- Email: [email protected]
Cosmetic surgery
Letters to the Editor
Linear Nevus Sebaceous Syndrome Dear Editor: Dr. Duncan and coworkers1 begin their excellent paper with the unfortunate statement, “Linear nevus sebaceous syndrome (LNSS), or nevus sebaceous of Jadassohn, is a rare disorder . . .” The sentence equates the rare syndrome with the more common isolated sebaceous nevus that occurs in otherwise normal patients.2 Similarly, complex limbal choristomas may occur either alone or with other abnormal findings, such as lid notching,3 without participation in a full syndrome. The term linear, although not coined in this paper, is inappropriate, as not all sebaceous nevi in the syndrome have a linear shape. The authors also do not mention that in the LNSS melanocytic nevi may be present on the facial skin, which may or may not have a linear configuration. NORMAN C. CHARLES, MD New York, New York References 1. Duncan JL, Golabi M, Fredrick DR, et al. Complex limbal choristomas in linear nevus sebaceous syndrome. Ophthalmology 1998;105:1459 – 65. 2. Diven DG, Solomon AR, McNeely M, Font RL. Nevus sebaceus associated with major ophthalmologic abnormalities. Arch Dermatol 1987;123:383– 6. 3. Gorduren S. Aberrant lacrimal gland associated with other congenital abnormalities. Br J Ophthalmol 1962;46:277– 80.
Authors’ reply Dear Editor: While confusion does exist in the literature, most authors equate “nevus sebaceous of Jadassohn” with “linear nevus sebaceous syndrome.” Jadassohn himself described “Talgdru¨sen-naevi,” or sebaceous-gland nevi, as consisting of large but histologically normal sebaceous lobules in a patient with neurologic deficit, implying an association with systemic abnormalities.1 Feuerstein and Mims2 are credited with the first full description of linear nevus sebaceous syndrome, a rare disorder including nevus sebaceous, seizures, and mental retardation. Jadassohn’s own definition of nevus sebaceous made no specific reference to a linear shape,1 however, and Dr. Charles is correct to point out that not all sebaceous nevi are linear.3 We also recognize that complex limbal choristomas can occur in isolation. JACQUE L. DUNCAN, MD EMMETT T. CUNNINGHAM, JR., MD, PHD San Francisco, California References 1. Jadassohn J. II. Bemerkungen zur Histologie der systematisirten Naevi und u¨ber “Talgdru¨sen-Naevi.” Archiv fur Dermatologie und Syphilis 1895;33:355–72. 2. Feuerstein RC, Mims LC. Linear nevus sebaceus with convulsions and mental retardation. Am J Dis Child 1962;104:675–9.
3. Mehregan AH, Pinkus H. Life history of organoid nevi: special reference to nevus sebaceus of Jadassohn. Arch Derm 1965;91: 574 – 88.
Cosmetic Surgery Dear Editor: Drs. Bartley and Linberg, in their thoughtful guest editorial, “Cosmetic Surgery May be Hazardous . . . For the Doctor as Well as the Patient,” present several reasons why cosmetic surgery is popular.1 I would like to emphasize that many patients desire cosmetic surgery for profound, valid, and universal reasons. Secondly, I would like to rebut the prevailing tendency to dismiss cosmetic surgery as a vanity that caters to fickle cultural norms of beauty. Indeed, in discussing the “why” of cosmetic facial surgery, it is important to note that several ways in which humans express, communicate, and interpret facial gestures (i.e., happiness, disgust, surprise, sadness, anger, and fear) are not culture-specific but, as documented by Darwin2 in 1872 and confirmed by further studies, are both innate and universal. If one considers the human face to be merely an object of an arbitrary and culturally defined notion of beauty, then it would make sense to encourage cosmetic patients to accept their appearance and to label any further attempts at improvement as vanity, “disjuncture,” or symptoms of cultural depravity and indulgence. Admittedly, the concept that the face and its expressions should constitute an object of culturally defined beauty and pleasing mathematical proportion is well entrenched among artists and scientists and is duly parroted by the public and press. Even influential cultural relativists such as Margaret Mead argued against the universality of any human facial expressions. Mead conceded in private, however, that she had avoided any study of the biologic basis of human behavior because of her prescient concerns regarding the extent to which any genetic basis of behavior might be used to justify the horrific extremism of the then rising Nazi party.2 Nonetheless, applying concepts of cultural relativism to patients who wish to alter a face that displays an undesirable innate or universal human facial expression (i.e., anger from glabellar furrows) has created a serious and longstanding stumbling block to the development of the aesthetic surgeon, and, in my opinion, represents a profound but unrecognized error in the development of 20th century aesthetic facial surgery. This concept of the face as a beauty object has also fueled the misguided romantic myth of the surgeon as an artist and a sculptor. Indeed, for those who need further argument, the limits of underlying bone structure, preservation of vital facial functions, and iatrogenic injury pose severe limitations on the surgical usefulness of this line of thought. In my cosmetic practice, most patients have wellfounded and clearly evident concerns about their eyelid appearance. Usually, their eyelids and eyebrows evidence a
207
Ophthalmology Volume 106, Number 2, February 1999 universally recognized signal of tiredness and/or anger. Specifically, they are noting that the overhanging upper eyelid skin makes them appear tired or sad, the furrows between the eyebrows send out a signal of anger, frowning or disapproval, and the puffy lower eyelid fat sends out a signal of tiredness or sickness. These patients who come from diverse cultures are not striving to embody any cultural norm of beauty. Rather, they have figured out that their face is not communicating effectively, and they wish to correct the responsible age- or heredity-induced communications miscue. These observations have convinced me that the true purpose of the human face is to function as a communications device that signals the bearer’s ethnicity, gender, emotional intent, social status, and age. When the facial organ malfunctions, the signals emitted are jumbled and do not accurately represent the person’s emotional state. An example would be someone with strong glabellar furrow lines and low brows, who appears to be angry all the time, when in fact these universal signals of anger are in reality both inherited and age related miscues or malfunctions of the face. If a patient’s hand did not function from arthritis or if his or her speech was damaged from laryngitis, we would not begrudge the patient further treatment. Why then should we label as “vanity” the desire to have one’s face communicate effectively? Once one accepts that the surgeon should consider the face to be an organ of communication and expression rather than beauty, one can approach the patient in a rigorous and defined manner. When confronted with a patient who is dissatisfied by his or her facial appearance, the surgeon should stand back, evaluate the face, and see what type of universal miscues are being emitted by the face. For example, with excess upper eyelid skin, there is often a secondary eyebrow elevation, which can create a look of skepticism. Hence, the surgeon’s first role is to identify the anatomic sources of signaling miscues. The surgeon’s second role is to suggest possible corrections. This can be demonstrated to the patient in front of the mirror by stretching and moving parts of the patient’s face. The rigorous measurement of “success” in cosmetic surgery sought by Drs. Bartley and Linberg could be derived from grading preoperative and postoperative facial photos for evidence of specific communication miscues. The functional approach to the face has helped patients in my practice and will benefit other cosmetic surgeons as they and their patients experience firsthand the profound implications of redefining the approach to aesthetic facial surgery. Certainly, as Bartley and Linbergh astutely opine, the surgeon who believes that cosmetic surgery offers only compensation for the surgeon and beauty for the patient has embarked on a path that is hazardous on both accounts. However, the surgeon who accurately diagnoses and treats the facial organ’s malfunction walks a familiar and traditional path, one best described as the practice of a healing art. JEMSHED A. KHAN, MD Kansas City, Missouri
208
References 1. Bartley GB, Linberg JV. Cosmetic surgery may be hazardous . . . for the doctor as well as the patient [editorial]. Ophthalmology 1998;105:763– 4. 2. Darwin C. The Expression of the Emotions in Man and Animals. 3rd ed. London: Harper Collins Publishers, 1998.
Intraoperative Mitomycin C for Pterygium Surgery Dear Editor: Dr. Lam and coworkers,1 in their recently published article, “Intraoperative Mitomycin C to Prevent Recurrence of Pterygium after Excision,” report that intraoperative application of a single dose of 0.02% or 0.04% mitomycin C (MMC) for 3 minutes was ineffective in the treatment of primary/recurrent pterygium, with recurrence rates of 37.9%/66.7% and 17.9%/42.9%, respectively. However Mastropasqua et al2 and Frucht-Pery et al3 reported succesful use of intraoperative MMC for 3 minutes, with respective recurrence rates of 6.7% and 4.08%. It has been shown that application of 0.04% MMC even for 1 minute inhibits fibroblast proliferation like a 5-minute application in vitro.4 Lam et al have stated that these differences might have been caused by racial, environmental, and other factors and suggested that a multicenter study to evaluate the efficacy and potential complications of intraoperative MMC at various concentrations and duration of application in different parts of the world should be meaningful and rewarding. Our results from Turkey, where pterygium is highly prevalent, with intraoperative 0.04% MMC for 3 minutes in the treatment of primary pterygium disclosed a decreased recurrence rate to 5.3% from 41.2% in the control group (without MMC).5 By the end of July 1998, we will have been following our patients in the intraoperative MMC group for a mean of 60.3 months (range, 56 – 65 months). Our technique differed from the previous and later reports. To decrease the toxic effect to the cornea, we applied intraoperative MMC to the scleral bed underneath the limbus-based conjunctival flap and irrigated with at least 200 ml of balanced salt solution before the dissection of the head of the pterygium from the cornea and left 4 mm of bare sclera.5 We have not observed either recurrences after the first 6 months, as already published,5 or late complications like corneoscleral melting. However, we think more follow-up is necessary. The long-term effects of MMC are unknown. As it is a radiomimetic agent,6 the follow-up should be continued for a long period after surgery. SIBEL C¸ALISKAN, MD MEHMET ORHAN, MD MURAT IRKEC¸, MD Ankara, Turkey References 1. Lam DSC, Wong AKK, Fan DSP, et al. Intraoperative mitomycin C to prevent recurrence of pterygium after excision: a 30-month follow-up study. Ophthalmology 1998;105:901–5. 2. Mastropasqua L, Carpineto P, Ciancaglini M, et al. Long term results of intraoperative mitomycin C in the treatment of recurrent pterygium. Br J Ophthalmol 1996;80:288 –91.
Linear Nevus Sebaceous Syndrome Dear Editor: Dr. Duncan and coworkers1 begin their excellent paper with the unfortunate statement, “Linear nevus sebaceous syndrome (LNSS), or nevus sebaceous of Jadassohn, is a rare disorder . . .” The sentence equates the rare syndrome with the more common isolated sebaceous nevus that occurs in otherwise normal patients.2 Similarly, complex limbal choristomas may occur either alone or with other abnormal findings, such as lid notching,3 without participation in a full syndrome. The term linear, although not coined in this paper, is inappropriate, as not all sebaceous nevi in the syndrome have a linear shape. The authors also do not mention that in the LNSS melanocytic nevi may be present on the facial skin, which may or may not have a linear configuration. NORMAN C. CHARLES, MD New York, New York References 1. Duncan JL, Golabi M, Fredrick DR, et al. Complex limbal choristomas in linear nevus sebaceous syndrome. Ophthalmology 1998;105:1459 – 65. 2. Diven DG, Solomon AR, McNeely M, Font RL. Nevus sebaceus associated with major ophthalmologic abnormalities. Arch Dermatol 1987;123:383– 6. 3. Gorduren S. Aberrant lacrimal gland associated with other congenital abnormalities. Br J Ophthalmol 1962;46:277– 80.
Authors’ reply Dear Editor: While confusion does exist in the literature, most authors equate “nevus sebaceous of Jadassohn” with “linear nevus sebaceous syndrome.” Jadassohn himself described “Talgdru¨sen-naevi,” or sebaceous-gland nevi, as consisting of large but histologically normal sebaceous lobules in a patient with neurologic deficit, implying an association with systemic abnormalities.1 Feuerstein and Mims2 are credited with the first full description of linear nevus sebaceous syndrome, a rare disorder including nevus sebaceous, seizures, and mental retardation. Jadassohn’s own definition of nevus sebaceous made no specific reference to a linear shape,1 however, and Dr. Charles is correct to point out that not all sebaceous nevi are linear.3 We also recognize that complex limbal choristomas can occur in isolation. JACQUE L. DUNCAN, MD EMMETT T. CUNNINGHAM, JR., MD, PHD San Francisco, California References 1. Jadassohn J. II. Bemerkungen zur Histologie der systematisirten Naevi und u¨ber “Talgdru¨sen-Naevi.” Archiv fur Dermatologie und Syphilis 1895;33:355–72. 2. Feuerstein RC, Mims LC. Linear nevus sebaceus with convulsions and mental retardation. Am J Dis Child 1962;104:675–9.
3. Mehregan AH, Pinkus H. Life history of organoid nevi: special reference to nevus sebaceus of Jadassohn. Arch Derm 1965;91: 574 – 88.
Cosmetic Surgery Dear Editor: Drs. Bartley and Linberg, in their thoughtful guest editorial, “Cosmetic Surgery May be Hazardous . . . For the Doctor as Well as the Patient,” present several reasons why cosmetic surgery is popular.1 I would like to emphasize that many patients desire cosmetic surgery for profound, valid, and universal reasons. Secondly, I would like to rebut the prevailing tendency to dismiss cosmetic surgery as a vanity that caters to fickle cultural norms of beauty. Indeed, in discussing the “why” of cosmetic facial surgery, it is important to note that several ways in which humans express, communicate, and interpret facial gestures (i.e., happiness, disgust, surprise, sadness, anger, and fear) are not culture-specific but, as documented by Darwin2 in 1872 and confirmed by further studies, are both innate and universal. If one considers the human face to be merely an object of an arbitrary and culturally defined notion of beauty, then it would make sense to encourage cosmetic patients to accept their appearance and to label any further attempts at improvement as vanity, “disjuncture,” or symptoms of cultural depravity and indulgence. Admittedly, the concept that the face and its expressions should constitute an object of culturally defined beauty and pleasing mathematical proportion is well entrenched among artists and scientists and is duly parroted by the public and press. Even influential cultural relativists such as Margaret Mead argued against the universality of any human facial expressions. Mead conceded in private, however, that she had avoided any study of the biologic basis of human behavior because of her prescient concerns regarding the extent to which any genetic basis of behavior might be used to justify the horrific extremism of the then rising Nazi party.2 Nonetheless, applying concepts of cultural relativism to patients who wish to alter a face that displays an undesirable innate or universal human facial expression (i.e., anger from glabellar furrows) has created a serious and longstanding stumbling block to the development of the aesthetic surgeon, and, in my opinion, represents a profound but unrecognized error in the development of 20th century aesthetic facial surgery. This concept of the face as a beauty object has also fueled the misguided romantic myth of the surgeon as an artist and a sculptor. Indeed, for those who need further argument, the limits of underlying bone structure, preservation of vital facial functions, and iatrogenic injury pose severe limitations on the surgical usefulness of this line of thought. In my cosmetic practice, most patients have wellfounded and clearly evident concerns about their eyelid appearance. Usually, their eyelids and eyebrows evidence a
207
Ophthalmology Volume 106, Number 2, February 1999 universally recognized signal of tiredness and/or anger. Specifically, they are noting that the overhanging upper eyelid skin makes them appear tired or sad, the furrows between the eyebrows send out a signal of anger, frowning or disapproval, and the puffy lower eyelid fat sends out a signal of tiredness or sickness. These patients who come from diverse cultures are not striving to embody any cultural norm of beauty. Rather, they have figured out that their face is not communicating effectively, and they wish to correct the responsible age- or heredity-induced communications miscue. These observations have convinced me that the true purpose of the human face is to function as a communications device that signals the bearer’s ethnicity, gender, emotional intent, social status, and age. When the facial organ malfunctions, the signals emitted are jumbled and do not accurately represent the person’s emotional state. An example would be someone with strong glabellar furrow lines and low brows, who appears to be angry all the time, when in fact these universal signals of anger are in reality both inherited and age related miscues or malfunctions of the face. If a patient’s hand did not function from arthritis or if his or her speech was damaged from laryngitis, we would not begrudge the patient further treatment. Why then should we label as “vanity” the desire to have one’s face communicate effectively? Once one accepts that the surgeon should consider the face to be an organ of communication and expression rather than beauty, one can approach the patient in a rigorous and defined manner. When confronted with a patient who is dissatisfied by his or her facial appearance, the surgeon should stand back, evaluate the face, and see what type of universal miscues are being emitted by the face. For example, with excess upper eyelid skin, there is often a secondary eyebrow elevation, which can create a look of skepticism. Hence, the surgeon’s first role is to identify the anatomic sources of signaling miscues. The surgeon’s second role is to suggest possible corrections. This can be demonstrated to the patient in front of the mirror by stretching and moving parts of the patient’s face. The rigorous measurement of “success” in cosmetic surgery sought by Drs. Bartley and Linberg could be derived from grading preoperative and postoperative facial photos for evidence of specific communication miscues. The functional approach to the face has helped patients in my practice and will benefit other cosmetic surgeons as they and their patients experience firsthand the profound implications of redefining the approach to aesthetic facial surgery. Certainly, as Bartley and Linbergh astutely opine, the surgeon who believes that cosmetic surgery offers only compensation for the surgeon and beauty for the patient has embarked on a path that is hazardous on both accounts. However, the surgeon who accurately diagnoses and treats the facial organ’s malfunction walks a familiar and traditional path, one best described as the practice of a healing art. JEMSHED A. KHAN, MD Kansas City, Missouri
208
References 1. Bartley GB, Linberg JV. Cosmetic surgery may be hazardous . . . for the doctor as well as the patient [editorial]. Ophthalmology 1998;105:763– 4. 2. Darwin C. The Expression of the Emotions in Man and Animals. 3rd ed. London: Harper Collins Publishers, 1998.
Intraoperative Mitomycin C for Pterygium Surgery Dear Editor: Dr. Lam and coworkers,1 in their recently published article, “Intraoperative Mitomycin C to Prevent Recurrence of Pterygium after Excision,” report that intraoperative application of a single dose of 0.02% or 0.04% mitomycin C (MMC) for 3 minutes was ineffective in the treatment of primary/recurrent pterygium, with recurrence rates of 37.9%/66.7% and 17.9%/42.9%, respectively. However Mastropasqua et al2 and Frucht-Pery et al3 reported succesful use of intraoperative MMC for 3 minutes, with respective recurrence rates of 6.7% and 4.08%. It has been shown that application of 0.04% MMC even for 1 minute inhibits fibroblast proliferation like a 5-minute application in vitro.4 Lam et al have stated that these differences might have been caused by racial, environmental, and other factors and suggested that a multicenter study to evaluate the efficacy and potential complications of intraoperative MMC at various concentrations and duration of application in different parts of the world should be meaningful and rewarding. Our results from Turkey, where pterygium is highly prevalent, with intraoperative 0.04% MMC for 3 minutes in the treatment of primary pterygium disclosed a decreased recurrence rate to 5.3% from 41.2% in the control group (without MMC).5 By the end of July 1998, we will have been following our patients in the intraoperative MMC group for a mean of 60.3 months (range, 56 – 65 months). Our technique differed from the previous and later reports. To decrease the toxic effect to the cornea, we applied intraoperative MMC to the scleral bed underneath the limbus-based conjunctival flap and irrigated with at least 200 ml of balanced salt solution before the dissection of the head of the pterygium from the cornea and left 4 mm of bare sclera.5 We have not observed either recurrences after the first 6 months, as already published,5 or late complications like corneoscleral melting. However, we think more follow-up is necessary. The long-term effects of MMC are unknown. As it is a radiomimetic agent,6 the follow-up should be continued for a long period after surgery. SIBEL C¸ALISKAN, MD MEHMET ORHAN, MD MURAT IRKEC¸, MD Ankara, Turkey References 1. Lam DSC, Wong AKK, Fan DSP, et al. Intraoperative mitomycin C to prevent recurrence of pterygium after excision: a 30-month follow-up study. Ophthalmology 1998;105:901–5. 2. Mastropasqua L, Carpineto P, Ciancaglini M, et al. Long term results of intraoperative mitomycin C in the treatment of recurrent pterygium. Br J Ophthalmol 1996;80:288 –91.