Archives of Aesthetic Plastic Surgery Vol. 17, No. 2, 112-118, 2011 Y-M 성형술을이용한내안각췌피교정 김대희 윤성원 김정헌 차의과학대학교의학전문대학원성형외과학교실 Epicanthoplasty Using Y-M Plasty Dae Hee Kim, M.D., Sung Won Yoon, M.D., Chung Hun Kim, M.D. Department of Plastic and Reconstructive Surgery, School of Medicine, CHA University, Bundang CHA Medical Center, Gyeonggi-do, Republic of Korea 112 Lots of Koreans have relatively thick skin, small palpebral fissures and unfolded eyelids with a prominent epicanthal fold. Various methods have been developed to correct epicanthal fold. However, excessive or hypertrophic scar can be occurred, especially in the medial canthal and nasal area. And the recurrence may restrict the application of these methods. We developed a new epicanthoplasty using Y-M plasty to correct the epicanthal folds without obvious scar. From February 1999 to August 2010, all patients underwent Y-M plasty for the correction of epicanthal folds. Y-shaped incision line was designed not extending to the nasal area and the orbicularis oculi muscles were resected with skin. The dog ear deformities were corrected and sutured using nylon 7-0. The epicanthal folds were completely corrected. Prominent scar and recurrence were not observed. Most of the patients are satisfied with the results. Mean preoperative ICD (intercanthal distance) was 38.84 mm and average 2.24 mm ICD was reduced after the operation. Epicanthoplasty using Y-M plasty is relatively safe, easy and rapid method to design and apply even in the beginners with low risk of scars and recurrences. So, the authors propose this new versatile technique in the case of minimal to moderate epicanthal folds. (Archives of Aesthetic Plastic Surgery 17: 112, 2011) Key Words: Eyelids, Blepharoplasty, Scar, Skin abnormality I. 서론 현대여성들은크고시원한눈매를가져보다매력적으로보이기를원하고있으며, 이에따라쌍꺼풀성형술이보 편화되어있는실정이다. 그런데예전에는단순히쌍꺼풀 을만드는것에관심을보였던환자들이최근에와서는보 다서구적이며시원하고아름다운눈을원하고있어, 내안 각췌피가심한사람에서는단순히쌍꺼풀수술만하기보 Received March 30, 2011 Revised June 18, 2011 Accepted June 20, 2011 Address Correspondence : Chung Hun Kim, M.D., Department of Plastic and Reconstructive Surgery, Bundang CHA General Hospital, School of Medicine, CHA University, 351 Yatap-dong, Bundang-gu, Seoungnam, Gyeonggi-do 463-712, Korea. Tel: 031) 780-5280 / Fax: 031) 780-5285 / E-mail: pskim0203@hanmail.net 다는내안각성형술을함께시행하는경우가많아지게되었다. 내안각췌피는눈안쪽에있는구조물로상안검에서시 작하여코바깥쪽에있는피부와연결되어아래쪽으로주 행하며하안검에서끝나는초승달모양의피부주름으로안구의내측을덮고있기때문에, 내안각췌피가있는경우 에는실제눈의크기보다작고가늘게보이며눈사이가멀 어보이게된다. 그동안내안각성형술은많은방법이소개되어왔으며 현재에도계속적인개발및변형이이루어지고있는추세이다. 최근많이시행되고있는내안각성형술에는변형 Mustarde 피판술, 1 Z- 성형술및이를변형한방법, 2-4 W-성형술, 5 6 Y-V 전진피판술이나 V-M 성형술, 7 피부 redraping 법등 8,9 여러가지삼각피판을이용한방법들이있다. 하지만 술후과도한장력에의한내안각내측의반흔은지금도몇
김대희등 : Y-M 내안각췌피성형술 몇초보적인술자및환자들에게문제가되고있는실정이 다. 10 이에저자들은초보적인술자들도쉽게이용할수있 는방법을개발하여내안각성형술에적용하였다. 내안각 췌피의절개선이비근부나내안각췌피의내측피부로연장되지않는도안을통해반흔을최소화하였으며, 절제할 췌피의양을미리도안하지않고수술중자유롭게결정할 수있게하였으며절개선도가능한감춰질수있도록하였 다. 또한그결과를추적조사하여만족할만한결과를얻었기에이를보고하고자한다. 가. 대상 II. 방법 1999 년2월부터 2010 년 8월까지 Y-M 방법으로내안각성형술을시행받은환자중추적조사가가능하였던 71명의 환자를대상으로하였다. 71명의환자중내안각성형술만을단독으로시행한환자는 13 명이었으며, 나머지 56명의 환자는쌍꺼풀성형술을비롯한상, 하안검성형술과동시에시행하였다 (Table I). Table I. Clinical Characteristics of Patients Case No. S/A (yrs) ICD/reduction length (mm) Combined procedure Follow-up (months) Satisfaction score (0~4) Complications 1 F/22 38/2 DF 8 3-2 F/21 39/3 DF 27 4-3 F/26 36/1.5-6 2 Conspicuous scar 4 F/18 38/2 DF 20 4-5 F/21 38/2 DF 28 4-6 F/17 41/3.5 DF 17 2-7 F/38 40/3 UB 20 4-8 F/36 38/2 LB 16 4-9 F/35 39/3 LB 15 4-10 F/19 42/3 DF 22 3-11 F/30 40/3.5 DF 10 2-12 F/22 38/2 DF 18 4-13 M/57 37/1.5 UB 37 4-14 F/30 36/1.0 DF 16 4-15 M/24 37/1.5 DF 34 3-16 F/17 40/3-38 3-17 F/36 38/3 UB 19 4-18 F/28 35/2 DF 33 4-19 F/26 39/3-37 4-20 F/27 41/3-34 4-21 F/25 40/3 DF 23 4-22 F/20 42/3 DF 20 4-23 F/38 39/2 DF 25 4-24 F/22 40/3 DF 21 3-25 F/25 38/2-18 3-26 F/26 44/3 DF 22 4-27 F/23 39/2.5 DF 10 3-28 F/24 42/3 DF 23 4-29 F/23 42/3 DF 26 4-30 F/35 36/1.5 DF 13 2-31 F/22 36/2 DF 27 3-113
Archives of Aesthetic Plastic Surgery Vol. 17, No. 2, 2011 Table I. Clinical Characteristics of Patients (Continue) 114 Case No. S/A (yrs) ICD/reduction length (mm) Combined procedure Follow-up (months) Satisfaction score (0~4) Complications 32 F/20 34/2-8 4-33 F/18 36/2 DF 27 4-34 F/20 38/2-9 4-35 F/22 38/2-20 4-36 F/27 38/2 DF 22 4-37 F/23 38/2 DF 29 2-38 M/20 39/2.5 DF 19 3-39 F/22 41/2-19 4-40 F/24 36/2 DF 17 4-41 F/30 36/2 DF 29 3-42 F/20 43/3 DF 14 4-43 F/28 38/2 DF 25 4-44 F/37 38/2 DF 28 4-45 F/21 43/3.5-12 4-46 F/17 38/2 DF 13 4-47 F/24 41/2.5-15 3-48 F/35 39/1.5 UB 20 4-49 F/30 37/2 DF 19 4-50 F/19 38/2 DF 7 4-51 M/29 41/2 DF 8 4-52 F/20 40/2 DF 5 4-53 F/21 38/1.5 DF 14 4-54 F/30 37/2 DF 4 4-55 F/21 43/3 DF 14 3 constant pain 56 F/25 36/1.5 DF 26 4-57 F/30 40/2 UB 33 4-58 F/23 38/2 DF 19 4-59 F/19 40/3 DF 16 4-60 F/20 43/3 DF 20 4-61 F/27 38/2-24 4-62 F/30 38/2 DF 24 4-63 F/22 42/2.5 DF 29 4-64 F/27 38/2 DF 28 4-65 F/32 38/2-28 3-66 F/23 38/2 DF 31 4-67 F/20 39/2 DF 21 4-68 F/24 38/2 DF 15 3-69 F/19 36/2 DF 19 4-70 F/41 40/2 DF 14 4-71 F/19 37/2 DF 22 4 - Mean 25.5 38.84/2.24 20.4 3.66 ICD, Intercanthal distance; UB, Upper blepharoplasty; LB, Lower blepharoplasty; DF, Double eyelidplasty.
김대희등 : Y-M 내안각췌피성형술 내안각성형술은환자의내안각간거리가 40 mm 이상인경우, 혹은내안각간거리와양측눈길이와의비가 1 : 1 : 1 보다클경우에시행하였다. 나. 수술방법 환자가앉아있는상태에서눈길이와내안각사이의거리를측정하여몇 mm정도의내안각절개가필요한지계산 하였으며, 디자인은환자를수술대에눕힌후실시하였다. 우선미리계획한대로내측으로옮기고자하는내안각의위치를점 A 로잡고, 점 A 로부터외측으로수평선 (horizontal line) 을그어내안각췌피위의점 B 를도안하였다. 대체로선 AB간의길이는약 2~3 mm 정도였다. 이후점 A의 내측위, 아래부분에각각점 C와점 D 를잡는데, 이때선 AC, 선 AD의길이는약 1 mm 가량되도록하였다. 또한각 CAD는지나치게예각이될경우봉합시피부긴장이증가할수있어가급적 90 도이상의둔각을이루도록도안했고, 내안각췌피뒤쪽부분에점 A를투사한위치를점 E라고 가정하였다. 내안각부위에마취용액 (2% lidocaine + 1 : 100,000 epinephrine) 을국소주입한후, 도안된선을따라 15번수술용칼 로 Y자모양의절개를하고점B와점 E를연결한선은미세가위를이용하여절개하여 ACD를연결한삼각피판을생성했다. 우선삼각피판의꼭지점에해당하는점 A를점 E에연결하여 7 번나일론을이용해봉합하였고, 이때삼각피판주위 에남아있는눈둘레근 (orbicularis oculi muscle) 으로인해봉합이어려울경우에는일부제거하였다. 그후점 C 및점 D를점 E 로부터위, 아래 1 mm 정도떨어진위치의피부에 7번나일론으로봉합하면새로만들어진내안각위와아래부분에눈둘레근을포함한피부피판의개귀 (dog ear) 가생 기게되는데, 위에생긴개귀는절제선이쌍꺼풀연장선상에놓이도록절제하여반흔을감춰주고, 아래부분의개귀 는눈밑의자연스러운피부주름을따라절제하였다. 그결과피부봉합선은 M 자모양이되었으며, 개귀절제는피부및근육층이함께제거되도록시행하였다 (Fig. 1). 115 Fig. 1. (Above, left) Preoperative design. A is the final point where we want to transfer. From the point A, we draw a horizontal line to medial portion of the epicanthal fold until the point B. Then, the C and D is positioned about 1 mm apart from the A, so that the angle CAD becomes obtuse. The E is a projection point of A on the posterior surface of epicanthal fold. (Above, right) The skin was incised from A to B and E. Triangular flap was made by dissecting from A to C and D. The orbiculairs oculi muscle under the skin flap was also dissected with microscissors. (Below, left) The triangular flap was sutured to the posterior skin flap. Above all, A was sutured to E with 7-0 nylon. C and D were also approximated to the dissected posterior skin flap with 7-0 nylon. Upper and lower dog ears were appeared by suturing of triangular flap to posterior skin flap. (Below, right) Upper and lower dog ears were trimmed. The upper dog ear was manipulated to lead to the supratarsal fold. And the lower dog ear was dissected parallel to the natural skin wrinkles of lower eyelid and repaired with 7-0 nylon.
Archives of Aesthetic Plastic Surgery Vol. 17, No. 2, 2011 다. 수술후처치및평가 수술다음날가벼운소독을시행하였고, 발사후상처벌 어짐 (wound dehiscence) 등으로인한합병증의예방을위해 3 일째에는개귀부분, 5일째에는점 C 및점 D, 마지막 7 일째에는점 A 부위를각각나누어발사하였고, 술후사진 촬영을통해수술전과비교평가했다. 환자의만족도는설문조사방식으로진행하였으며, 방 문이어려운환자에게는전화를통한조사를시행하였다. 환자에게내안각췌피성형술의결과에대하여만족하는정도에따라 4점 ( 매우만족함), 3점 ( 만족함), 2점 ( 보통), 1 점 ( 다소불만족) 에서 0점 ( 매우불만족) 까지다섯단계의점수를매기도록하였다. III. 결과 환자의평균연령은 25.5 세로 17세에서 57세까지다양하게분포하고있었으며, 20대와 30대가대부분을차지하고있었다. 성별은남성이 4 명, 여성이 67명으로여성이압도 적이었다. 수술후추적조사기간은최소 4개월에서최대 38 개월, 평균 20.4 개월이었다. 수술전내안각간거리 (intercanthal distance, ICD) 는평균 38.84 mm (34~44 mm) 이었고, 내안각췌피성형술을통해줄어든거리는평균 2.24 mm (1.0~3.5 mm) 였다. 또한환 자들의만족도는 4점만점기준에서평균 3.66점으로나타나대체로만족할만한결과를보였다 (Table I). 116 Fig. 2. 17 years old woman, who underwent epicanthoplasty with double eyelidplasty. (Left) Preoperative view. (Right) Postoperative view. Fig. 3. 19 years old woman, who underwent epicanthoplasty with double eyelidplasty. (Above, left) The preoperative photograph. (Above, right and Below, left) The intraoperative findings. (Below, right) The postoperative photograph after 7 days of procedures. The epicanthus was disappeared and lacrimal lake and medial portion of eyes were markedly exposed.
김대희등 : Y-M 내안각췌피성형술 내안각췌피성형술후가려져있던내측의누구 (caruncle) 와안구가뚜렷하게노출되어안검열 (palpebral fissure) 의 폭이보다넓어진소견을확인할수있었다 (Fig. 2-3). 수술후감염이나누관 (lacrimal duct) 기능의이상을호소하는환자는보이지않았고, 재수술을필요로할정도의 내안각췌피재발역시없었다. 수술초기하안검에남은반흔을호소하는 4명의환자가있었지만약 3개월정도후에 는거의눈에띄지않았고, 수술 3개월이후에도지속적으로남은반흔을보이는 1명의환자가있었으나장기추적관 찰시흐려져추가적인반흔성형술 (scar revision) 을필요로하지는않았다. 그외에술후지속되는따끔거림을호소하는환자가 1 명있었다 (Table I). IV. 고찰 내안각췌피는대부분의동양인, 특히몽고족에특징적으로나타나는내안각피부의접힘으로 4가지유형으로분 류할수있다. 첫번째유형 (epicanthus supraciliaris) 에서는 내안각피부주름이상안검의가장자리에평행하게주행 하다가콧등가까이가면서차츰사라져버린다. 두번째유형 (epicanthus palpebralis) 은내안각피부주름이눈물못으 로접근하면서차츰상안검가장자리를덮다가눈물못의 위쪽피부가장자리로들어간다. 세번째유형 (epicantus tarsalis) 의경우, 상안검의눈꺼풀판앞피부는눈물못을완 전히덮으면서아래로내려와점차눈물못아래에있는하안검피부로이행한다. 네번째유형의내안각췌피는뒤집 힌눈구석주름 (epicanthus inversus) 라고불리기도하는데, 내안각췌피가하안검에서시작하여눈물못상방에있는상안검혹은내안각위쪽으로뻗어있다. 동양인에서는일반적으로두번째와세번째유형이흔하다고알려져있으며, 상안검에서시작된피부주름이내 안각을덮으면서콧등쪽의피부와연결되어누호를덮고있기때문에눈길이가짧아보이게된다. 또한내안각과상 안검에의해덮인속눈썹이실제보다짧은것처럼보이며 결과적으로내안각부위가답답하고두툼해보이게된다. 이를교정하지않고이중검수술만시행할경우에는안검 열의수직길이는길어져보이는반면상대적으로수평길이는늘어나지않아, 수술후동그란내안각및폭이좁은 안검열을보이게되어놀란표정의눈이만들어지는경우가많다. 따라서쌍꺼풀이없으면서내안각췌피가심하게 있는경우쌍꺼풀수술과내안각성형술을동시에시행하 는것이바람직하다. 내안각췌피가생기는원인은아직까지명확하게밝혀 지지는않았지만, 그동안여러연구들에의해제시된내안 각췌피의해부학적혹은발생학적문제점으로는비부뿌 리부분 (nasal root) 의골발생부족 (underdevelopment of bone), 내안각피부의수평적과도함 (horizontal excess) 및수직적부족함 (vertical shortage), 내안각췌피안쪽눈둘레 근의과도함및비정상적인주행, 즉눈둘레근섬유의일 부가내안각췌피에직접붙어있어피부에수직방향으로 과도한장력이형성된다는이론, 그리고내안각췌피가 있는사람의경우안쪽눈구석힘줄이더바깥쪽까지연장 (laterally elongated) 되어있다는보고가있었다. 11 서론에서기술한바와같이현재까지수많은내안각췌피성형술이개발되고시행되어왔지만, 이러한방법들은 도안이까다로워시술하기에어렵거나, 과도한장력등으 로인해내안각내측에눈에띄는반흔이생기는경우가종종있었다. 10 이에저자들은내안각췌피는피부가남는것이란전제하에초보자들도쉽게이해하고도안할수있으며, 수술후 반흔을최소화할수있는수술방법을고안하였다. 이방법은코쪽으로깊이연장되는절개선이없다. 코쪽의피부는 내안각췌피의피부보다두꺼워절개선이중앙으로연장될수록반흔의발생가능성은높아진다. 그러므로저자들 은절개선의내측끝이새로만들어지는내안각에서끝나도록하였으며, 새로만들어지는내안각이너무예각이되거나익상구축 (webbing contracture) 현상이발생하지않도 록길이 1 mm의삼각피판을추가하였다. 또한수술시생기 는상부의개귀는절제시절개선이쌍꺼풀절개선에완전히 감추어지고, 하부개귀절개선은자연스러운피부주름으로보이게되어눈에띄는반흔을최소화할수있었다. 뿐만아니라피부봉합시 A, C, D 세점만봉합하여도절제부 위에걸리는장력이거의없어비후성반흔 (hypertrophic scar) 의발생위험이매우낮았으며, 실제이방법으로수술 한후추적관찰이가능하였던 71명의환자를대상으로한조사결과에서도비교적높은만족도를확인할수있었다. 본술기는수술도안시, 내안각가장안쪽에서수평으로내안각의감소가필요한만큼수평선을그린후, 둔각의삼각피판을 Y자모양으로작도하는것으로기존의방법들에 비해비교적간단해수술시간을단축시키는효과가있고, Uchida 법에비해술중각환자의눈형태에맞추어자유로 운도안의변형이가능해숙련되지않은초심자들도비교적쉽게적용할수있으며상, 하부개귀의절제로인한절 개선을각각쌍꺼풀의내측선과피부주름선의방향에맞 추어줄수있어술후 M자형반흔이눈에덜띄게되는장점을지니고있다. 117
Archives of Aesthetic Plastic Surgery Vol. 17, No. 2, 2011 118 기존의 V-M 방법은원래화상후발생한반흔구축의교정에사용되었던술기로, 내안각의내측면에한개, 외측면 에각각두개의 V자피판을도안하여 Y-V 방법과여러개의 Z 성형술을결합해내안각췌피를교정하는것으로, 저 자들의술기와는디자인과수술후남는반흔의모양자체가근본적으로다르다. 7 일반적으로내안각췌피의피부안쪽에는대부분눈둘 레근이함께주행하고있어, 이에대한교정이없이피부만 내측으로당겨주게될경우과도한장력으로인해시간이 지남에따라비후성반흔이유발되고증상이재발하는경우가있다. 따라서저자들은내안각성형술을시행하면서 피부와함께안쪽의비정상적으로주행하고있는눈둘레 근을일부절제하여췌피가형성되는해부학적인요인자체를제거하였으며, 실제로환자들에대한추적조사에서 도재수술을원할정도의재발이없었음을확인할수있었다. 추후보다정확한확인을위해술후일정기간이지난후 환자들의내안각간거리를일괄적으로재측정하여재발 여부를판정하는과정이필요할것으로사료된다. V. 결론 내안각췌피성형술은동양에서비교적흔히이루어지 는수술이지만여전히반흔의발생빈도가상대적으로높고, 재발등의합병증이흔해부담스러운시술로여겨져 왔다. 저자들은보다쉬운도안이가능하고, 수술후반흔을최 소화할수있는방법을고안하였으며, 이방법을시행한후추적조사가가능하였던 71명의환자의만족도를조사해 본결과대체로만족스러운결과를확인할수있었으며, 재 수술을필요로할정도의내안각췌피재발소견역시보이 지않았다. 이에저자들은경도및중등도의내안각췌피의교정에 있어서저자들의방법도기존의수술방법에뒤지지않은 좋은방법이라고사료되어문헌고찰과함께보고하는바이다. REFERENCES 1. Yoon K: Modification of Mustardé technique for correction of epicanthus in Asian patients. Plast Reconstr Surg 92: 1182, 1993 2. Park JI: Z-epicanthoplasty in Asian eyelids. Plast Reconstr Surg 98: 602, 1996 3. Park JI: Modified Z-epicanthoplasty in the Asian eyelids. Arch Facial Plast Surg 2: 43, 2000 4. Yoo WM, Park SH, Kwag DR: Root Z-epicanthoplasty in Asian eyelids. Plast Reconstr Surg 109: 2067, 2002 5. Mulliken JB, Hoopes JE: W-epicanthoplasty. Plast Reconstr Surg 55: 435, 1975 6. Kao YS, Lin CH, Fang RH: Epicanthoplasty with modified Y-V advancement procedure. Plast Reconstr Surg 102: 1835, 1998 7. Lin SD: Correction of the epicanthal fold using the VM-plasty. Br J Plast Surg 53: 95, 2000 8. Oh YW, Seul CH, Yoo WM: Medial epicanthoplasty using the skin redraping method. Plast Reconstr Surg 119: 703, 2007 9. Jung JH, Kim HK, Choi HY: Epiblepharon correction combined with skin redraping epicanthoplasty in children. J Craniofac Surg 22: 1024, 2011 10. Kang JS: Plastic surgery. 3rd ed, Seoul, Koonja Publishing Co., 2004, p888 11. Zhang H, Zhuang H, Yu H, Feng Y, Wang T, Hu S, Yang Y, Wang Q: A new Z-epicanthoplasty and a concomitant double eylidplasty in Chinese eyelids. Plast Reconstr Surg 118: 900, 2006