the questionnaire, only 53% of them had proper knowledge about indication of topical steroids, 56% about acne therapy, 22% about treatment of tinea pedis, 35% about scabies and 41% about urticaria. The average score was 53%. The score of family medicine group and urologist group was 69% and 66% each, which were significantly higher than that of other major groups except 98% of dermatologist group. In the slide test for clinical diagnosis, the average score was 71%. The score of family medicine group which had received postgraduate education on dermatology in their resident training was 84%, also significantly higher than that of other major groups except 100% of dermatologist group. The percentage of correct responders about tinea faciei is only 13%, tinea versicolor 42%, tinea cruris 49%, impetigo 53%, pityriasis rosea 60%, atopic dermatitis 67%, psoriasis 72% and fixed drug eruption 74%, etc. The average score was 71%. In conclusion, this study showed that physicians who are not dermatologists have difficulty in diagnosing and treating even common dermatoses. We think it is important to put stress on the common dermatoses in the field of dermatologic education in medical college. Moreover we could find the importance and need of postgraduate education on dermatology in the resident training of primary care physicians such as not only family medicine doctors but also internists and pediatricians.

군 장병에게 흔한 봉소염 환자의 치료경과 단축에 따른 군 전투력 손실의 최소화 방안

민복기 ( Pok-kee Min ),서구일 ( Koo-il Seo ),김진하 ( Jin-ha Kim ),강효준 ( Hyo-jun Kang ),신동주 ( Dong-ju Shin ),이석종 ( Seok-jong Lee ),정상립 ( Sang-lip Chung ) 국군의무사령부 2000 대한군진의학학술지 Vol.31 No.1

보툴리눔 독소(보톡스(R))로 치료한 얼굴 주름의 임상적 고찰

윤상웅 ( Sang Woong Youn ),서구일 ( Koo Il Seo ),유종엽 ( Jong Yeop Yoo ),박경찬 ( Kyoung Chan Park ),은희철 ( Hee Chul Eun ) 대한피부과학회 2002 대한피부과학회지 Vol.40 No.4

N/A Background : Botulinum toxin type A is being widely used for the treatment of facial wrinkles sheeted by facial expression muscles. Due to the sudden and exponential surge in popularity of its use for facial wrinkles, there are scanty reports of facial wrinkles treated with botulinum toxin type A especially in Asians. Objective : This study was performed to investigate the clinical features of facial wrinkles affected by facial expression muscles and the effects of botulinum toxin A on the treatment of wrinkles. Methods : Medical records of 61 patients with facial wrinkles treated with botulinum toxin type A were reviewed. Demographic profiles of the patients, the age of onset of facial wrinkle, the distributions of facial wrinkles, treatment dose of botulinum toxin type A. side effects, and follow up data went analyzed. Results : Female patients were predominant(93.4%) than male patients(6.6%). The m . e of the patients was 41.3 years. Crow, s feet were the mast frequently treated site of facial wrinkles. Average number of treated sites were 2.38. Side effect profiles were similar as previous reports in Cents,tons. The number of patients who took the regular retreatment was less than expected. Conclusion : The clinical profiles of wrinkle patients in Koreans treated with botulinum toxin A were assessed. We think it is one a of the effective treatment modalities for antiwrinkling.