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.

Genetic Inheritance Models of Non-Syndromic Cleft Lip with or without Palate: From Monogenic to Polygenic.

Non-syndromic cleft lip with or without palate (NSCL/P) is a prevalent birth defect that affects 1/500-1/1400 live births globally. The genetic basis of NSCL/P is intricate and involves both genetic and environmental factors. In the past few years, various genetic inheritance models have been proposed to elucidate the underlying mechanisms of NSCL/P. These models range from simple monogenic inheritance to more complex polygenic inheritance. Here, we present a comprehensive overview of the genetic inheritance model of NSCL/P exemplified by representative genes and regions from both monogenic and polygenic perspectives. We also summarize existing association studies and corresponding loci of NSCL/P within the Chinese population and highlight the potential of utilizing polygenic risk scores for risk stratification of NSCL/P. The potential application of polygenic models offers promising avenues for improved risk assessment and personalized approaches in the prevention and management of NSCL/P individuals.

Fat Grafting Reduces Skin Hyperpigmentation of Localized Scleroderma Patients: A Prospective Self-controlled Study.

BACKGROUND: Localized scleroderma (LS) is characterized by skin fibrosis, hyperpigmentation and soft tissue atrophy. Fat grafting has been widely used to correct LS deformity. OBJECTIVE: To investigate the effect of fat grafting on the skin pigmentation of LS lesions. METHODS: A prospective self-controlled study was conducted. Skin melanin and erythema indexes were measured by Mexameter® MX18 before and 3 months after surgery. Differences between lesions and contralateral normal sites were compared to evaluate changes induced by fat grafting. Localized Scleroderma Cutaneous Assessment Tool and PUMC Localized Scleroderma Facial Aesthetic Index were used for clinical evaluation. RESULTS: Fourteen frontal linear LS patients participated in the study. Before surgery, the melanin index of the lesions was significantly higher than the contralateral sites (p = 0.023), while the erythema indexes were not significantly different (p = 0.426). Three months post-operation, the melanin index of the lesions significantly decreased (p = 0.008). There was no significant change in the erythema index of the lesions before and after fat grafting (p = 0.322). The LoSCAT and PUMC LSFAI scores demonstrated improved disease condition and facial esthetics after surgery. CONCLUSION: Fat grafting could alleviate skin hyperpigmentation and skin damage of LS lesions while having little effect on skin erythema and disease activity. LEVEL OF EVIDENCE III: 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 .

Flap perfusion assessment with indocyanine green angiography in deep inferior epigastric perforator flap breast reconstruction: A systematic review and meta-analysis.

BACKGROUND: Indocyanine green angiography (ICG-A) has been widely applied for intraoperative flap assessment in DIEP flap breast reconstruction. However, the beneficial effect of ICG-A in DIEP flap breast reconstruction is still uncertain and no standardized protocol is available. This study aims to analyze the clinical outcome and comprehensively review protocols of this field. METHODS: A systematic review was conducted in MEDLINE, EMBASE, and Cochrane CENTRAL databases until September 15, 2022. Studies on the utility of intraoperative ICG-A in DIEP breast reconstruction were included. Data reporting reconstruction outcomes were extracted for pooled analysis. RESULTS: A total of 22 studies were enrolled in the review, among five studies with 1021 patients included in the meta-analysis. The protocols of ICG-A assessment of DIEP flap varied among studies. According to the pooled results, the incidence of postoperative fat necrosis was 10.89% (50 of 459 patients) with ICG-A and 21.53% (121 of 562 patients) with clinical judgment. The risk for postoperative fat necrosis was significantly lower in patients with intraoperative ICG-A than without (RR 0.47 95% CI 0.29-0.78, p = .004, I2 = 51%). Reoperation occurred in 5 of 48 patients (10.42%) in the ICG-A group and in 21 of 64 patients (32.82%) in the control group summarized from reports in two studies. The risk for reoperation was lower in the ICG-A group than in the control group (RR 0.41 95% CI 0.18-0.93, p = .03, I2 = 0%). Other complications, including flap loss, seroma, hematoma, dehiscence, mastectomy skin necrosis, and infection, were comparable between the two groups. Heterogeneities among studies were acceptable. No significant influence of specific studies was identified in sensitivity analysis. CONCLUSIONS: ICG-A is an accurate and reliable way to identify problematic perfusion of DIEP flaps during breast reconstruction. Protocols of ICG-A differed in current studies. Intraoperative ICG-A significantly decreases the rate of fat necrosis and reoperation in patients undergoing DIEP breast reconstruction. The synthesized results should be interpreted sensibly due to the sample size limitation. RCTs on the outcomes and high-quality studies for an optimized ICG-A protocol are still needed in the future.

Exploration of Influencing Factors for Postoperative Recurrence in Patients with Madelung's Disease on the Basis of Multivariate Stepwise Cox Regression Analysis.

Purpose: Madelung's disease (MD) is a rare condition of massive deposits of fat accumulations between superficial and deep fascia at typical locations. There is an absence of systematic studies related to MD in the Chinese cohort. Thus, the objective of the study was to investigate the clinical features of the MD cases in our institution and to explore the clinical variables associated with postoperative recurrence. Materials and Methods: We retrospectively analyzed the clinical information of 21 individuals with MD from 2013 to 2021 enrolled in our institution. The paired t-test and χ 2 test were, respectively, used to determine the difference between continuous and classified variables. The univariate Kaplan-Meier analysis by log-rank and multivariate stepwise Cox regression analysis were used to explore variables possibly associated with postoperative recurrence in MD individuals. Results: In the current study, 90.48% of the studied patients were male with a mean age of 48.76 years old. About 61.90% exhibited type I MD. MD patients who experienced postoperative recurrence had a higher age, BMI, incidence of chronic complications, and prevalence of alcoholism than the other MD patients without recurrence (P < 0.05). The univariate Kaplan-Meier analysis by log-rank identified that age, BMI, alcoholism, and comorbidities were influencing factors related with postoperative recurrence (P < 0.05). Conclusion: Demographic characteristics of the 21 studied Chinese cases with MD were generally in accordance with previously published data of other foreign populations. The factors possibly influencing the postoperative recurrence for patients with MD were age, BMI, alcoholism, and a combination of comorbidities. This is the first time that a summarization of clinical characteristics and postoperative recurrence variables of Chinese patients with MD has been reported.

Post-mastectomy adjuvant radiotherapy for direct-to-implant and two-stage implant-based breast reconstruction: A meta-analysis.

BACKGROUND: In recent years, immediate replacement with a prosthesis (direct-to-implant, DTI) is gaining more popularity than two-staged methods (tissue expander followed by an implant, TEI). The safety of immediate implant-based breast reconstruction (IBR) is debatable when postmastectomy radiotherapy (PMRT) is indicated. This meta-analysis aims to evaluate the outcomes of DTI and TEI procedures followed by PMRT. METHODS: Studies searched in the PubMed/Embase/The Cochrane Library databases (1995-2021) were filtered by exclusion criteria. Cases were divided into PMRT and non-irradiated groups, PMRT with a permanent implant or tissue expander. The outcomes were capsular contracture and other complications. RESULTS: A total of 22 studies with 6964 patients were included. PMRT increased the risk of capsular contracture in DTI patients and caused other complications in TEI patients. In PMRT and non-irradiated groups, the mean rates of capsular contracture were 17.01% versus 3.30% (p < 0.01) in IBR and 15.49% versus 5.70% (p < 0.01) in DTI. The mean rates of other complications were 22.59% versus 11.29% (p < 0.01) in IBR, 31.88% versus 27.87% (p = 0.35) in DTI, and 22.11% versus 9.90% (p < 0.01) in TEI. Implants and tissue expanders caused a similar rate of capsular contracture and other complications. CONCLUSION: PMRT is related to a higher risk of complication and capsular contracture in IBR, including DTI procedure. This negative effect may not be related to the type of breast contents during radiotherapy.

Long-term facial changes and clinical correlations in patients with treated acromegaly: a cohort study.

BACKGROUND: Facial abnormality is the most significant feature in acromegaly patients. However, it is unclear whether and how patient facial appearance improves after treatment. This study aimed to identify 3D facial changes in acromegaly patients after surgical treatment. METHODS: This study included 30 acromegaly patients who underwent resection of a pituitary GH adenoma. The location and extent of facial changes were identified by comparing baseline and 2-year follow-up 3D images of the face. Relationships between facial changes and GH and IGF-1 were evaluated with simple or multivariable linear regression models. RESULTS: Significant soft tissue improvements were observed in acromegaly patients with complete remission, especially in the nose and lip region. Significant reductions in nasal width (3.46 mm, P < 0.001), tip protrusion (1.18 mm, P = 0.003), face curve length (3.89 mm, P = 0.004) and vermilion area (1.42 cm3, P = 0.001) were observed at the 2-year follow-up. Further, changes in nasal width were associated with decreases in GH (ß = 4.440, P = 0.017), the GH nadir (ß = 4.393, P = 0.011) and IGF-1 (ß = 5.263, P = 0.002). The associations were maintained after adjusting for confounders. CONCLUSIONS: Acromegaly patients achieved considerable facial improvements after surgical treatment. The change in nose width was associated with GH and IGF-1 decrease. Better control of patient hormone levels after surgery improves patient facial recovery.

Comparison of concentrated fresh mononuclear cells and cultured mesenchymal stem cells from bone marrow for bone regeneration.

Autologous bone marrow mononuclear cell (BMMNC) transplantation has been widely studied in recent years. The fresh cell cocktail in BMMNCs, without going through the in vitro culture process, helps to establish a stable microenvironment for osteogenesis, and each cell type may play a unique role in bone regeneration. Our study compared the efficacy of concentrated fresh BMMNCs and cultured bone marrow-derived mesenchymal stem cells (BMSCs) in Beagle dogs for the first time. Fifteen-millimeter segmental bone defects were created in the animals' tibia bones. In BMMNCs group, the defects were repaired with concentrated fresh BMMNCs combined with ß-TCP (n = 5); in cultured BMSC group, with in vitro cultured and osteo-induced BMSCs combined with ß-TCP (n = 5); in scaffold-only group, with a ß-TCP graft alone (n = 5); and in blank group, nothing was grafted (n = 3). The healing process was monitored by X-rays and single photon emission computed tomography. The animals were sacrificed 12 months after surgery and their tibias were harvested and analyzed by microcomputed tomography and hard tissue histology. Moreover, the microstructure, chemical components, and microbiomechanical properties of the regenerated bone tissue were explored by multiphoton microscopy, Raman spectroscopy and nanoindentation. The results showed that BMMNCs group promoted much more bone regeneration than cultured BMSC group. The grafts in BMMNCs group were better mineralized, and they had collagen arrangement and microbiomechanical properties similar to the contralateral native tibia bone. These results indicate that concentrated fresh bone marrow mononuclear cells may be superior to in vitro expanded stem cells in segmental bone defect repair.

Surgical management of giant juvenile fibroadenoma with skin reducing tumor resection and immediate breast reconstruction: A single-center experience.

BACKGROUND AND OBJECTIVES: Giant juvenile fibroadenoma (GJF) is a rare benign tumor that disfiguring affects the breast shape and quality of life of patients. This study aimed to report the experience of GJF management. METHODS: A Wise-pattern skin reducing tumor resection followed by immediate breast reconstruction with a dermal flap pocket was used. The long-term outcomes were assessed retrospectively by BREAST-Q questionnaire from 2008 to 2018. RESULTS: The study included eight patients with GJF. All patients achieved satisfactory results without severe complications. The BREAST-Q revealed that postoperative scores for satisfaction with breasts (69.3 ± 17.6) and sexual wellbeing (62.3 ± 27.6) were higher than the normative scores. The psychosocial wellbeing (69.7 ± 14.6) and physical wellbeing-chest (86.8 ± 13.0) scores were slightly lower than the normative scores. CONCLUSION: Although GJF is a benign tumor, it should be surgically removed. And the Wise-pattern skin reducing tumor resection with immediate breast reconstruction is a proper way to improve patients' satisfaction with breast size and shape and quality of life.

Bone Marrow Mononuclear Cells Combined with Beta-Tricalcium Phosphate Granules for Alveolar Cleft Repair: A 12-Month Clinical Study.

Alveolar cleft is the most common congenital bone defect. Autologous iliac crest bone graft (ICBG) is the most widely adopted procedure for alveolar cleft repair, but the condition is associated with door-site morbidities. For the first time, this study used bone marrow mononuclear cells (BMMNCs) combined with beta-tricalcium phosphate (ß-TCP) granules to repair alveolar bone defect. The effectiveness of this technique was compared with autologous ICBG after 12 months of follow-up. The bone formation volume was quantitatively evaluated by three-dimensional computed tomography and computer aided engineering technology. BMMNCs/ß-TCP granule grafting was radiographically equivalent to ICBG in alveolar cleft repair. Although considerable resorption was observed up to 6 months after surgery, no significant differences were noted in the Chelsea score and bone formation volume between groups. These finding indicate that BMMNCs/ß-TCP grafting is a safe and effective approach for alveolar bone regeneration.

Volumetric Analysis of Alveolar Bone Defect Using Three-Dimensional-Printed Models Versus Computer-Aided Engineering.

Knowing the volume of a graft is essential in repairing alveolar bone defects. This study investigates the 2 advanced preoperative volume measurement methods: three-dimensional (3D) printing and computer-aided engineering (CAE). Ten unilateral alveolar cleft patients were enrolled in this study. Their computed tomographic data were sent to 3D printing and CAE software. A simulated graft was used on the 3D-printed model, and the graft volume was measured by water displacement. The volume calculated by CAE software used mirror-reverses technique. The authors compared the actual volumes of the simulated grafts with the CAE software-derived volumes. The average volume of the simulated bone grafts by 3D-printed models was 1.52 mL, higher than the mean volume of 1.47 calculated by CAE software. The difference between the 2 volumes was from -0.18 to 0.42 mL. The paired Student t test showed no statistically significant difference between the volumes derived from the 2 methods. This study demonstrated that the mirror-reversed technique by CAE software is as accurate as the simulated operation on 3D-printed models in unilateral alveolar cleft patients. These findings further validate the use of 3D printing and CAE technique in alveolar defect repairing.