Personal Computer-Based Cephalometric Landmark Detection With Deep Learning, Using Cephalograms on the Internet.

BACKGROUND: Cephalometric analysis has long been, and still is one of the most important tools in evaluating craniomaxillofacial skeletal profile. To perform this, manual tracing of x-ray film and plotting landmarks have been required. This procedure is time-consuming and demands expertise. In these days, computerized cephalometric systems have been introduced; however, tracing and plotting still have to be done on the monitor display. Artificial intelligence is developing rapidly. Deep learning is one of the most evolving areas in artificial intelligence. The authors made an automated landmark predicting system, based on a deep learning neural network. METHODS: On a personal desktop computer, a convolutional network was built for regression analysis of cephalometric landmarks' coordinate values. Lateral cephalogram images were gathered through the internet and 219 images were obtained. Ten skeletal cephalometric landmarks were manually plotted and coordinate values of them were listed. The images were randomly divided into 153 training images and 66 testing images. Training images were expanded 51 folds. The network was trained with the expanded training images. With the testing images, landmarks were predicted by the network. Prediction errors from manually plotted points were evaluated. RESULTS: Average and median prediction errors were 17.02 and 16.22 pixels. Angles and lengths in cephalometric analysis, predicted by the neural network, were not statistically different from those calculated from manually plotted points. CONCLUSION: Despite the variety of image quality, using cephalogram images on the internet is a feasible approach for landmark prediction.

The dawn of computer-assisted robotic osteotomy with ytterbium-doped fiber laser.

Currently, laser radiation is used routinely in medical applications. For infrared lasers, bone ablation and the healing process have been reported, but no laser systems are established and applied in clinical bone surgery. Furthermore, industrial laser applications utilize computer and robot assistance; medical laser radiations are still mostly conducted manually nowadays. The purpose of this study was to compare the histological appearance of bone ablation and healing response in rabbit radial bone osteotomy created by surgical saw and ytterbium-doped fiber laser controlled by a computer with use of nitrogen surface cooling spray. An Ytterbium (Yb)-doped fiber laser at a wavelength of 1,070 nm was guided by a computer-aided robotic system, with a spot size of 100 µm at a distance of approximately 80 mm from the surface. The output power of the laser was 60 W at the scanning speed of 20 mm/s scan using continuous wave system with nitrogen spray level 0.5 MPa (energy density, 3.8 × 10(4) W/cm(2)). Rabbits radial bone osteotomy was performed by an Yb-doped fiber laser and a surgical saw. Additionally, histological analyses of the osteotomy site were performed on day 0 and day 21. Yb-doped fiber laser osteotomy revealed a remarkable cutting efficiency. There were little signs of tissue damage to the muscle. Lased specimens have shown no delayed healing compared with the saw osteotomies. Computer-assisted robotic osteotomy with Yb-doped fiber laser was able to perform. In rabbit model, laser-induced osteotomy defects, compared to those by surgical saw, exhibited no delayed healing response.

Infrared venography of the hand in Apert syndrome.

As well as craniofacial synostosis, complex syndactyly of hands is a distinctive feature of Apert syndrome. Consideration of blood flow to the digits is very important in separation surgery. Several reports offer information about arterial distribution in Apert's hands. Though, venous pattern has not been well discussed. Infrared venography offers a real-time image with minimal invasion. An Apert syndrome patient underwent a series of finger splitting surgeries. Infrared venography was carried out to assess veins. There was a palmar venous arch, placing distally to the metacarpophalangeal joint. The arch had to be cut to divide fused fingers sufficiently. As well as arterial abnormality, venous uniqueness should be noted in Apert syndactyly surgeries. Infrared venography, which can be carried out easily, offers good information that surgeon require.

Three-Dimensional Craniofacial Landmark Detection in Series of CT Slices Using Multi-Phased Regression Networks.

Geometrical assessments of human skulls have been conducted based on anatomical landmarks. If developed, the automatic detection of these landmarks will yield both medical and anthropological benefits. In this study, an automated system with multi-phased deep learning networks was developed to predict the three-dimensional coordinate values of craniofacial landmarks. Computed tomography images of the craniofacial area were obtained from a publicly available database. They were digitally reconstructed into three-dimensional objects. Sixteen anatomical landmarks were plotted on each of the objects, and their coordinate values were recorded. Three-phased regression deep learning networks were trained using ninety training datasets. For the evaluation, 30 testing datasets were employed. The 3D error for the first phase, which tested 30 data, was 11.60 px on average (1 px = 500/512 mm). For the second phase, it was significantly improved to 4.66 px. For the third phase, it was further significantly reduced to 2.88. This was comparable to the gaps between the landmarks, as plotted by two experienced practitioners. Our proposed method of multi-phased prediction, which conducts coarse detection first and narrows down the detection area, may be a possible solution to prediction problems, taking into account the physical limitations of memory and computation.

Stretching Promotes Wound Contraction Through Enhanced Expression of Endothelin Receptor B and TRPC3 in Fibroblasts.

One factor that can contribute to the development of hypertrophic scar contracture is mechanical stress. Mechanical cyclic stretch stimuli enhance the secretion of endothelin-1 (ET-1) from keratinocyte. Cyclical stretching of fibroblasts also increases the expression level of the transient receptor potential ion channel (TRPC3), which is known to couple with the endothelin receptor and induce intracellular Ca2+ signaling via the calcineurin/nuclear factor of activated T cells (NFAT) pathway. The aim of this study was to investigate the relationship between keratinocytes and fibroblasts when they are stretched. Methods: The conditioned medium from stretched keratinocyte was added to the fibroblast populated collagen lattice. Then, we analyzed the levels of endothelin receptor in the human hypertrophic scar tissue and stretched fibroblasts. To address the function of TRPC3, we have used an overexpression system with the collagen lattice. Finally, the TRPC3 overexpressing fibroblasts were transplanted to mouse dorsal skin, and the rate of skin wound contraction was assessed. Results: Conditioned medium from stretched keratinocytes increased the rate of contraction of fibroblast populated collagen lattice. In human hypertrophic scar and stretched fibroblasts, endothelin receptor type B was increased. Cyclic stretching of TRPC3 overexpressing fibroblasts activated NFATc4, and stretched human fibroblasts showed more activation of NFATc4 in response to ET-1. The wound treated with TRPC3 overexpressing fibroblasts showed more contraction than control wound. Conclusion: These findings suggest that cyclical stretching of wounds have an effect on both keratinocytes and fibroblasts, where keratinocytes secret more ET-1, and fibroblasts develop more sensitivity to ET-1 by expressing more endothelin receptors and TRPC3.

Surgical Correction of Nipple Hypertrophy after Nipple-sparing Mastectomy with Breast Reconstruction.

Nipple hypertrophy is a relatively common phenomenon, particularly in the Asian patient population. The incidence and prevalence or cause of nipple hypertrophy are not well defined in the literature. As survival rates for breast cancer patients continue to improve, there is an increasing emphasis on enhancing their quality of life. Treatment options, such as lumpectomy and radiation therapy or mastectomy, now prioritize preservation of the nipple-areolar complex (NAC) through techniques like nipple-sparing mastectomy (NSM). This approach has been shown to improve patient satisfaction and quality of life. However, it is important to note that NSM is associated with certain complications, including NAC necrosis, malposition, and local recurrence of the tumor. Among those complications, nipple hypertrophy is quite rare. In this report, we present a case of nipple hypertrophy that developed after breast reconstruction, using autologous tissue. The patient, a 48-year-old woman, underwent NSM for breast cancer, and had a tissue expander placed simultaneously. Following tissue expansion, breast reconstruction with a deep inferior epigastric perforator (DIEP) flap was performed. However, during the tissue expansion phase, the patient's nipple gradually enlarged, and the protrusion became more pronounced after the DIEP flap transfer. Nipple reduction surgery was subsequently performed for both diagnostic and cosmetic purposes. We present this case along with a review of relevant literature.

"Bibloc advancement" with a combination of internal and external distracters.

Frontofacial monobloc advancement is one of the most rewarding techniques for correcting aesthetic and functional problems of patients with severe craniofacial synostosis, which can advance the upper and middle third of the face simultaneously. Application of gradual distraction technique has been reported to reduce notorious risks after a frontofacial monobloc advancement. The so-called "bibloc advancement" is a derivative of the frontofacial monobloc advancement. "Facial bloc" is horizontally divided into 2 different components: fronto-orbital component and maxillozygomatic component. From a different angle, it can be described as a combination of fronto-orbital advancement and Le Fort III advancement. Two pairs of distracters (1 internal for the supraorbital area and 1 external for the maxillozygomatic area with a pair of cross-facial pinning) were applied after the so-called bibloc osteotomy. Advancement of the upper and middle third of the face was done individually. This technique can be a good option for treating infants with severe syndromic craniofacial synostosis.

Cutaneous fistula on the cheek associated with oculo-auriculo-vertebral spectrum.

A Japanese boy, presented with epibulbar dermoid and ipsilateral preauricular appendages, had a pit on his cheek of the same side. An atrial septal defect and vertebral fusions were also identified. He was diagnosed with a mild type of oculo-auriculo-vertebral spectrum (OAVS). At the age of 18 months, his cheek was swollen with a slight fever. An infected cyst and cutaneous fistula enveloped by the risorius muscle were extracted. It was assumed to be a remnant of the fissure between the maxillary and mandibular prominences. This was the first case of cutaneous fistula confirmed histologically with OAVS, although there seem to be more cases. The possibility of the mechanism of smiling cheek dimple is also discussed.

A traumatic ulnar artery aneurysm in an infant.

Ulnar artery aneurysm is very rare in infancy. Only a few reports have been done. We report an 8-month-old baby with true ulnar artery aneurysm on her hypothenar eminence. She had no specific past medical history, but an episode of falling. We resected the pulsating mass compressing the ulnar nerve, utilizing a surgical microscope. Reconstruction of the vascular deficit was not performed. She presented no functional deficit of the hand and no evidence of growth disturbance so far. As hypothenar eminence is a susceptible part for repetitive strikes, and as vein is fragile to the pressure, bypassing arterial route with vein graft is not recommended unless there is no other option.

An occult case of the first branchial cleft anomaly.

We report a case of the first branchial cleft anomaly, clinically typical but occult in images and pathology. An 8-year-old female who had an induration below her right mandibular angle was referred to our department with a diagnosis of an infectious epidermal cyst. CT and MRI had shown no evidence of fistula or cyst. At the initial operation, a string structure was observed, but pathologically no epithelial structure was observed. However, the infection at the same site repeated and the symptoms became more severe than before. Considering a high probability of the first branchial anomaly, partial parotidectomy was performed as radical surgery. A cord structure attached to subcutaneous tissue at the intertragal notch was found. Although no epithelial component in the pathology was detected, this string structure was clinically considered as the rudimentary form of the first branchial anomaly.

Effects of adiponectin on growth and differentiation of human keratinocytes--implication of impaired wound healing in diabetes.

Impaired wound healing is one of the most common complications associated with diabetes. Adiponectin is an abundant circulating adipocyte-derived cytokine that has beneficial effects on disorders accompanying diabetes. Herein we report that adiponectin has a regulatory effect on the growth and differentiation of HaCaT human keratinocyte cells. Furthermore, adiponectin regulated the expression of TGFbeta isoforms in keratinocytes in a dose-dependent manner, which implies that adiponectin modulates other types of cells related to wound repair via secretion of growth factors from keratinocytes. Moreover, TUNEL assay results revealed that adiponectin enhances apoptosis of keratinocytes. Taken together, the present results indicate that adiponectin has suppressive effects on the formation of hyperkeratosis commonly seen in patients with diabetic foot and its application may be beneficial for developing treatment for that disorder.

Lateral orbital expansion and gradual fronto-orbital advancement: an option to treat severe syndromic craniosynostosis.

In some patients with severe syndromic craniosynostosis, bony orbits are so small and shallow that the eyeballs dislocate. Dry cornitis and conjunctivitis can be seen often. When conventional fronto-orbital advancement is attempted in these cases, side walls of the orbit cannot go forward, because the width of bony orbit is smaller than the eyeball. To expand bony orbits and cranial volume, supralateral rim of the orbit was expanded laterally at the time of operation and gradually advanced foward postoperatively. With a coronal skin incision approach, frontal bone was taken off. Supralateral orbital rim bone was detached and cut at the centers of the orbits. Lateral expansion, 5 to 10 mm, was made and fixed with polylactate plates. A pair of distraction devices was fixed between the orbital rim and the temporal bone. Frontal bone was let floating on the dura mater and tied loosely with the orbital rim. Advancement of 1 to 1.5 mm/d was carried out, and the devices were taken off after 1-month consolidation period. Five patients with Pfeiffer syndrome, 1 with Crouzon, and 1 with Beare-Stevenson cutis gyrata syndrome were treated with this method. Procedure, outcomes, and complications are discussed.

Congenital lipomatous tumour, presented as a polypoidal projection on upper eyelid.

A Japanese baby was born with a polypoidal projection with hair, on the lateral corner of upper eyelid. The tumour had extent to bulbar sub-conjunctival area. He presented no other malformation nor pathological symptoms. There was no sign of association with Goldenhar, hemifacial macrosomia, epidermal nevus or linear nevus sebaceous syndromes. The tumour was resected at his age of 4 months. The ocular conjunctiva was incised but not excised. Histopathologically, it was mainly consisted of multi-lobuled mature adipose tissue, dense fibrous tissue was observed at the centre of mass, assumed to be the link of palpebral tarsal plate to lateral canthal ligament. As for the location and component, the tumour was diagnosed as a lipomatous hamartoma. Detached tarsal plate was reattached to the lateral canthal ligament. Satisfactory result was achieved aesthetically and functionally. Congenital lipomatous hamartoma, with protuberant appendage appearance on eyelid, without syndromic association, is presented.

A new rabbit model of impaired wound healing in an X-ray-irradiated field.

Radiation is an important therapy for cancer with many benefits; however, its side effects, such as impaired wound healing, are a major problem. While many attempts have been made to overcome this particular disadvantage, there are few effective treatments for impaired wound healing in an X-ray-irradiated field. One reason for this deficiency is the lack of experimental models, especially animal models. We have previously reported a mouse model of impaired wound healing in which the irradiation area was restricted to the hindlimbs. In this mouse model, due to the size of the animal, a diameter of five millimeters was considered the largest wound size suitable for the model. In addition, the transplanted cells had to be harvested from other inbred animals. To investigate larger wounds and the impact of autologous specimen delivery, a rabbit model was developed. Rabbits were kept in a special apparatus to shield the body and hindlimbs while the irradiation field was exposed to radiation. Six weeks after irradiation, a 2 x 2 cm, full-thickness skin defect was made inside the irradiation field. Then, the wound area was observed over time. The wound area after irradiation was larger than that without irradiation at all time points. Both angiogenesis and collagen formation were reduced. For further study, as an example of using this model, the effect of autologous platelet-rich plasma (PRP) was observed. Autologous PRP from peripheral blood (pb-PRP) and bone marrow aspirate (bm-PRP) was processed and injected into the wounds in the irradiated field. Two weeks later, the wounds treated with bm-PRP were significantly smaller than those treated with phosphate buffer vehicle controls. In contrast, the wounds treated with pb-PRP were not significantly different from the controls. This rabbit model is useful for investigating the mechanism of impaired wound healing in an X-ray-irradiated field.

An Attempt to Make Platelet Rich Fibrin from Bone Marrow Aspirate.

INTRODUCTION: Platelet Rich Fibrin (PRF) was developed as a new generation of platelet concentration from peripheral blood. Method to make PRF is simple. It is easy to handle with its moderate firmness. Histologically, platelets and nucleated cells are packed along the yellow-red border. Bone marrow aspirate contains bone marrow cells that potentially work for tissue regeneration, and platelets which contain growth factors. The specific gravities of them are comparable. It implies that, if it is possible to make PRF from bone marrow aspirate, then high concentration of platelets and bone marrow cells can be obtained simultaneously by taking out yellow-red interface of it. AIM: To find out a method to make PRF from bone marrow aspirate. MATERIALS AND METHODS: Iliac crest of rabbits were punctured and aspirated with or without anti-coagulant, under general anaesthesia. The bone marrow aspirate was centrifuged in glass tubes. For the bone marrow aspirate taken with anti-coagulant, calcium chloride was added just before centrifugation. Products were taken out and observed grossly. The products were fixed with formaldehyde and observed histologically. RESULTS: Coagulated gels with two-toned colour were obtained by all methods. In the gels without anti-coagulant, interfaces between two colours were obscure. Histologically, platelets and nucleated cells scattered as clusters. Filtering caused haemolysis and reduced the yield of the product. With the aspirate taken with anti-coagulant, platelets and nucleated cells formed a band along the interface. CONCLUSION: PRF can be made from bone marrow aspirate by adding anti-coagulant in aspiration and reversed with calcium chloride just before centrifugation.

Free flap transfer reconstruction in managing tongue carcinoma during pregnancy.

Malignant oral cancers do not commonly occur in pregnant women. But when they do, the presence of a foetus and maternal physiological changes complicate and limit the treatment options. Risk benefit assessment and balancing of them are always important. A 33-year-old woman, who was 25 weeks pregnant, presented with a squamous cell carcinoma on her tongue. She was clinically staged II (T2, N0 and M0). Discussions between the patient, surgical teams and obstetricians agreed to continue her pregnancy while managing the tumour. Hemi-glossectomy and ipsilateral neck dissection was performed. Free antero-lateral thigh flap was transferred to reconstruct the tongue defect, successfully. The patient gave birth to a healthy baby afterward. She is tumour free for 6 years. Free flap reconstruction can be an option, even if the patient is pregnant.

Bilateral Maxillary Reconstruction Using Fibular Flap in Bisphosphonate-related Osteonecrosis.

Recent reports have shown successful transfer of vascularized fibular flap in bisphosphonate-induced mandibular osteonecrosis. We present a case of a 50-year-old patient who presented with bisphosphonate-related osteonecrosis of bilateral maxilla, which is reconstructed using a fibular flap.

Lymphoedema of the penis and scrotum as a sequela of chronic skin infection.

A Japanese male patient presented with an enormously disfigured penis and scrotum. The penis was swollen and distorted rightward, and the skin was hard and lumpy. The patient had had a subdermal abscess for 6 years. The current condition was considered secondary lymphoedema of the penis and scrotum resulting from chronic skin infection. Wide excision of the affected area with bilateral inguinal lymph node dissection were performed. The degloved penile shaft and scrotum were covered with skin grafts, and a satisfactory result was obtained.

An augmented reality system in lymphatico-venous anastomosis surgery.

Indocyanine green lymphography, displayed as infrared image, is very useful in identifying lymphatic vessels during surgeries. Surgeons refer the infrared image on the displays as they proceed the operation. Those displays are usually placed on the walls or besides the operation tables. The surgeons cannot watch the infrared image and the operation field simultaneously. They have to move their heads and visual lines. An augmented reality system was developed for simultaneous referring of the infrared image, overlaid on real operation field view. A surgeon wore a see-through eye-glasses type display during lymphatico-venous anastomosis surgery. Infrared image was transferred wirelessly to the display. The surgeon was able to recognize fluorescently shining lymphatic vessels projected on the glasses and dissect them out.

Sebaceous carcinoma arising in nevus sebaceus.

A 53-year-old woman had had a pale-brown lesion on her right cheek and neck from birth. Since she was about 40 years old, part of the lesion had gradually elevated and increased in size. At the first examination, there was a huge mass measuring 110 x 70 x 35 mm on the right cheek. A wide local excision of the area including a superficial parotidectomy and submandibular lymph node dissection was performed, followed by full thickness skin grafting. Histological examination of the tumor revealed an invasive dermal neoplasm characterized by lobes that were composed of foamy cells stained with Sudan-IV mixed with many atypical cells showing remarkable variation in the shapes and sizes of their nuclei. The surrounding epithelial changes were consistent with nevus sebaceus. From these findings, the gigantic tumor was diagnosed as a sebaceous carcinoma arising in nevus sebaceus.