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Lymphedema is characterized by the abnormal accumulation of lymphatic fluid in the skin and subcutaneous tissue owing to impaired lymph flow. This condition may be primary or secondary to other diseases. Most lymphedema occurs in the lower extremities, which greatly interferes with the activities of the patients, especially walking. Further, it may affect the psychological condition of patients. In Indonesia, several patients with severe lymphedema have visited our clinic. In our center, lymphography is not available. However, as our center is a provincial referral hospital, many patients with lymphedema present with severe conditions. Nonoperative and operative treatment is available, including lymphovenous anastomosis. Herein, we present the rare case of a 33-year-old man with severe lymphedema in his left leg for the past 7 years. The patient was diagnosed with stage III secondary lymphedema of the left lower extremity and underwent lymphaticovenular anastomosis using a modification of the Seki method (Seki 2015). Five large lymphatic vessels were identified using methylene blue, and a transverse incision was made approximately 2-3 cm from the skin to the fatty tissue under the superficial fascia. Lymphaticovenular anastomosis was performed using a microscope. On postoperative day 1, the edema in the leg shrank significantly, and 6 months after surgery, the patient's foot size began normalizing. The patient could wear pants and became more confident.

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A cauliflower ear is an auricular deformity characterized by thickened soft tissue and cartilage. A subperichondrial hematoma or fluid collection causes this malformation. As a result of being cut off from the perichondrium blood supply, the ear cartilage becomes ischemic, developing scar tissue, fibrous tissue, new cartilage overgrowth, or necrosis beneath the skin, resulting in a permanent alteration in the shape of the external ear resembling that of a cauliflower. To properly fix defects, the surgeon must grasp ear anatomy and be familiar with a variety of reconstructive alternatives. It requires meticulous attention, due to the intricate design of the ear. Simple and complex techniques for treating cauliflower ears have been developed. However, in severe cases, simple techniques are often insufficient. As a result, complex techniques such as replacement with an auricular prosthesis or implant or autogenous costal cartilage framework were developed. We present a case of a 25-year-old man who experienced a severe cauliflower ear as a result of an infection during adolescence. The patient was concerned about the shape of his ear and was depressed. Ear reconstruction was accomplished using the costal cartilage framework engraved according to a three-dimensional cutting guide for surgical planning. Costal cartilage is chosen to provide a framework for reconstruction as it is strong and rigid, and its curved shape is similar to that of the external ear. There were no complications after surgery. The ear projection and shape have performed admirably. The patient was pleased with the outcome and felt more confident after surgery.

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Malocclusion is an abnormal relationship between the teeth of the upper and lower jaws, with irregular tooth position, including crossbite and underbite. Malocclusion can occur in the form of crooked, protruding, or crowded teeth, affecting appearance, pronunciation, and mastication. Many factors lead to malocclusions, such as heredity, growth disturbance, and bad habits. Many Indonesians undergo orthodontic treatment to improve both function and appearance. The large demand for orthodontic treatment is due to increasing public knowledge about the impact of untreated malocclusion and the rising standard of living. We present a severe and rare case of malocclusion in Indonesia. A 20-year-old man presented with bilateral mandibular condylar hyperplasia and Angle's class III malocclusion. A multidisciplinary team, including plastic and oral surgeons, orthodontists, and psychologists, was created to address this problem. The first surgical procedure was chosen to achieve correction in the shortest possible time. Le Fort I osteotomy and mandibular bilateral sagittal split and anterior subapical osteotomies using Kole's procedure were performed. The patient underwent preoperative and postoperative examinations. After surgery, the occlusion was corrected and facial symmetry significantly improved.

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BACKGROUND: Hypertrophy of the gastrocnemius muscle is considered to be a hindrance to lower leg beauty in the Asian aesthetic market. A noninvasive technique that has been gaining recognition involves botulinum toxin A injection; however, there are no proper guidelines or standardized protocols for the administration of botulinum toxin to correct gastrocnemius hypertrophy. OBJECTIVES: This study sought to determine the most effective botulinum toxin injection method for correcting the contour of the lower leg calf, as well as to determine the dose that can produce the maximum effect in meeting the demands of the physician and patient. METHODS: Eighteen female patients aged between 18 and 35 years were enrolled in this study from January 2015 to July 2015. Two injection methods were compared: (I) 48 injection points with a distance of 2 cm between every point; and (II) 10 injection points. Magnetic resonance imaging examinations were conducted at baseline prior to treatment and at one month and 6 months after treatment. A 3-dimensional study was performed to analyze the volumetric changes. RESULTS: The most effective and significant treatment method for hypertrophic gastrocnemius muscle was the 48-point method (scattering injection). Following injection, this method exhibited a significant level of satisfaction with outcome. CONCLUSIONS: Our study reveals that injection dosage and method have a strong relationship with achieving a better contouring result. LEVEL OF EVIDENCE: 3.

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Rhinoplasty is one of the most delicate procedures in plastic and reconstructive surgery. Precision in every millimeter is vital in ensuring a better quality of surgical outcome. Many methods have been developed to fulfill this requirement. One such method is an implant, whether autogenous or artificial. Artificial implants involve several surgical complications, such as recipient rejection of implant material, infections, and rigid feel of the nasal tip. Hence, autogenous implants were eventually more widely applied, with material being obtained from the septum, concha, or rib cartilages. Therefore, the authors developed a new technique of rhinoplasty, using the osteochondral rib as an autogenous implant based on the ancient Chinese architectural technology called the DouGong method. The authors hereby present the results of 288 patients treated in our faculty wherein the data from the patients and the preoperative and postoperative 3-dimensional computed tomography scans were processed using Mimics software. The uniqueness of these implants is that the joint between the nasal dorsum and the columella strut is fixated without any screw, stitches, or K-wire. This procedure proved to be very useful as this technique not only minimized the application of fixation techniques, but also helped achieve a better nasofrontal angle, nasolabial angle, and columella length. After monitoring follow-ups of our patients, the authors hereby propose the use of this DouGong-based novel technique to improve the overall quality and outcome of corrective rhinoplasty.

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BACKGROUND: Keloid is a skin fibrosis disease that characterised by invasive growth of fibroblasts and aberrant deposition of extracellular matrix. Studies indicated that keloid fibroblasts (KFs) is a class of 'activated' fibroblasts, which show accelerated proliferation and excessive extracellular matrix formation as compared with normal fibroblasts (NFs). However, the mechanism underlying keloid fibroblasts dysfunction is still unknown. OBJECTIVE: To verify CD26 expression difference between KFs and NFs, and investigate the function of CD26 positive fibroblasts in keloid progression. METHODS: KFs and NFs were isolated from Keloid tissues and normal skin tissues respectively. Flow cytometry was performed to isolate CD26+/CD26- fibroblasts from KFs and NFs. Proliferation of different fibroblasts were analyzed by CCK8 assay and Ki 67 straining. Profibrotic phenotype difference was detected by qRT-PCR, western blot, ELISA and immunofluorescence. Scratching experiment and transwell assay were used to assess invasion ability of CD26+/CD26- fibroblasts. Diprotin A was used as a CD26 inhibitor to further investigated the function of CD26 fibroblasts in keloid disease. RESULT: CD26 expression was increased in KFs, and the proportion of CD26+ fibroblasts was significantly increased in KFs. Cell viability analysis showed that CD26+ fibroblasts was more active in proliferation. Furthermore, the expression of profibrotic genes were increased in CD26+ fibroblasts, including TGF-ß1, IGF-1, IL6, collagen 1, collagen 3 and fibronectin. And meanwhile, CD26+ fibroblasts showed stronger invasion ability as compared to CD26- fibroblasts. Moreover, Diprotin A significantly suppressed proliferation and extracellular matrix secretion of CD26+ fibroblasts isolated from keloid tissues. CONCLUSION: Our findings suggest that CD26+ fibroblasts possess proliferation advantage in compare to CD26- fibroblasts, and the advantage caused expansion of CD26 positive fibroblast population promotes keloid progression.

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BACKGROUND: Large temporal plexiform neurofibroma (PNF) is an irritating problem that causes facial disfigurement. Surgical resection of PNF is the only effective way to remove the tumor as well as to improve the patient's facial appearance. However, temporal branch of the facial nerve (TBFN) in the tumor is prone to be destroyed during PNF removal. Thus, TBFN palsy is the inevitable complication after surgery and might induce other malformation and dysfunction. Therefore, the aim of this study is to reconstruct a nearly normal face contour while preserving the facial nerve function. PURPOSE: Selective PNF removal technique was designed to protect TBFN during PNF lesions resection in our patients. METHODS: From May 2011 to June 2015, the authors had 10 patients who suffered from PNF in the temporal region with facial disfigurement and underwent selective PNF removal to correct the facial disfigurement while preserving TBFN as well. RESULT: All patients obtained the improvement of facial appearance after surgery. The temporal PNF was removed and the TBFN function successfully maintained. Plexiform neurofibroma recurrence has not been relapsed during 6 to 49 months' follow-up. CONCLUSIONS: In our initial exploration, TBFN function maintenance and facial appearance improvement can be achieved simultaneously by using PNF-selective removal surgery technique.

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PURPOSE: Augmented reality (AR) navigation, is a visible 3-dimensional display technology, that, when combined with robot-assisted surgery (RAS), allows precision and automation in operational procedures. In this study, we used an innovative, minimally invasive, simplified operative method to position the landmarks and specialized robot-assisted arms to apply in a rapid protyping (RP) model. This is the first report of the use of AR and RAS technology in craniomaxillofacial surgery. METHOD: Five patients with prominent mandibular angle were randomly chosen for this feasibility study. We reconstructed the mandibular modules and created preoperational plans as semi-embedded and nail-fixation modules for an easy registration procedure. The left side of the mandibular modules comprised the experimental groups with use of a robot, and the right sides comprised the control groups without a robot. With AR Toolkits program tracking and display system applied, we carried out the operative plans and measured the error. RESULTS: Both groups were successfully treated in this study, but the RAS was more accurate and stable. The average position and angle were significant (p < 0.01) between the 2 groups. CONCLUSIONS: This study reports a novel augmented reality navigation with specialized robot-assisted arms for mandibular angle split osteotomy. AR and RAS can be helpful for patients undergoing craniomaxillofacial surgery.

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The aim of the present study was to investigate bioprinting with electrospraying technology using multiple types of human cell suspensions as bio-ink, in order to lay the initial foundations for the application of the bioprinting technology in tissue engineering. In the current study, six types of human cells were selected and cultured, including human fibroblasts, human adipose-derived stem cells (hADSCs), human periodontal ligament cells (HPDLCs), adult human retinal pigment epithelial cells (ARPE-19), human umbilical vascular endothelial cells (HUVECs) and human gastric epithelial cell line (GES-1). Each cell type was divided into two groups, the experimental and control group. All the experimental group cells were electrosprayed using an electrospraying printer (voltage, 15 kV; flow rate, 150 µl/min) and collected in a petri dish placed 15 cm away from the needle (needle diameter, 0.5 mm). Subsequently, cell viability was detected by flow cytometry with a Live/Dead Viability kit. In addition, the cell morphological characteristics were observed with a phase-contrast microscope after 6 h of culturing in order to obtain adherent cells, while cell proliferation was analyzed using a Cell Counting Kit-8 assay. The control groups, without printing, were subjected to the same procedures as the experimental groups. The results of the cell viability and proliferation assays indicated a statistically significant difference after printing between the experiments and control groups only for the hADSCs (P<0.05); by contrast, no significant difference was observed in cell viability and proliferation for the other five cell types (P>0.05). In addition, there were no observable differences between all experimental and the control groups at any examined time point in the terms of cell morphological characteristics. In conclusion, bioprinting based on electrospraying technology demonstrated no distinct negative effect on cell vitality, proliferation and morphology in the present study, and thus the application of this novel technology to cell printing may provide a promising method in tissue engineering.

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BACKGROUND: Augmented reality (AR) technology can superimpose the virtual image generated by computer onto the real operating field to present an integral image to enhance surgical safety. The purpose of our study is to develop a novel AR-based navigation system for craniofacial surgery. We focus on orbital hypertelorism correction, because the surgery requires high preciseness and is considered tough even for senior craniofacial surgeon. METHODS: Twelve patients with orbital hypertelorism were selected. The preoperative computed tomography data were imported into 3-dimensional platform for preoperational design. The position and orientation of virtual information and real world were adjusted by image registration process. The AR toolkits were used to realize the integral image. Afterward, computed tomography was also performed after operation for comparing the difference between preoperational plan and actual operational outcome. RESULTS: Our AR-based navigation system was successfully used in these patients, directly displaying 3-dimensional navigational information onto the surgical field. They all achieved a better appearance by the guidance of navigation image. The difference in interdacryon distance and the dacryon point of each side appear no significant (P > 0.05) between preoperational plan and actual surgical outcome. CONCLUSIONS: This study reports on an effective visualized approach for guiding orbital hypertelorism correction. Our AR-based navigation system may lay a foundation for craniofacial surgery navigation. The AR technology could be considered as a helpful tool for precise osteotomy in craniofacial surgery.

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BACKGROUND: As three-dimensional technology becomes more ubiquitous, many plastic surgical applications have emerged. The authors investigate a three-dimensional scanning and printing system for facial soft tissue reconstruction in conjunction with an anterolateral thigh dermal adipofascial flap for the treatment of Parry-Romberg syndrome. METHODS: Seven patients with facial atrophy of the zygomatic, buccal, and mandibular areas were included. Three-dimensional scanning of each patient's face in conjunction was analyzed with computer-aided design (CAD) to quantify areas of facial asymmetry. Models were then created using three-dimensional printing to map areas of soft tissue deficiency. Free anterolateral thigh (ALT) dermal adipofascial flaps were designed based on the three-dimensional models of soft tissue deficiency. RESULTS: All flaps survived. One case had a postoperative hematoma. Six patients had restored facial symmetry. One patient required fat injections to obtain symmetry. No patients required revision surgery of their healed flaps for contouring. CONCLUSIONS: Three-dimensional laser scanning and three-dimensional printing in combination with a free ALT dermal adipofascial flap offer surgeons a precise means to reconstruct facial contour deformities.

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