Using 3D facial information to predict malnutrition and consequent complications.

BACKGROUND: Phase angle (PhA) correlates with body composition and could predict the nutrition status of patients and disease prognosis. We aimed to explore the feasibility of predicting PhA-diagnosed malnutrition using facial image information based on deep learning (DL). METHODS: From August 2021 to April 2022, inpatients were enrolled from surgery, gastroenterology, and oncology departments in a tertiary hospital. Subjective global assessment was used as the gold standard of malnutrition diagnosis. The highest Youden index value was selected as the PhA cutoff point. We developed a multimodal DL framework to automatically analyze the three-dimensional (3D) facial data and accurately determine patients' PhA categories. The framework was trained and validated using a cross-validation approach and tested on an independent dataset. RESULTS: Four hundred eighty-two patients were included in the final dataset, including 176 with malnourishment. In male patients, the PhA value with the highest Youden index was 5.55°, and the area under the receiver operating characteristic curve (AUC) = 0.68; in female patients, the PhA value with the highest Youden index was 4.88°, and AUC = 0.69. Inpatients with low PhA had higher incidence of infectious complications during the hospital stay (P = 0.003). The DL model trained with 4096 points extracted from 3D facial data had the best performance. The algorithm showed fair performance in predicting PhA, with an AUC of 0.77 and an accuracy of 0.74. CONCLUSION: Predicting the PhA of inpatients from facial images is feasible and can be used for malnutrition assessment and prognostic prediction.

A Randomized, Evaluator-Blinded, Multi-Centered Study to Compare Injectable Poly-D, L-Lactic Acid Versus Hyaluronic Acid for Nasolabial Fold Augmentation.

BACKGROUND: Injectable poly-D, L-lactic acid (PDLLA), under the brand name of AestheFill (Chaeum Pharma GmbH, Berlin, Germany), is a biocompatible, biodegradable, and biostimulatory product used to correct soft tissue volume loss. Its efficacy and safety have not been fully studied in a large cohort. OBJECTIVES: To evaluate the efficacy and safety of a novel dermal filler injectable poly-D, L-lactic acid. METHODS: This is an evaluator-blinded, multi-centered, randomized controlled trial to compare the efficacy and safety of PDLLA versus hyaluronic acid in the correction of nasolabial fold. Two hundred and sixty patients with moderate to severe nasolabial fold were enrolled and randomized to treatment group (PDLLA) or control group (hyaluronic acid). Each patient received PDLLA or hyaluronic acid injection for nasolabial fold augmentation and followed up for 52 weeks. Wrinkle Severity Rating Scale (WSRS) and Global Aesthetic Improvement Scale (GAIS) were used to evaluate topical nasolabial fold augmentation and overall improvement, respectively. RESULTS: At 24 weeks, 67.6% of patients in the PDLLA group had at least 1-grade improvement in WSRS, compared to 60.9% of patients in the control group with at least 1-grade improvement in WSRS (p<0.05). At each visit, PDLLA group showed more improvement from the baseline in WSRS than the control group. PDLLA was safe and well-tolerated with no severe adverse events. CONCLUSIONS: PDLLA shows non-inferior efficacy in correcting nasolabial fold compared to hyaluronic acid.

Case report: Macrophage activation syndrome in a patient with Kabuki syndrome.

Macrophage activation syndrome (MAS), is a severe and fatal complication of various pediatric inflammatory disorders. Kabuki syndrome (KS), mainly caused by lysine methyltransferase 2D (KMT2D; OMIM 602113) variants, is a rare congenital disorder with multi-organ deficiencies. To date, there have been no reported cases of MAS in patients with KS. This report describes a case of a 22-year-old male with Kabuki syndrome (KS) who developed MAS. This unique case not only deepens the understanding of the involvement of KMT2D in immune regulation and disease, but expands the phenotype of the adult patient to better understand the natural history, disease burden, and management of patients with KS complicated with autoimmune disorders.

A Comprehensive Ultrasound Investigation of Lower Facial and Neck Structure.

BACKGROUND: The jawline and neck significantly influence facial aesthetics. Botulinum toxin and filler are highly favored as minimally invasive jawline rejuvenation procedures. However, little evidence exists on the age-related skin and superficial fat tissue transformations in healthy individuals to guide targeted interventions. METHODS: A quantitative sonographic assessment was conducted on 51 patients. Total soft tissue thickness (the skin and superficial fat compartments) was measured at eight sites along the jawline and four sites at the neck. Among them, 21 patients received botulinum toxin A (BTX-A) injections for jawline lift. Three-dimensional images and questionaries were obtained before and after the treatment. RESULTS: In this ultrasound study, total superficial soft tissue thickness decreased significantly from the prejowl sulcus to the lateral cheek, with the jowl showing the greatest thickness. Vertically, significant differences in thickness were noted between superior and inferior points, especially at the inferior prejowl sulcus for the middle-aged and the jowl for the elderly group when comparing across age groups. Soft tissue thickness at the neck decreased from zones 1 to 3, consistent in all age groups. BMI and age positively correlated with soft tissue thickness at the jawline and neck. Regarding BTX-A injections, participants described a pain-free injection process, of which 85.7% reported substantial aesthetic improvement and sharpening of the submental-cervical angle. CONCLUSIONS: This study quantified age-related changes in superficial soft tissues at the jawline and neck regions with ultrasound imaging. With aging, soft tissue thickness alters with high region-specificity. Tailoring interventions to the specific alterations within each age group can achieve optimal results with enhanced safety. This study provided a quantitative analysis of skin and superficial fat compartment thicknesses for the young, middle-aged, and elderly groups. This study illustrated how skin and superficial fat compartments change with age in a regionally specific manner for both the jawline and neck regions. This study revealed a positive association between BMI and age with skin and superficial fat tissue thicknesses, especially in areas like the jowl, submental, and neck. This study provided guidance for a safe and effective botulinum toxin. A injection method focusing on the injection depths and regions to achieve optimal jawline rejuvenation outcomes and patient experience. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Development and evaluation of a deep learning framework for the diagnosis of malnutrition using a 3D facial points cloud: A cross-sectional study.

BACKGROUND: The feasibility of diagnosing malnutrition using facial features has been validated. A tool to integrate all facial features associated with malnutrition for disease screening is still demanded. This work aims to develop and evaluate a deep learning (DL) framework to accurately determine malnutrition based on a 3D facial points cloud. METHODS: A group of 482 patients were studied in this perspective work. The 3D facial data were obtained using a 3D camera and represented as a 3D facial points cloud. A DL model, PointNet++, was trained and evaluated using the points cloud as inputs and classified the malnutrition states. The performance was evaluated with the area under the receiver operating characteristic curve, accuracy, specificity, sensitivity, and F1 score. RESULTS: Among the 482 patients, 150 patients (31.1%) were diagnosed as having moderate malnutrition and 54 patients (11.2%) as having severe malnutrition. The DL model achieved the performance with an area under the receiver operating characteristic curve of 0.7240 ± 0.0416. CONCLUSION: The DL model achieved encouraging performance in accurately classifying nutrition states based on a points cloud of 3D facial information of patients with malnutrition.

Automated anatomical landmark detection on 3D facial images using U-NET-based deep learning algorithm.

Background: Facial anthropometry based on 3-dimensional (3D) imaging technology, or 3D photogrammetry, has gained increasing popularity among surgeons. It outperforms direct measurement and 2-dimensional (2D) photogrammetry because of many advantages. However, a main limitation of 3D photogrammetry is the time-consuming process of manual landmark localization. To address this problem, this study developed a U-NET-based deep learning algorithm to enable automated and accurate anatomical landmark detection on 3D facial models. Methods: The main structure of the algorithm stacked 2 U-NETs. In each U-NET block, we used 3×3 convolution kernel and rectified linear unit (ReLU) as activation function. A total of 200 3D images of healthy cases, acromegaly patients, and localized scleroderma patients were captured by Vectra H1 handheld 3D camera and input for algorithm training. The algorithm was tested to detect 20 landmarks on 3D images. Percentage of correct key points (PCK) and normalized mean error (NME) were used to evaluate facial landmark detection accuracy. Results: Among healthy cases, the average NME was 1.4 mm. The PCK reached 90% when the threshold was set to the clinically acceptable limit of 2 mm. The average NME was 2.8 and 2.2 mm among acromegaly patients and localized scleroderma patients, respectively. Conclusions: This study developed a deep learning algorithm for automated facial landmark detection on 3D images. The algorithm was innovatively validated in 3 different groups of participants. It achieved accurate landmark detection and improved the efficiency of 3D image analysis.

Botulinum Toxin Treatment for Calf Contouring Based on the Study of Combined Injection of Gastrocnemius and Soleus.

BACKGROUND: Botulinum toxin is administered to paralyze the gastrocnemius muscle and reduce its size, thereby improving the calf contour and reducing the leg circumference of the calf. OBJECTIVES: In pursuit of better efficacy, we designed a new injection protocol that targeted both the gastrocnemius and soleus. An algorithm of botulinum toxin injection for calf contouring was proposed based on the results of the study and ultrasonographic data. METHODS: A prospective, self-controlled, double-blind study was conducted. The gastronemius muscle (GM) group (n = 17) included the patients whose gastrocnemius muscles were treated, and the GM + soleus muscle (SM) group (n = 17) included the patients who had both the gastrocnemius and soleus treated. Parameters including the maximum leg circumference and the subcutaneous fat, gastrocnemius muscle, and soleus muscle thicknesses were collected before and after injection. RESULTS: Both GM and GM + SM injection helped improve calf contour. Although the thickness of the gastrocnemius muscle was reduced, reducing the leg circumference, the subcutaneous fat and soleus muscle had compensatory thickening after injection, especially over the long term, which may affect the efficacy. Compared with the GM group, the GM + SM group effectively reduced the tendency of the soleus muscle to thicken. Calf muscle thickness could be roughly estimated by constructing a fitting equation and measuring height, weight, and leg circumference. CONCLUSIONS: Two injection methods achieved the effect of improving calf contour and reducing the leg circumference with equivalent patient satisfaction. The GM + SM injection group did not show any obvious extra clinical benefit when compared with the GM injection group.

Defining Ideal Pretarsal Rolls Through a Morphometric Analysis in Asians.

BACKGROUND: Pretarsal rolls are a crucial aesthetic feature. Despite numerous studies conducted on periorbital aesthetics, there remains a dearth of research on the ideal pretarsal rolls. OBJECTIVES: This study aimed to investigate 4 aesthetic characteristics of ideal pretarsal rolls: presence, width, proportion, and morphology. METHODS: Respondents (385, including 80 aesthetic specialists) were presented with 7 series of images of pretarsal rolls, including 2 series of pretarsal roll existence, 2 series of varying widths, 2 series of different ratios between pretarsal roll and palpebral fissure height, and 1 series about morphology. Participants were asked to rank each image within a given series from most attractive to least attractive. The rankings were then analyzed according to population demographics. RESULTS: The majority of respondents deemed images with pretarsal rolls to be more aesthetically pleasing (P < .001) than those without such features. Additionally, pretarsal rolls with a width of 5 mm (P < .001), a ratio to palpebral fissure height of 0.5:1 (P < .001), and a crescent shape (P < .001) were perceived as the most attractive. Moreover, individuals aged 40 or younger exhibited a significant preference for images with pretarsal rolls compared to older groups (P < .001), and females displayed a greater inclination toward a medium ratio of pretarsal roll to palpebral fissure height than males did (0.5:1 P = .003, 0.618:1 P < .001). CONCLUSIONS: This study validates the optimal characteristics of pretarsal rolls, which provides insight into pretarsal roll aesthetics and holds significant implications for surgical planning and effect assessment in future periocular procedures involving pretarsal rolls.

Protocol Establishment and Reliability Verification of Three-Dimensional Digital Stereophotogrammetry in Lower Eyelid Anthropometry.

BACKGROUND: Three-dimensional (3D) stereophotogrammetry has been widely used in anthropometry for both medical and esthetic purposes. However, no studies have assessed its reliability on measuring the lower eyelid by 3D imaging. This study aimed to establish a standardized 3D anthropometric protocol for lower eyelid region and validate its reliability. METHODS: Fifty-eight participants (116 eyes) were recruited with mean age of 39.14 ± 11.25 years. Two sets of VECTRA 3D images were taken for each subject, and each set of images was individually measured twice by two raters. Twenty-seven landmarks were identified in the lower eyelid region, and then 19 linear, 4 curvilinear, 7 angular and 2 areal metrics were assessed for intrarater, interrater and intramethod reliability. RESULTS: High reliability was found in this 3D imaging-based lower eyelid anthropometry. The mean absolute difference within 2 intrarater measurement were 0.22 and 0.08 units, the technical errors measurement were 0.31 and 0.15 units, the relative errors of measurement were 0.90% and 0.31%, the relative technical errors of measurement were 1.53% and 0.64%, and the intra-group correlation coefficient was 0.99 and 0.99. The results for interrater measurement were 0.53 units, 0.59 units, 2.94%, 3.41% and 0.96, and for intramethod measurement were 0.71 units, 0.77 units, 4.12%, 4.05% and 0.95 units, respectively. CONCLUSION: 3D stereophotogrammetry is reliable for lower eyelid anthropometry. The standardized protocol can be further applied for many purposes such as lower eyelid aging evaluation, surgical related assessment and periocular rejuvenation plan. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Development and Validation of a Comprehensive Perioral Evaluation Method Using Three-Dimensional Stereophotogrammetry.

BACKGROUND: The non-invasive three-dimensional (3D) stereophotogrammetry is widely used in anthropometry for medical purpose. Yet, few studies have assessed its reliability on measuring the perioral region. OBJECTIVES: This study aimed to provide a standardized 3D anthropometric protocol for the perioral region. METHODS: 38 female and 12 male Asians were recruited (mean age 31.6 ± 9.6 years). Two sets of 3D images using the VECTRA 3D imaging system were acquired for each subject, and two measurement sessions for each image were performed independently by two raters. 25 landmarks were identified, and 28 linear, 2 curvilinear, 9 angular and 4 areal measurements were evaluated for intrarater, interrater, and intramethod reliability. RESULTS: Our results showed high reliability of 3D imaging-based perioral anthropometry by mean absolute difference (0.57 and 0.57 unit), technical error measurement (0.51 and 0.55 unit), relative error of measurement (2.18% and 2.44%), relative technical error of measurement (2.02% and 2.34%), and intraclass correlation coefficient (0.98 and 0.98) for intrarater 1 and intrarater 2 reliability; respectively 0.78 unit, 0.74 unit, 3.26%, 3.06% and 0.97 for interrater reliability; and respectively 1.01 unit, 0.97 unit, 4.74%, 4.57% and 0.95 for intramethod reliability. CONCLUSIONS: This standardized protocol utilizing 3D surface imaging technologies are feasible and highly reliable in perioral assessment. It could be further applied for diagnostic purpose, surgical planning and therapeutic effect evaluation in clinical practice in relation to perioral morphologies. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Quantitative Three-Dimensional Tear Trough Deformity Assessment and Its Application in Orbital Septum Fat Transposition.

BACKGROUND: Existing evaluation tools of tear trough deformity are based on subjective impression of clinicians. More accurate quantitative assessment methods are needed. This study aimed to propose a quantitative three-dimensional assessment method for the tear trough deformity in comparison with the Barton's grading system and apply it to the efficacy evaluation of orbital septum fat transposition. METHODS: 117 healthy Chinese adults (234 eyes) were enrolled and divided into four groups according to the Barton's grading system. Three-dimensional facial images were captured using Vectra H1 handheld camera. 6 anthropometric landmarks were identified on each eye and 8 linear measurements were generated accordingly. Intra-observer reliability was determined and measurements were compared between groups. Pre- and post-operative three-dimensional measurements were compared in 19 patients who received lower blepharoplasty with orbital septum fat transposition. RESULTS: The severity of tear trough was positively correlated with age (P < 0.001) but not BMI (P = 0.145) or gender (P = 0.280). Intra-rater reliability of the 8 linear measurements was excellent except for the vertical distance between the palpebrale inferioris margin and the tear trough below the pupillary center. Intergroup comparison showed that the horizontal distance between the lateral end of tear trough (P < 0.001) and medial canthus and the sagittal vector from tear trough point toward eyelid bag point (P = 0.009) increased with grade, while the vertical distance from mid-pupil to palpebrale inferioris margin decreased gradually (P = 0.001). Orbital septum fat transposition significantly improved the tear trough deformity as assessed by these three-dimensional measurements. CONCLUSIONS: We demonstrated a novel quantitative evaluation method of the tear trough deformity using three-dimensional stereophotogrammetry and proved it to be valid and reliable. It showed good value of clinical application and might help with periorbital rejuvenation planning and outcome assessment. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Introduction and validation of an automatic and low-cost three-dimensional facial imaging system: a comparison to direct anthropometry and Vectra H1.

Background: Three-dimensional (3D) imaging is a powerful tool for the analysis of soft tissue morphology. 3D photogrammetry outperforms conventional photogrammetric methods and gains popularity among plastic surgeons. However, commercial 3D imaging systems bundled with analytical software are costly. This study intends to introduce and validate an automatic, low-cost, and user-friendly 3D facial scanner. Methods: An automatic and low-cost 3D facial scanning system was developed. The system consisted of a 3D facial scanner running automatically on a sliding track and a 3D data processing tool. Fifteen human subjects underwent 3D facial imaging by the novel scanner. Eighteen anthropometric parameters were measured on the 3D virtual models and compared with caliper measurements (the gold standard). Further, the novel 3D scanner was compared to the commonly used commercial 3D facial scanner Vectra H1. Heat map analysis was used to evaluate the deviation between the 3D models obtained by the two imaging systems. Results: The 3D photogrammetric results were highly correlated with the direct measurement results (P<0.001). The mean absolute differences (MADs) were less than 2 mm. Bland-Altman analysis indicated that, for 17 of the 18 parameters, the largest differences within the 95% limits of agreement margin were within the 2.0 mm clinical acceptance. Heat map analysis showed the average distance between the 3D virtual models was 0.15 mm, with a root mean square of 0.71 mm. Conclusions: The novel 3D facial scanning system is proven to be highly reliable. It provides a good alternative to commercial 3D facial scanners.

Does Double-Eyelid Blepharoplasty Improve Forehead Wrinkles? A Prospective Study Using FACE-Q Scale and Anthropometric Measurements.

BACKGROUND: Single eyelids are common among Asians. It is not uncommon to see people with single eyelids raise their eyebrows to wide open their eyes. This results in frequent compensatory contraction of the frontalis muscle and thus leads to deep forehead wrinkles. Double-eyelid blepharoplasty creates a larger visual field. In theory, patients who receive the surgery will stop overusing the frontalis muscle. Therefore, the forehead wrinkles can be improved. METHODS: 35 patients who underwent double-eyelid blepharoplasty were enrolled. FACE-Q forehead wrinkle assessment scale was adopted to evaluate the forehead wrinkles preoperatively and postoperatively. In addition, anthropometric measurements were taken to indirectly evaluate frontalis muscle contraction in maximum eye-opening position. RESULTS: According to the FACE-Q scale, forehead wrinkles were improved after double-eyelid blepharoplasty, and the improvement was long-lasting in the 3-month follow-up. This was because the frontalis muscle contraction reduced after the surgery, as shown by the anthropometric measurements. CONCLUSION: This study used subjective and objective methods to prove that double-eyelid surgery improves forehead wrinkles. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Ultrasonographic Analysis of Trapezius Muscle for Efficient Botulinum Toxin Type A Injection.

BACKGROUND: Patients nowadays seek medical reduction of the upper trapezius muscle to achieve aesthetic pleasing necklines. Botulinum toxin type A (BoNT-A), a neurotoxin that reduces the force of muscle contraction, is widely used for shoulder contouring. However, detailed metrical data are lacking to guide clinical injection. METHODS: Forty healthy young women were enrolled. All subjects were seated for point marking and measuring of trapezius muscle (TM) anatomical data. At marked locations, the thickness of the subcutaneous tissue, the thickness of the TM, the TM's anterior border, and the depth from the skin surface to the middle of TM were measured using a real-time ultrasound scanner. In addition, photos were taken to assess the shoulder area proportion and shoulder angle. RESULTS: The shoulder area size among participants was 90 ± 15.2 cm2, the average area proportion was 0.55 ± 0.1, and the shoulder angle was 23.12° ± 2.9°. Ultrasonography data reveal that the thickness of the subcutaneous tissue, the thickness of the TM, and the depth from the skin surface to the middle of TM all thickened from the anterior line to the posterior line (P < 0.001). The length of the TM extending forward was 1.47 ± 0.4 cm (range 0.51-1.31 cm). To better evaluate the appearance of the trapezius muscle, we constructed a grading system correlated to shoulder angle. CONCLUSION: In this study, ultrasonography and photos were applied to assess the TM's anatomical features. Trapezius hypertrophy was described on a scale from 0 to 2 based on the shoulder angle. The findings of the present study provide a practical clinical guidance for precise and efficient BoNT-A administration. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Ultrasonographic analysis of the calves for efficient botulinum toxin type A injection.

BACKGROUND: Large calves are considered unattractive. Botulinum toxin type A (BoNT-A), acting as a neurotoxin that reduces muscle contraction, is widely used in calf contouring. However, there lacks detailed anatomical data to guide clinical injection. OBJECTIVES: This study aims to use ultrasonography to provide depth information of the calf muscles and determine the morphological types of the gastrocnemius muscle. METHODS: Ultrasound scanning was performed at six sites on 40 Chinese adults. A real-time ultrasound scannerwas used to detect the depth of the gastrocnemius muscle and the soleus muscle. RESULTS: The thickness of the gastrocnemius muscle and the soleus muscle was measured. The depth from the skin to the surface, the middle, and the bottom of the gastrocnemius muscle was measured. The morphology of gastrocnemius muscle was classified into four different types under ultrasound according to the muscle bulge pattern. CONCLUSION: This study took ultrasonic measurements of Asian calves to guide accurate and effective BoNT-A injection in real clinical practice.

Risk of second primary malignancies associated with radiotherapy in prostate cancer patients: competing risk analysis.

Background: The effect of radiotherapy (RT) for second primary malignancies (SPMs) among prostate cancer survivors is controversial. Methods: Applying logistic regression, competing risk analysis and propensity score matching method, this study analyzed clinical data from the Surveillance, Epidemiology, and End Results program to compare the risk for SPMs between patients receiving RT and non-RT. Results: In this study, prostate cancer patients treated with RT developed more SPMs in the anus, bladder, rectum, liver, lung and bronchus and lymphoma than non-RT groups. Conclusion: More intensive surveillance should be adopted for these cancers among prostate cancer survivors.

Plain language summary Patients with prostate cancer have the highest 5-year survival rate, which increases the risk for developing second primary malignancies (SPMs). The effect of radiotherapy (RT) for SPMs is controversial among prostate cancer survivors. This study analyzed a mass of prostate cancer patients from a public database to compare risk for SPMs between RT and non-RT groups. RT indeed increased certain categories of SPM and intensive surveillance should be considered.

The "Visible" Muscles on Ultrasound Imaging Make Botulinum Toxin Injection More Precise: A Systematic Review.

BACKGROUND: Botulinum toxin (BoNT) injection is the most commonly performed procedure in cosmetic surgery. However, blind injection is unable to take individual anatomical variations into consideration, which is the main contributing factor to complications. Ultrasound (US) imaging was introduced to reduce complications and improve effects. This article will review uses of US in aesthetic BoNT injection. METHOD: A systematic electronic search was performed using the PubMed, MEDLINE, Web of science. Search terms were set to focus on aesthetic BoNT injection. Two independent reviewers subsequently reviewed the resultant articles based on strict inclusion and exclusion criteria. Selected manuscripts were analysed and grouped by procedure categories. Clinical cases were all performed by one plastic surgeon in our department. RESULTS: The search finally retained 24 articles. Five procedural categories were identified, including masseter (n = 16), frontalis (n = 2), glabella complex (n = 2), trapezius (n=1), and gastrocnemius (n = 3). US imaging is practical and instructive for pre-operative assessments as in needle-type selection, injection point localization and depth setting, as well as post-operative follow-ups regarding injection feedback (for instance, the extent of muscle volume decreases). What's more, ultrasound-guided injection makes needle trajectory visualized so as for the needle to reach the target muscle in avoidance of potential damage to neurovascular bundle, gland or adjacent muscle. CONCLUSION: Muscles, such as masseter, frontalis, glabella complex, trapezius and gastrocnemius, and their adjacent structures can be well visualized using US, and as such, US can be a useful tool for a variety of pre-operative, intra-operative and post-operative procedures. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Second primary malignancies associated with radiation therapy in cervical cancer patients diagnosed between 1975 and 2011: a population-based competing-risk study.

BACKGROUND: Cervical cancer is a major health threat for women. Radiotherapy plays an important role in the treatment of cervical cancer. However, its overall benefit has been questioned due to the risk of second primary malignancies. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was used to search for cervical cancer patients diagnosed between January 1975 and November 2011. Factors that could possibly affect the occurrence of second primary malignancies included the year of diagnosis, gender, ethnicity, histologic type, SEER cancer stage, histology, grade, and whether surgery, chemotherapy, or radiotherapy were used. Age-adjusted and propensity scoring matching (PSM)-adjusted competing-risk analysis was applied for analysis. RESULTS: Of the 23,112 patients identified through SEER, 14,800 (64.0%) received radiotherapy. Second malignancies were diagnosed in 2,545 (11.0%) cases. PSM-adjusted competing analysis revealed that patients receiving radiotherapy had a significantly higher risk of developing a second cancer in the colon, rectum and anus [hazard ratio (HR): 1.43; 95% confidence interval (CI): 1.09-1.87; P=0.01], lung and bronchus (HR: 1.41; 95% CI: 1.13-1.76; P=0.002), corpus uteri (HR: 3.71; 95% CI: 1.71-8.06; P<0.001), ovary (HR: 2.79; 95% CI: 1.38-5.64; P=0.004), and urinary bladder (HR: 2.18; 95% CI: 1.35-3.54; P=0.002). However, radiotherapy significantly lowered the risk of second cancers in the female breast (HR: 0.67; 95% CI: 0.52-0.86; P=0.002). Age-adjusted competing-risk analysis showed generally consistent results. CONCLUSIONS: Radiotherapy increased the risk of second cancers among cervical cancer patients. Those who underwent radiotherapy had a significantly higher risk of developing a second cancer in the colon, rectum and anus, lung and bronchus, corpus uteri, ovary, and urinary bladder.

Clinicopathological models for predicting lymph node metastasis in patients with early-stage lung adenocarcinoma: the application of machine learning algorithms.

BACKGROUND: Lymph node metastasis (LNM) status can be a critical decisive factor for clinical management of lung cancer. Accurately evaluating the risk of LNM during or after the surgery can be helpful for making clinical decisions. This study aims to incorporate clinicopathological characteristics to develop reliable machine learning (ML)-based models for predicting LNM in patients with early-stage lung adenocarcinoma. METHODS: A total of 709 lung adenocarcinoma patients with tumor size ≤2 cm were enrolled for analysis and modeling by multiple ML algorithms. The receiver operating characteristic (ROC) curve and decision curve were used for evaluating model's predictive performance and clinical usefulness. Feature selection based on potential models was performed to identify most-contributed predictive factors. RESULTS: LNM occurred in 11.3% (80/709) of patients with lung adenocarcinoma. Most models reached high areas under the ROC curve (AUCs) >0.9. In the decision curve, all models performed better than the treat-all and treat-none lines. The random forest classifier (RFC) model, with a minimal number of five variables introduced (including carcinoembryonic antigen, solid component, micropapillary component, lymphovascular invasion and pleural invasion), was identified as the optimal model for predicting LNM, because of its excellent performance in both ROC and decision curves. CONCLUSIONS: The cost-efficient application of RFC model could precisely predict LNM during or after the operation of early-stage adenocarcinomas (sensitivity: 87.5%; specificity: 82.2%). Incorporating clinicopathological characteristics, it is feasible to predict LNM intraoperatively or postoperatively by ML algorithms.