Thickness of Korean Upper Eyelid Skin at Different Levels

Hwang, Kun,Kim, Dae Joong,Hwang, Se Ho Mutaz B. Habal, MD 2006 JOURNAL OF CRANIOFACIAL SURGERY - Vol.17 No.1

This study aims at elucidating the thickness of the Korean upper eyelid at different levels. Left eyelids of 10 (9 males and 1 female) fresh Korean cadavers were dissected. Full thickness upper eyelids were cut and trichrome stained. The thickness was measured under a microscope.The thickness of upper eyelid skin varied at different levels. The thickest part of the upper eyelid is just below the eyebrow (D) (1.127 ± 238 μm), and the thinnest skin is near the ciliary margin (A) (320 ± 49 μm). The upper tarsal area (C) and mid tarsal area (B) are 832 ± 213 and 703 ± 103 μm, respectively. “A” area was significantly thinner than mid tarsal “B” area (P = 0.000). The skin above the tarsus was thicker than the “B” area, but there was no significant difference (P = 0.081). The skin just below the eyebrow, “D,” was thicker than the upper tarsal border, “C” area (P = 0.011). The epidermis accounted for 11.2% of the entire skin near the ciliary margin. However, epidermis presented less (4.2-5.5%) of the whole skin at other levels (P = 0.000). The distance between ciliary margin and the point where the skin turns suddenly thicker was 1.89 ± 0.23 mm. The size of the tarsal plate was 8.88 ± 0.81 mm. These data of upper eyelid skin thickness may apply to Asian double fold surgery and also to full thickness skin donation for grafting.

Could Skin Retraction Incision Minimize Nerve Injury Over the Iliac Crest?

Hwang, Kun,Nam, Yong Seok,Kim, Dae Joong,Han, Seung Ho,Hwang, Se Ho Mutaz B. Habal, MD 2007 JOURNAL OF CRANIOFACIAL SURGERY - Vol.18 No.6

The aim of this study is to elucidate the nerve passage over the iliac crest shifted by skin retraction in harvesting iliac bone graft. A total of 44 iliac crests obtained of 22 nonembalmed Korean fresh cadavers were dissected (six males and 16 females; age range, 57-91 years). In A group (22) of 'reposed skin,' a skin incision was made from the anterior superior iliac spine (ASIS) to the highest level of iliac crest (HLIC). In B group (22) of 'medial retraction,' skin was tugged medially 1.5 cm and an incision was made from ASIS to HLIC. In A group, the nerve branches were injured in 19 (86.4%) and 15 (68.2%) in B group. Most injured nerves crossed over the iliac crest and at the posterior half site of ASIS to HLIC. The involved nerves were the subcostal nerve, iliohypogastric nerve, and ilioinguinal nerve. Subcostal nerve was less inflicted with injury in B group (one branch, 4.5%) than A group (four branches, 18.2%). P value is 0.151. Iliohypogastric nerve was significantly least injured in B group (three branches, 13.6%) compared with A group (10 branches, 45.5%). P value is 0.022. An injuring rate of ilioinguinal nerve was almost the same between A group (13 branches, 59.1%) and B group (14 branches, 63.61%). P value is 0.760. In the procedure of harvesting iliac bone graft, it is suggested to make an incision on the skin retracted medially and on the anterior half site of ASIS to HLIC to avert an injury of superficial sensory nerves.

Does the Upper Eyelid Skin Become Thinner With Age?

Hwang, Kun,Kim, Dae Joong,Kim, Seong Kee Mutaz B. Habal, MD 2006 JOURNAL OF CRANIOFACIAL SURGERY - Vol.17 No.3

The aim of this study was to elucidate whether the thickness of the upper eyelid skin is affected by aging. The upper eyelid skins of 61 Korean women were subject to the study. Fusiform pieces of the skin, 3-mm wide, were obtained at the midpupillary line, 7 mm above the eyelashes, during blepharoplasty. The specimens were stained with hematoxylin and eosin. Thickness of the skin was measured by a micrometer under a microscope. It was substantially the same in all of the age groups. The thickness varied from 818 ± 85 μm in subjects 60 years or older to 884 ± 112 μm in subjects between 21-and 30-years old; the mean was 860 ± 305 μm. Thickness of the epidermis varied from 46 ± 6 μm in subjects between 41- and 50-years old to 52 ± 10 μm in subjects between 31- and 40-years old; the mean was 49 ± 9 μm. There were no significant differences among the age groups (P = 0.440). Thickness of the dermis varied from 771 ± 78 μm in subjects older than 61 years to 834 ± 112 μm in subjects between 21-and 30-years old; the mean was 811 ± 117 μm. There were no significant differences between the age groups (P = 0.553). It is noticeable that upper eyelid skin thickness is not affected remarkably by aging.

Peripheral Nerve Regeneration Using a Three Dimensionally Cultured Schwann Cell Conduit

Kim, Soung-Min,Lee, Suk-Keun,Lee, Jong-Ho Mutaz B. Habal, MD 2007 JOURNAL OF CRANIOFACIAL SURGERY - Vol.18 No.3

The use of artificial nerve conduit containing viable Schwann cells is one of the most promising strategies to repair peripheral nerve injury. To fabricate an effective nerve conduit whose microstructure and internal environment are more favorable in nerve regeneration than those currently existing, a new three-dimensional (3D) Schwann cell culture technique using Matrigel and dorsal root ganglion (DRG) was developed.Nerve conduit of 3D arranged Schwann cells was fabricated using direct seeding of freshly harvested DRG into Matrigel-filled silicone tubes (inner diameter 1.98 mm, 14 mm length) and in vitro rafting culture for 2 weeks. The nerve regeneration efficacy of 3D cultured Schwann cell conduit (3D conduit group, n = 6) was assessed using an Sprague-Dawly rat sciatic nerve defect of 10 mm and compared with that of a silicone conduit filled with Matrigel and Schwann cells prepared with the conventional plain culture method (two-dimensional [2D] conduit group, n = 6). After 12 weeks, sciatic function was evaluated with sciatic function index (SFI) and gait analysis, and histomorphology of nerve conduit and the innervated tissues of sciatic nerve were examined using image analyzer and electromicroscopic methods.The SFI and ankle stance angle in the functional evaluation were −60.1 ± 13.9, 37.9° ± 5.4° in the 3D conduit group (n = 5) and −87.0 ± 12.9, 32.2° ± 4.8° in the 2D conduit group (n = 4). The myelinated axon was 44.91% ± 0.13% in the 3D conduit group and 13.05% ± 1.95% in the 2D conduit group. In the transmission electron microscope study, the 3D conduit group showed more abundant myelinated nerve fibers with well-organized and thickened extracellular collagen than the 2D conduit group, and the gastrocnemius muscle and biceps femoris tendon in the 3D conduit group were less atrophied and showed decreased fibrosis with less fatty infiltration than the 2D conduit group. A new 3D Schwann cell culture technique was established, and nerve conduit fabricated using this technique showed much improved nerve regeneration capacity than the silicone tube filled with Matrigel and Schwann cells prepared from the conventional plain culture method.

Experimental Study of Autologous Cartilage, Acellular Cadaveric Dermis, Lyophilized Bovine Pericardium, and Irradiated Bovine Tendon: Applicability to Nasal Tip Plasty

Hwang, Kun,Hwang, Jin Hee,Park, Jun Ho,Kim, Dae Joong,Shin, Yong Ho Mutaz B. Habal, MD 2007 JOURNAL OF CRANIOFACIAL SURGERY - Vol.18 No.3

The purpose of this study was to compare the volumetric and histologic changes of the acellular cadaveric dermis, lyophilized bovine pericardium, irradiated bovine tendon, and autologous cartilage transplanted subcutaneously in the rats. Four different kinds of implants were placed in subcutaneous pockets of the dorsum of 40 Wister rats. The implants with the subcutaneous pockets were retrieved in the first, fourth, eighth, and 12th weeks after implantation. The size and histologic change of each implant were observed. The xiphoid cartilage showed the peak survival (71.0%, P = 0.247) on the 12th week, but part of the cartilage was absorbed irregularly and its shape changed unpredictably. The lyophilized bovine pericardium had a high survival rate as well (64.4%, P = 0.016). However, the size decreased significantly in the first through 12th weeks. A survival of acellular cadaveric dermis was lower (38.8%, P = 0.036) than the cartilage and pericardium, but it sustained the structure for 12 weeks and changed peripherally into the neocollagen. Irradiated bovine tendon disclosed the lowest survival rate (31.4%, P = 0.008). The structure was gradually distorted and replaced entirely by neocollagen in the 12th week after implantation. Autologous cartilage is the best choice for soft tissue and nasal tip augmentation. Although other implants than the cartilage showed significant diminution of its volume in 12 weeks, lyophilized bovine pericardium could be the next substitute to the cartilage in soft tissue augmentation.

Correction of Congenital Transverse Cleft of the Earlobe

Hwang, Kun,Kim, Dong Hyun,You, Sun Hye Mutaz B. Habal, MD 2011 JOURNAL OF CRANIOFACIAL SURGERY - Vol.22 No.1

Congenital cleft earlobe is classified into longitudinal, transverse, triple, and defective types. The transverse type is rare. We report an 11-year-old girl with a transverse cleft of the earlobe that was corrected with a dermofat graft and a de-epithelialized tongue flap. The anterior (superior) and posterior (inferior) lobes of the transverse clef were divided. Dermofat tissue from the ipsilateral retroauricular area was grafted between the lobes, and an anterior de-epithelialized (tongue) flap was inset in addition. Dermofat graft and de-epithelialized flap were applied effectively to a soft tissue defect in a congenital cleft of the earlobe. The shape and contour of the earlobe were then acceptable. Congenital transverse cleft of the earlobe can be corrected by supplementing a soft tissue defect with a dermofat graft and a de-epithelialized flap.

Innervation of Upper Orbicularis Oris Muscle

Hwang, Kun,Jin, Sheng,Hwang, Se Ho,Chung, In Hyuk Mutaz B. Habal, MD 2006 JOURNAL OF CRANIOFACIAL SURGERY - Vol.17 No.6

The aim of this study is to elucidate the innervation of upper orbicularis oris muscle. The upper lips of 17 hemifaces of Korean adult cadavers were dissected. The number of nerve branches crossing and entering the outer margin of pars peripheralis and pars marginalis were counted, respectively. The location of ramifying point of the buccal branch was measured. The nerve branches crossing the outer margin of pars peripheralis were about 4 (3.71 ± 1.05) on each side of the face and branches crossing the outer margin of pars marginalis was 4.65 ± 1.46. About four (4.06 ± 0.83) branches entering the pars marginalis were found. Most ramifying points (14/17, 82%) located within a circle of 5 mm in radius diameter and the center was at 12 mm lateral and 26 mm superior to the mouth corner. An anatomical knowledge might be contributive to understand a wrinkle depletion of the upper lip and function of the orbicularis oris muscle.

Lateral Rectus Muscle Injury, Orbital Fracture, Mouth Locking, and Facial Palsy Resulting From Reduction Malarplasty

Mutaz B. Habal, MD 2011 JOURNAL OF CRANIOFACIAL SURGERY - Vol.22 No.1

I report here on a patient with serious complications (lateral rectus muscle injury, orbital fracture, mouth locking, and facial palsy) that were caused by reduction malarplasty.A 32-year-old woman was referred to our department with complaints of inability to move her right eyeball laterally and inability to open her mouth. She has undergone reduction malarplasty 30 days previously at a local clinic. On examination, her maximal mouth opening was less than 3 mm. Her upper lip deviated to the left side when whistling. The orbit was displaced laterally and inferiorly. The upward and lateral gaze were limited. Computed tomography revealed fracture of the right orbital floor and lateral orbital wall extending to the orbital roof. The right lateral rectus muscle showed disconnection. The osteotomized segments were displaced inferiorly, and they pressed on the masseter muscle and coronoid process on the left side.On the 43rd postoperative day, a revision operation for the zygoma and orbit was carried out. Four days after the revision operation, surgery was performed for the myorrhaphy of the lateral rectus muscle and transposition of the medial rectus muscle.This case suggests the possibility of orbital fracture that can occur as a result of sawing in the wrong direction when using the intraoral approach. Although orbital fracture is extremely rare, it is hoped that this case will heighten the awareness of surgeons for this potential orbital fracture.

Intramuscular Hemangioma of the Lower Lip

Nam, Yong Seok,Hwang, Kun Mutaz B. Habal, MD 2007 JOURNAL OF CRANIOFACIAL SURGERY - Vol.18 No.4

We report a case of intramuscular hemangioma in the lower orbicularis oris muscle. A 5-year-old boy presented a fairly firm mass in the lower lip. The mass was noticed a few weeks after birth and had been progressing slowly for years. On histology, proliferating vascular channels infiltrated diffusely the skeletal muscle, adipose, and connective tissue. The vascular channel was lined inside by endothelium and varying amounts of component smooth muscle.

The Relationship of Capsulopalpebral Fascia With Orbital Septum of the Lower Eyelid: An Anatomic Study Under Magnification

Hwang, Kun,Kim, Dae Joong,Hwang, Se Ho,Chung, In Hyuk Mutaz B. Habal, MD 2006 JOURNAL OF CRANIOFACIAL SURGERY - Vol.17 No.6

The aim of this study is to elucidate each insertion of the capsulopalpebral fascia (CPF) and orbital septum (OS) in the lower eyelid. Fifteen eyelid specimens were obtained from 15 Korean male adult cadavers for the study. Three parasagittal sections were made apart at medial limbus, midpupillary line and lateral limbus. The specimens were cut in 10-μm sections, stained with Masson-trichrome and observed under light microscopy. The head of the CPF split open superiorly and inferiorly wrapping around the inferior oblique muscle and met anteriorly. CPF inserted to the inferior border of the tarsus, merging the anterior border of the inferior tarsal muscles. OS blended with CPF most closely at 3.7-5.4 mm beneath the lower tarsal border: and differently at 3.7 ± 0.7 mm on the medial limbus line, 4.3 ± 0.8 mm on the midpupillary line and 5.4 ± 1.0 mm on the lateral limbus line. The blending level is closer to the tarsus at the medial side than the lateral side. The closest distance between the lower tarsal border and the first identifiable smooth muscle nuclei of the inferior tarsal muscle was 2.1-2.7 mm, and differently 2.7 ± 0.7 mm on the medial limbus line, 2.7 ± 0.7 mm on the midpupillary line and 2.1 ± 0.9 mm on the lateral limbus line. Precise anatomical understanding of OS and CPF may be conducive to the lower eyelid surgery.