Thursday, November 10, 2016

Doc, can you do something about my sausage lip?

Having a full lip can make a person more sensuous and attractive. However, an artificial pump-up lips which are not proportional to one's face can make one an object of ridicule.

Natural versus unnatural lips.

This woman had lip injection  in a beauty saloon two years ago to give her a better pout. She was told the injection consisted of hyaluronic acid. Two years later, the lips remained swollen and the upper lip had poor contour with the left side bigger than the right. She was depressed as people ridiculed her for having "sausage lips". 

Swollen upper lip with asymmetrical contour.



Side view of the lips

She consulted a few aesthetic physicians and had injections including steroid and hyalurodinase to reduce the swelling but to no avail. Examination showed the lips to be thickened and hard to touch, it was likely that she was injected with silicone rather than hyaluronic acid. The only treatment of choice is to surgically remove the granuloma. 

Surgical removal of the granuloma and to reshape the contour 
of the upper lip.

Excised lip tissue showing granuloma.

Post lip reduction with good contour.

Side view of the upper lip post lip reduction.

Sunday, September 11, 2016

Doc, Can You Straighten My Eyes? VI

Patients with high myopia may sometimes develop a very significant convergent squint which is not only cosmetic disfiguring but severely affect the vision. The mechanism is thought to be herniation of the globe outside the muscle cone usually between the superior and lateral rectus (as mentioned in previous post). Surgical correction is often complex as simple recession/resection technique is usually insufficient to significantly correct the malposition. One way of correcting this difficult squint is with muscle transposition. However, it is important to inform the patients that more than one operation may be needed for good outcome.

Surgical procedure showing transposition of muscles for myopic strabismus fixus. 
The medial rectus was released and allowed to hang back by 8mm. a. The superior 
rectus is isolated; b. the superior rectus is split into two equal halves; c. the lateral rectus 
is isolated and split into two equal halves; d e and f. a 5/0 silk is used to tie the upper 
half of the rectus at 15mm from its origin of insertion to the lateral half 
of the superior rectus. The technique strengthen the lateral rectus 
and push the globe back into the muscle cone.

Diagramtic presentation of the procedure shown in the photos.

This patient has residual convergent squint but is able to perform 
her daily activities without help. 

Despite the located lenses due to high myopia, this patient regains good vision after 
the surgery while awaiting surgical removal of the dropped lenses.

This patient has residual hypotropia but is pleased with his appearance.

Doc, Can You Straighten My Eyes? V

Most cases of squints are mild to moderate and involve the horizontal muscles. In such cases, simple techniques of recession/resection of the horizontal muscles (medial rectus and horizontal rectus) are all that are needed to restore the position of the eyes. However, there are occasionally difficult squints that call for special techniques and can only be treated by doctors who are proficient in performing challenging cases. 

Examples of challenging cases are these three patients who presented with severe convergent squints and high myopia of more than -12.00. Some of the eyes are so far pulled inward that the cornea became invisible. They all suffered from a condition called myopic strabismus fixus. In this condition, the eye globes were abnormally elongated and prolapsed between the superior and lateral rectus (as shown by the diagram and the MRI scans). Simple recession/resection would not be enough to restore the positions of these eyes.

A 35 year-old woman with  -15.00D both eyes and bilateral severe convergent 
squints. The left cornea was almost invisible. She had problems 
seeing due to the severe squints.

A 60 year-old man with bilateral severe convergent squints and dislocated lenses 
due to high myopia. He was referred for squint correction so that surgery 
could be performed to remove the dislocated lenses.

A patient with high myopia and a right severe convergent squint. The right vision 
has been poor since young and patient wished for restoration 
of the eye position for cosmetic reason.

MRI showing prolapse of the globes between the superior and lateral 
rectus in a patient with myopic strabismus fixus.

Diagram showing prolapse of the globe between the superior and lateral rectus 
so that the eye becomes severely inward turning.