須永 中

INTRODUCTION: A specialized device equipped with a sharp blade filter has been developed to enable more efficient purification of a micronized cellular adipose matrix (MCAM) containing stem cells. The aim of this study is to compare the characteristics and functions of the population of stromal cells (mSVF) and cultured cells (mASCs) purified using this device with those of cSVF and cASCs obtained through conventional enzymatic purification. METHODS: Cell viability, proliferation capacity and yield were assessed. Characterization of stem cell potency was performed by analyzing cell surface markers including CD34, a marker of activated adipose-derived stem cells. The trilineage differentiation potential was evaluated using RT-PCR and histology. RESULTS: The yield rate of mSVF obtained from MCAM was significantly higher than that with the conventional method, although use of the device resulted in a slight decrease in cell viability. After culture, mASCs exhibited a remarkable clonogenic potential and significantly higher cell proliferation potential than cASCs. The mASCs also displayed a distinct pattern of ASC cell surface markers, increased expression of genes related to CD34, high pluripotency, and a high trilineage differentiation ability. CONCLUSION: The specialized device enhanced the yield of SVF and produced cells with high proliferation rates and characteristics that include expression of stem cell markers.

BACKGROUND: Radiation therapies are often associated with permanent devitalization in the surrounding tissue. We hypothesized that stem cells are damaged depending on each irradiation dose and frequency of fractionated radiotherapies, which results in impaired tissue function including wound healing capacity. METHODS: To test the hypothesis, susceptibility of human adipose-derived stem cells (ASCs) to a single irradiation (0-10 Gy) was assessed in vitro. In vivo chronic radiation effects were also assessed on the mouse dorsal skin (N=4-5) for 6 months after a total of 40 Gy irradiation (0 Gy as control) using one of three fractionated protocols (2 Gy daily for 20 days, 10 Gy weekly for 4 weeks, or 10 Gy monthly for 4 months). Oxygen partial pressure, oxygen saturation of hemoglobin, and dorsal skin viscoelasticity were periodically measured, and wound healing and tissue immunohistology were compared at 6 months. RESULTS: A single irradiation of cultured human ASCs resulted in a dose-dependent increase in cell death up to 2 Gy but with no further increases between 2 and 10 Gy. Most of the apoptotic ASCs were in the proliferation phase. Among the three in vivo irradiation protocols, the 2 Gy×20 group had the most severe chronic tissue damage (i.e., skin dysfunction, subcutaneous atrophy, and depletion of CD34+ stem cells) 6 months after the irradiation. Wound healing was also impaired most significantly in the 2 Gy×20 group. CONCLUSIONS: These results have important clinical implications for surgeons and radiotherapists such as the timing of surgical interventions and the optimization of fractionation protocols.Clinical Relevance Statement: Irradiation damages stem cells depending on the radiation dose and frequency. Using the ultimately optimized protocol, we can minimize the long-term functional deficits of radiated tissue without losing anti-cancer efficacy of radiation therapy.

In this article we explain in detail the Multidirectional Cranial Distraction Osteogenesis(MCDO)procedure for treating craniosynostosis, in which the multiple cranial bone flaps are pulled up in different directions by the external distractor with the helmet-type frame. MCDO has several advantages over conventional procedures such as unilateral cranial distraction osteogenesis(UCDO). First, the design of the osteotomy in MCDO is flexible depending on the deformities. Each bone flap can be moved to the desired direction in MCDO, while being moved only in one direction along the axis of the distractor in UCDO. This enables remodeling of the deformed cranium to the desired shape. Second, compared with UCDO, the distance between each bone flap after distraction is narrower in MCDO, allowing earlier bone formation and fusion, and thus a shorter consolidation period. Third, the expansion efficacy of MCDO is greater than that of UCDO. The maximum defects of MCDO were the large amount of osteotomy and the resulting heavy bleeding. Therefore, we have recently attempted to improve the design and procedure of osteotomy. The MCDO method allows all phenotypes of skull deformity to be reshaped by distraction osteogenesis.

Bradycardia and asystole due to oculocardiac reflex (OCR) are potential intraoperative complications of periocular surgery. We report a case of asystole due to OCR that occurred during surgical repair performed 40 hours after an orbital blowout fracture. The patient had vomiting, bradycardia, and ocular motility disorder before the operation. During the operation, asystole occurred when the entrapped tissue was grasped with forceps. After administration of anticholinergic drugs, the heart promptly resumed beating, and no sequelae due to asystole were observed after surgery. Before and during periocular surgery, it is important for the surgeon to maintain a protective surgical procedure and communicate appropriately with the anesthesiologist, including discussion of risks and emergency measures. In addition, prolonged entrapment of the extraocular muscles is likely to cause irreversible damage, so it is important to make a diagnosis and perform surgery as soon as possible.

Frontometaphyseal dysplasia (FMD), also known as Gorlin-Cohen syndrome, is a rare genetic syndrome. This syndrome affects the skeletal system and connective tissue, and causes a wide spectrum of manifestations of the skull, tubular bones, cardiovascular system, urinary system, and/or gastrointestinal system. Craniofacial findings of FMD are characterized by protruding supraorbital ridge, broad nasal bridge, hypertelorism, down-slanting palpebral fissures, and/or micrognathia. We describe a case of a 2-year-old girl diagnosed with sagittal synostosis accompanied with FMD. She presents anterior sagittal synostosis cranial form, compressed cerebrospinal fluid space (which suggested increased intracranial pressure), and the supraorbital hyperostosis. She underwent multi-directional cranial distraction osteogenesis in the calvaria and shaving of the supraorbital ridges. Despite concerns about bone fragility associated with FMD, the surgery was accomplished as usual. The patient had no intra- and postoperative complications. After 6 months of follow-up, the cranial shape has improved and the cerebrospinal fluid space has widened, but the supraorbital ridge has protruded again. Re-protrusion of the supraorbital ridge appears to be due to age-appropriate vigorous osteogenesis. The multi-directional cranial distraction osteogenesis procedure has been useful for treating sagittal synostosis even concomitant with FMD.

We investigated the effect of oxygen tension on the proliferation and hair-inductive capacity of human dermal papilla cells (DPCs) and dermal sheath cells (DSCs). DPCs and DSCs were separately obtained from human hair follicles and each cultured under atmospheric/hyperoxic (20% O2), physiological/normoxic (6% O2), or hypoxic (1% O2) conditions. Proliferation of DPCs and DSCs was highest under normoxia. Compared with hyperoxia, hypoxia inhibited proliferation of DPCs, but enhanced that of DSCs. In DPCs, hypoxia downregulated the expression of hair-inductive capacity-related genes, including BMP4, LEF1, SOX2, and VCAN. In DSCs, both normoxia and hypoxia upregulated SOX2 expression, whereas hypoxia downregulated BMP4 expression. Microarray analysis revealed that normoxia increased the expression of pluripotency-related genes, including SPRY, NR0B1, MSX2, IFITM1, and DAZL, compared with hyperoxia. In an in vivo hair follicle reconstitution assay, cultured DPCs and DSCs were transplanted with newborn mouse epidermal keratinocytes into nude mice using a chamber method. In this experiment, normoxia resulted in the most efficient induction of DPC hair follicles, whereas hypoxia caused the most efficient induction and maturation of DSC hair follicles. These results suggest that application of physiological/hypoxic oxygen tension to cultured human DSCs enhances proliferation and maintenance of hair inductivity for skin engineering and clinical applications. Impact statement Dermal sheath cells (DSCs) and dermal papilla cells (DPCs) are useful cell sources for cell-based regenerative therapy. This is the first report to describe that low-oxygen conditions are better for DSCs. Normoxic and hypoxic culture of DSCs is beneficial for expanding these hair follicular cells and advancing development of cell-based therapy for both wound healing and hair regeneration. The current study supports that optimized oxygen tension can be applied to use expanded human DPCs and DSCs for skin engineering and clinical applications.

Alopecia has several causes, but its relationship with ischemia/hypoxia has not yet been investigated in detail. In this study, we studied the changes of hair follicles induced by ischemia and potential effects of normobaric hyperoxygenation (NBO) on the hair cycle and growth. We found that skin ischemia reduced hair growth rate, hair shaft size, and its pigmentation in the anagen phase of mice, which may reflect an aspect of pathophysiology of hair loss (alopecia) and depigmentation (gray/white hairs). Hyperoxygenation increased hair growth rate in organ culture of both human and murine hair follicles. Systemic NBO promoted hair growth in early anagen and mid-anagen, and delayed catagen onset in mice. However, telogen-to-anagen transition was not affected by NBO as far as non-ischemic skin is concerned. The results of this study indicated that the hair follicle is very sensitive to oxygen tension and oxygen tension affects the regulation of hair growth and cycle in vitro and in vivo. It was suggested that systemic NBO can be safely applied for a long period and can be a noninvasive therapeutic approach to alter hair growth and cycle by manipulating the microenvironment of hair follicles.

Fronto-orbital advancement by distraction osteogenesis is a useful means of surgically correcting bicoronal synostosis. However, the scope for morphological revision is limited. To address this issue, we developed a multidirectional cranial distraction osteogenesis (MCDO) technique that we quantitatively assessed in patients with bicoronal synostosis. In this case series, five patients with bicoronal synostosis were treated with MCDO at a mean age of 13.4 months (range 9-22 months). Distraction started 5 days after surgery and the activation period was 11.2 days (range 10-14 days). The distraction devices were removed 47.2 days (range 33-67 days) after completing distraction. Improved cranial shape was confirmed by CT data. Mean preoperative CI, APL, and ICV readings of 102.1%, 13.5 cm, and 1179.4 ml, respectively, had reached 94.0%, 14.9 cm, and 1323.9 ml, respectively, upon device removal. These values were well preserved at 1 year (90.4%, 15.8 cm, and 1461.3 ml, respectively). In conclusion, MCDO successfully enables both cranial expansion and correction of a flat forehead, constituting a valid treatment alternative for patients with bicoronal synostosis.

BACKGROUND: Previously, the authors developed a new method of distraction osteogenesis for the treatment of craniosynostosis, multidirectional cranial distraction osteogenesis (MCDO). The purpose of this study is to review the authors' experience of MCDO for remodeling of the anterior cranium in the patients of craniosynostosis. METHODS: Forty-five patients with craniosynostosis underwent MCDO for anterior cranial remodeling from 2003 to 2017. The ages of the patients ranged from 8 to 72 months (mean: 23.9 months, median: 13 months). The involved sutures included the bicoronal suture in 14 patients, unicoronal suture in 4 patients, sagittal suture in 14 patients, metopic suture in 2 patient, and multiple sutures in 10 patients. RESULTS: An improvement of in cranial shape was achieved in 40 patients. In 1 patient, intraoperative massive bleeding forced us finishing the procedure before completing the planned osteotomy. Transient cerebrospinal fluid leakage occurred in 3 patients during the activation phase but recovered with conservative therapy. The mean blood transfusion was 25.5 mL/kg. The phase of activation ranged from 7 to 17 days (mean, 10.6 days) and the consolidation period ranged from 16 to 67 days (mean, 32.4 days). Loosening of traction pins occurred in 7 patients, resulting in undercorrection in 2 patients, and loosening of anchor pins occurred in 19 patients, resulting in acceleration of removal of the devices in 7 patients. CONCLUSIONS: Multidirectional cranial distraction osteogenesis was effective and has several advantages over the conventional procedures. Therefore, the authors conclude that MCDO will be a useful alternative for all phenotypes of craniosynostosis.

BACKGROUND: Dermabond Advanced (DBA) has been widely used globally; however, severe contact dermatitis (CD) can be a serious adverse effect of DBA use. In this study, we investigated the characterization and incidence rate of CD after using DBA and the safe use of DBA. METHODS: One hundred consecutive patients who underwent skin closure with DBA were investigated. All patients were women undergoing breast reconstruction. DBA was applied to their trunk and limbs following reconstruction. RESULTS: Seven patients (7%) presented with CD. Of these, 4 patients exhibited CD after the second DBA use; sensitization influence by the first DBA use was considered. One of 3 patients presenting with CD after the first DBA use was allergic to cosmetic glue, and the influence of immunological cross-reaction of acrylates was suggested. CONCLUSION: We consider that DBA use is inadequate for wounds with an improper margin and in dry and low-skin barrier areas such as the trunk and limbs because it may induce irritant CD and sensitization of DBA and subsequent allergic CD. Frequent use can also induce sensitization. If patients have a history of acrylate allergies, DBA use should be avoided because immunological cross-reaction from acetylates could result.

BACKGROUND: Clinical sequelae of irradiation result in tissue devitalization (e.g., ischemia, fibrosis, and atrophy) where wound healing capacity is impaired. Fat-derived products may work to treat such pathology. METHODS: Nonlethal irradiation at various doses (5, 10, and 15 Gy) and frequencies (one to three times on sequential days) was delivered to dorsal skin of nude mice, and subsequent gross and microscopic changes were evaluated for up to 4 weeks. Cutaneous punch wounds were then created to compare wound healing in irradiated and nonirradiated states. Wounds were also locally injected with vehicle, cultured adipose-derived stem cells, centrifuged fat tissue, or micronized cellular adipose matrix, and the therapeutic impact was monitored for up to 15 days. RESULTS: Nude mice given total doses greater than 15 Gy spontaneously developed skin ulcers, and radiation damage was dose-dependent; however, a fractionated irradiation protocol was able to reduce the damage. Histologic assessment revealed dose-dependent dermal fibrosis/thickening and subcutaneous atrophy. Dose-dependent (5 to 15 Gy) impairment of wound healing was also evident. At the highest dosage (15 Gy three times), open wounds persisted on day 15. However, wounds injected with cultured adipose-derived stem cells were nearly healed on day 12, and those treated with injection of centrifuged fat or micronized tissue healed faster than untreated controls (p < 0.05). There was no significant differences between treated groups. CONCLUSIONS: Tissue devitalization by irradiation was dose-dependent, although fractionated protocols helped to reduce it. Adipose-derived stem cells and other fat-derived products harboring adipose-derived stem cells successfully revitalized irradiated tissues and accelerated wound healing.

Chronic changes following radiotherapy include alterations in tissue-resident stem cells and vasculatures, which can lead to impaired wound healing. In this study, novel recombinant human collagen peptide (rhCP) scaffolds were evaluated as a biomaterial carrier for cellular regenerative therapy. Human adipose-derived stem cells (hASCs) were successfully cultured on rhCP scaffolds. By hASC culture on rhCP, microarray assay indicated that expression of genes related to cell proliferation and extracellular matrix production was upregulated. Pathway analyses revealed that signaling pathways related to inflammatory suppression and cell growth promotion were activated as well as signaling pathways consistent with some growth factors including vascular endothelial growth factor, hepatocyte growth factor, and transforming growth factor beta, although gene expression of these growth factors was not upregulated. These findings suggest the rhCP scaffold showed similar biological actions to cytokines regulating cell growth and immunity. In subsequent impaired wound healing experiments using a locally irradiated (20 Gray) mouse, wound treatment with rhCP sponges combined with cultured hASCs and human umbilical vein endothelial cells accelerated wound closure compared with wounds treated with rhCP with hASCs alone, rhCP only, and control (dressing alone), with better healing observed according to this order. These results indicating the therapeutic value of rhCP scaffolds as a topical biomaterial dressing and a biocarrier of stem cells and vascular endothelial cells for regenerating therapies. The combination of rhCP and functional cells was suggested to be a potential tool for revitalizing stem cell-depleted conditions such as radiation tissue damage.

Tendon is a dense connective tissue that transmits high mechanical forces from skeletal muscle to bone. The transcription factor scleraxis (Scx) is a highly specific marker of both precursor and mature tendon cells (tenocytes). Mice lacking scx exhibit a specific and virtually complete loss of tendons during development. However, the functional contribution of Scx to wound healing in adult tendon has not yet been fully characterized. Here, using ScxGFP-tracking and loss-of-function systems, we show in an adult mouse model of Achilles tendon injury that paratenon cells, representing a stem cell antigen-1 (Sca-1)-positive and Scx-negative progenitor subpopulation, display Scx induction, migrate to the wound site, and produce extracellular matrix (ECM) to bridge the defect, whereas resident tenocytes exhibit a delayed response. Scx induction in the progenitors is initiated by transforming growth factor β (TGF-β) signaling. scx-deficient mice had migration of Sca-1-positive progenitor cell to the lesion site but impaired ECM assembly to bridge the defect. Mechanistically, scx-null progenitors displayed higher chondrogenic potential with up-regulation of SRY-box 9 (Sox9) coactivator PPAR-γ coactivator-1α (PGC-1α) in vitro, and knock-in analysis revealed that forced expression of full-length scx significantly inhibited Sox9 expression. Accordingly, scx-null wounds formed cartilage-like tissues that developed ectopic ossification. Our findings indicate a critical role of Scx in a progenitor-cell lineage in wound healing of adult mouse tendon. These progenitor cells could represent targets in strategies to facilitate tendon repair. We propose that this lineage-regulatory mechanism in tissue progenitors could apply to a broader set of tissues or biological systems in the body.

Tumoral calcinosis is a rare condition in which a calcified mass grows around a large joint, and can occur in patients undergoing renal dialysis. Here, we report the case of a 64-year-old man with a long history of dialysis who presented with a giant, painless mass in his right shoulder joint. A near-complete surgical resection is performed without muscle function loss and with no sign of recurrence after 1 year.

BACKGROUND: Fat grafting frequently requires multiple treatments and thus repeated liposuction to achieve treatment goals. The purpose of this study was to evaluate whether cryopreservation of adipose tissue may facilitate future fat grafting. METHODS: Lipoaspirates were harvested from six women and preserved using two cryopreservation methods: (1) simple cooling to -80°C (cryo-1); or (2) programmed cooling to -196°C (cryo-2). Fresh fat, cryo-1 fat, and cryo-2 fat were analyzed both in vitro and in vivo. RESULTS: Immunohistochemistry of both types of cryopreserved adipose tissue revealed that most adipocytes were necrotic. The cell number and viability of stromal vascular fraction cells were significantly decreased in cryo-1 fat (1.7 × 10 cells, 42.6 percent viable) and cryo-2 fat (2.0 × 10 cells, 55.4 percent viable), compared with fresh fat (3.9 × 10 cells, 90.6 percent viable). Although adipose-derived stem cells were cultured successfully from all fats, functional adipose-derived stem cells from cryopreserved fats were much fewer, with comparable multilineage differentiating capacity. In vivo studies using human fat grafted into immunocompromised mice revealed that, 3 months after transplantation, all of the cryopreserved fats maintained their volume to some extent; however, the cryopreserved fats were mostly filled with dead tissue and produced significantly lower engraftment scores than fresh fat. CONCLUSIONS: Most adipocytes were killed in the process of cryopreservation and thawing. Adipose-derived stem cells were isolated from cryopreserved fat, but the number of functional adipose-derived stem cells was very limited in both cryopreservation methods. After grafting, cryopreserved fat was retained as dead and fibrous tissue, suggesting a risk of clinical complications such as oil cysts.

BACKGROUND: The deep inferior epigastric perforator (DIEP) flap, which is a modification of the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap, is being more frequently used in an effort to reduce postoperative abdominal morbidity. However, there is no consensus as to which of these flaps is superior. The authors aimed to compare quantitative measurements of abdominal function obtained with an isokinetic dynamometer after DIEP and muscle-sparing free TRAM flap elevation. METHODS: Patients who underwent unilateral single-pedicled DIEP (n = 42) or muscle-sparing free TRAM flap (n = 36) breast reconstruction performed by a single surgeon were included in this study. Preoperative and postoperative trunk flexion parameters were measured prospectively using an isokinetic dynamometer in all patients. The occurrence of postoperative pain, stiffness, and bulging along with patient activity level were also investigated. RESULTS: At 3 months postoperatively, abdominal functions were decreased in both groups, with a larger decline in the muscle-sparing free TRAM flap group. However, at 6 months postoperatively, abdominal muscle function recovered to preoperative levels in both groups. These findings were consistent with the absence of a statistically significant difference in patient postoperative abdominal pain and stiffness, activity level, and the incidence of bulging between the two groups at 6 months postoperatively. CONCLUSION: From these results, we propose that the surgeon can select the muscle-sparing free TRAM flap, without hesitation or concern regarding abdominal morbidity, when a thick and reliable perforator does not exist and multiple thin perforators must be incorporated. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Patients with syndromic craniosynostosis often require a large amount of cranial expansion to avoid intracranial hypertension, but the surgical procedure remains controversial. A patient of severe syndromic craniosynostosis with multiple bony defects and anomalous venous drainage at the occipital region was treated by multidirectional cranial distraction osteogenesis (MCDO) at the age of 8 months. Distraction started 5 days after surgery and ceased on postoperative day 16. The distraction devices were removed 27 days after completing distraction. After device removal, the increase of intracranial volume was 155 ml and the cephalic index was improved from 115.5 to 100.5. The resultant cranial shape was well maintained with minimal relapse at postoperative 9 months. In cases of syndromic craniosynostosis with multiple bony defects and/or anomalous venous drainage at the occipital region, expansion of the anterior cranium by MCDO is a viable alternative to conventional methods.

BACKGROUND: Although the charting of normal intracranial volume (ICV) is fundamental for managing craniosynostosis, Asian norms in this regard are unknown. The purpose of this study was to establish a growth curve for ICVs in a large series of normal Asian children, providing reference values to guide corrective surgery. METHODS: A total of 124 normal children (male, 63; female, 61) and 41 children diagnosed with craniosynostoses were analyzed. Patients aged 0-8 years presenting to the emergency room and subjected to computed tomography (CT) for head trauma served as the reference cohort. Axial CT head scan data were obtained from radiographic archives at Jichi Medical University. Imaging was done on a Siemens CT scanner (5-mm slice thickness), using a DICOM viewer to measure ICVs. RESULTS: ICVs were plotted against age, and best-fit logarithmic curves for normal subjects were generated, without and with gender stratification. Male and female growth curves were similar in shape but diverged past the age of 1 year (male > female). ICVs of patients with craniosynostoses were plotted to male and female growth curves by disease subset, revealing the following: sagittal synostosis, near normal (or marginally larger); metopic synostosis, below normal; other non-syndromic synostoses (unilateral, bilateral, and lambdoidal) and Crouzon syndrome, near normal; Apert syndrome, above normal; and Pfeiffer syndrome, variable. CONCLUSION: ICVs of early childhood were investigated in Asian subjects, creating growth curves that set criteria for timing, planning and goalsetting in surgical correction of craniosynostosis.

BACKGROUND: The proximal ends of internal mammary (IM) vessels are now the most common recipient vessels for breast reconstruction. On the other hand, bilateral deep inferior epigastric artery perforator (DIEP) flaps are often needed according to the territory and the volume required for reconstruction. The usefulness of retrograde IM vessels as second recipients has recently been reported, but there are very few quantitative studies on the hydrodynamics of the retrograde IM vessels. Because the flow is dependent on the pressure differential, the blood pressures of the antegrade IM artery (AIMA), antegrade IM vein (AIMV), retrograde IM artery (RIMA), retrograde IM vein (RIMV), and recirculated intraflap vein (FV) were investigated to solve this question and to confirm the reliability and usefulness of the retrograde IM vessels. METHODS: Ten free flap breast reconstructions were included in this study. The IM vessels were exposed, and the pressures were measured. After recirculation, the FV pressures were measured when the flap was not ischemic or congestive. Systemic blood pressure was also recorded during the whole measurement period. RESULTS: The AIMA and RIMA pressures were 70.4 ± 8.2 mmHg and 54.0 ± 8.6 mmHg (p = 0.000003), respectively, while the systemic pressure was 65.1 ± 10.0 mmHg. The AIMV pressure was always smaller than the RIMV pressure; the mean AIMV pressure was 5.3 ± 1.6 mmHg. In addition, the FV pressure was greater (p = 0.03) than the RIMV pressure (17.7 ± 9.9 mmHg), while the RIMV pressure was 8.7 ± 2.0 mmHg. CONCLUSIONS: Both the RIMA and RIMV are useful and reliable as second recipients for bipedicled free flap transfers. This is a great benefit because it would provide two recipients in one surgical site and would be especially useful in thin patients or patients with previous abdominal scars requiring double pedicled DIEP flaps. LEVEL OF EVIDENCE: Therapeutic Study, Level IV.

BACKGROUND: Multidirectional cranial distraction osteogenesis (MCDO) is a procedure of ours developed earlier for treating craniosynostosis. However, the numerous bone flaps led to prolonged operative time and occasional bone detachment from dura. We have since simplified the osteotomy design. In treating sagittal synostosis, required bone flaps have been reduced to 11 (from ~20). METHODS: In a 2-year period (2014-2015), 5 boys with sagittal synostosis underwent MCDO using our simplified and fixed-form osteotomy. Mean age at surgery was 9.4 months (range, 8-11 months). Pre- and postoperative cranial morphology was assessed by cephalic index and by mid-sagittal vector analysis. RESULTS: Improved cranial shape was confirmed by 3-dimensional CT scans and by mid-sagittal vector index. Mean preoperative cephalic index (68.7) progressively increased to means of 78.5 immediately after distraction device removal, 75.2 at postoperative month 6, and 75.1 at 1 year postoperatively. There were no major complications, although transient cerebrospinal fluid leakage and loosening of anchor pins occurred in 1 patient. CONCLUSIONS: Simplified MCDO has a number of advantages over conventional distraction procedures such as discretionary reshaping/expansion of cranium and predictable osteogenesis and is a valid treatment option for patients with sagittal synostosis.

Anteromedial maxillectomy is typically performed in conjunction with low-dose radiotherapy and intraarterial chemotherapy. In doing so, the extent of surgical defects is reduced. However, nasal deviation and oral incompetence may ensue, due to cicatricial contracture of wounds, and may be distressing to these patients. Herein, we report a series of eight free perforator flap procedures (anterolateral thigh [ALT] flap, 6; thoracodorsal artery perforator [TAP] flap, 2) used to correct such deformities. The TAP flap was combined with scapular tip [ST] osseous flap in patients with added zygomatic prominence defects. Three adipocutaneous parts developed from each perforator flap were applied as follows: two to reconstruct nasal lining and oral vestibule, and one to augment cheek volume. All aesthetic results proved satisfactory, although orbital dystopia and contracture of mimic muscles were not resolved completely. These secondary interventions are suitable for sequelae of simple anteromedial maxillectomy. Immediate reconstruction should be considered if orbital floor and mimic muscles are involved.

For chronic wounds, the delivery of stem cells in spheroidal structures can enhance graft survival and stem cell potency. We describe an easy method for the 3D culture of adipose-derived stem/stromal cells (ASCs) to prepare a ready-to-use injectable. We transferred suspensions of monolayer-cultured ASCs to a syringe containing hyaluronic acid (HA) gel, and then incubated the syringe as a 3D culture vessel. Spheroids of cells formed after 12 h. We found that 6 × 106 ASCs/ml in 3% HA gel achieved the highest spheroid density with appropriate spheroid sizes (20-100 µm). Immunocytology revealed that the stem cell markers, NANOG, OCT3/4, SOX-2, and SSEA-3 were up-regulated in the ASC spheroids compared with those in nonadherent-dish spheroids or in monolayer cultured ASCs. In delayed wound healing mice models, diabetic ulcers treated with ASC spheroids demonstrated faster wound epithelialization with thicker dermis than those treated with vehicle alone or monolayer cultured ASCs. In irradiated skin ulcers in immunodeficient mice, ASC spheroids exhibited faster healing and outstanding angiogenic potential partly by direct differentiation into α-SMA+ pericytes. Our method of 3D in-syringe HA gel culture produced clinically relevant amounts of ready-to-inject human ASC microspheroids that exhibited superior stemness in vitro and therapeutic efficacy in pathological wound repair in vivo.

BACKGROUND: Keloids are a dermal fibroproliferative scar of unknown etiology. There is no good animal model for the study of keloids, which hinders the development and assessment of treatments for keloids. METHODS: Human keratinocytes and dermal fibroblasts were isolated from 3 human skin tissues: normal skin, white scars, and keloids. A mixed-cell slurry containing keratinocytes and dermal fibroblasts was poured into a double chamber implanted on the back of NOD/Shi-scid/IL-2Rγnull mice. After 12 weeks, the recipient mice had developed reconstituted human skin tissues on their backs. These were harvested for histological studies. RESULTS: Macroscopically, the reconstituted skins derived from both normal skin and white scars were similar to normal skin and white scars in humans, respectively. Keloid-derived reconstituted skins exhibited keloid-like hypertrophic nodules. Histological findings and immunohistochemical staining confirmed that the reconstituted skin tissues were of human origin and the keloid-derived reconstituted skin had the typical features of human keloids such as a hypertrophic dermal nodule, collagen type composition, orientation of collagen fibers, and versican expression. CONCLUSION: The mouse model with humanized keloid tissue presented here should be a useful tool for future keloid research.

BACKGROUND: There is no standard method to ensure survival of random-pattern skin flaps. The authors developed a rat anemia model to observe survival of random-pattern skin flaps after blood transfusion and hemodilution. METHODS: Anemia was induced by withdrawal of 35 percent blood volume followed by compensation with the same amount of blood (blood transfusion model) or plasma equivalent (normovolemic hemodilution). Control rats were subjected to a sham procedure. Subsequently, a random-pattern skin flap (1.5 × 6 cm) was elevated on the back of each rat. Physiologic assessments of flap vascularity/viability were performed using laser Doppler spectrophotometry before and after flap elevation. RESULTS: The normovolemic hemodilution group showed anemia (hemoglobin, 9.5 ± 0.8 g/dl) but less flow occlusion and greater flap survival (72.8 ± 8.6 percent) compared with control (57.4 ± 9.6 percent; p < 0.01) and blood transfusion (62.1 ± 6.5 percent; p < 0.089) groups. In control and blood transfusion groups but not the normovolemic hemodilution group, blood flow was decreased and relative quantity of hemoglobin was increased toward the flap tip, indicating congestion. In control and blood transfusion groups, blood flow and tissue oxygen saturation dropped after flap elevation, but recovered by day 7; congestion gradually improved by day 7. CONCLUSIONS: The authors determined that congestion promoted necrosis and hemodilution reduced microcirculatory occlusion and increased blood flow and oxygenation in skin flaps. It was suggested that perioperative hemodilution is superior to blood transfusion in any flap operations unless there is a critical systemic need for blood transfusion.

BACKGROUND: Condensation of grafted fat has been considered a key for achieving better outcomes after fat grafting. The authors investigated the therapeutic potential of two mechanical tissue micronizing procedures: squeeze and emulsification. METHODS: Human aspirated fat was centrifuged (centrifuged fat) and fragmented with an automated slicer (squeezed fat). Alternatively, centrifuged fat was emulsified by repeated transfer between two syringes through a small-hole connecter and then separated by mesh filtration into two portions: residual tissue of emulsified fat and filtrated fluid of emulsified fat. The four products were examined for cellular components. RESULTS: Histologic and electron microscopic analyses revealed that squeezed fat and residual tissue of emulsified fat contained broken adipocytes and fragmented capillaries. Compared with centrifuged fat, the squeezed fat and residual fat products exhibited increased specific gravity and increased numbers of adipose-derived stem/stromal cells and endothelial cells per volume, suggesting successful cell/tissue condensation in both squeezed fat and residual tissue of emulsified fat. Although cell number and viability in the stromal vascular fraction were well maintained in both squeezed fat and residual fat, stromal vascular fraction culture assay showed that adipose-derived stromal cells were relatively damaged in residual tissue of emulsified fat but not in squeezed fat. By contrast, no adipose-derived stromal cells were cultured from filtrated fluid of emulsified fat. CONCLUSIONS: The authors' results demonstrated that mechanical micronization is easily conducted as a minimal manipulation procedure, which can condense the tissue by selectively removing adipocytes without damaging key components, such as adipose-derived stromal cells and endothelial cells. Depending on the extent of adipocyte removal, the product may be a useful therapeutic tool for efficient tissue volumization or therapeutic revitalization/fertilization. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

BACKGROUND: Immediate autologous breast reconstruction after skin-sparing mastectomy is an esthetically superior method, and a free abdominal flap is often used. However, in Asian patients, little redundant abdominal skin and thin subcutaneous tissue are common, necessitating the development of a more suitable flap design and setting. We devised a narrow flap, the sombrero-shaped flap (S-flap), set vertically, to reduce postoperative abdominal morbidity without sacrificing cosmetic results. METHODS: To assess this new flap design and setting, the recipient- and donor-site complications of consecutive patients treated by S-flap (n = 40) and conventional flap (C-flap) (n = 22) were retrospectively investigated. Postoperative abdominal pain, stiffness, and patient activity were also assessed in each group with our original grading scale. RESULTS: Compared with the C-flap group, the S-flap group had a significantly lower skin paddle vertical height (mean, 14.0 and 10.2 cm, respectively; P < 0.001), lower abdominal stiffness (P = 0.023), and higher rate of double-pedicled flap use (27.3% and 52.5%, respectively; P < 0.048). The rates of donor and recipient site complications, postoperative abdominal pain, and activity did not significantly differ between the groups. CONCLUSIONS: For immediate breast reconstruction after skin-sparing mastectomy in Asian patients, our newly designed S-flap and vertical flap setting achieved cosmetically good, consistent results with low abdominal morbidity, even though the abdominal flap was thin and narrow. The viability of the S-flap, including medial fan-shaped adipose flap, was reliable, even though the flap often required elevation with double pedicles.

Serious lip injuries can occur during orthognathic surgery. Although an Angle Wider device, which is commonly used during orthognathic surgery, provides some lip protection, it leaves more than half of the lip exposed to surgical instruments. Here, we describe a novel technique to protect the entire upper and lower lips during orthognathic surgery using a minilaparotomy wound edge protector (Lap-Protector). We used this method in 60 patients who have undergone orthognathic surgeries such as sagittal split ramus osteotomy and Le Fort I osteotomy since 2009, and no lip injuries have occurred. Although this technique can be somewhat challenging at first and creates some difficulty in exposing the surgical field on the lateral side, we believe that using a wound edge protector minimizes the risk of lip injury during orthognathic surgery.

BACKGROUND AND AIM: The reduced incidence of donor site morbidity after deep inferior epigastric perforator (DIEP) flap is because the rectus muscle and its fascia are preserved. However, no study has proved that trunk flexion recovers not by the compensatory effect of the contralateral rectus muscle but by reinnervation of the ipsilateral rectus muscle. We hypothesized that if sufficient reinnervation occurs, patients who undergo single-pedicled DIEP (S-DIEP) flap or double-pedicled DIEP (D-DIEP) flap breast reconstruction would have similar levels of preoperative trunk flexion. To determine this, we investigated perioperative changes in trunk flexor muscle ability quantitatively using an isokinetic dynamometer in patients who had received S-DIEP or D-DIEP. METHODS: Patients who underwent breast reconstruction with S-DIEP (n = 37) and D-DIEP (n = 30) were included in this study. Pre- and postoperative trunk flexor muscle ability was measured prospectively by an isokinetic dynamometer in all patients. Postoperative abdominal pain and stiffness, patients' activity, and incidence of bulging were also investigated. RESULTS: Six months after surgery, the trunk flexor muscle ability recovered and did not significantly decrease subsequently in either group. This finding was consistent with the result that patients' activities and the incidence of bulging were similar between the two groups. CONCLUSIONS: Our results show that reinnervation of the rectus muscle can be confirmed at 6 months after DIEP flap elevation. Thus, we recommend D-DIEP flap without concern for abdominal wall weakness, especially in patients with multiple abdominal scars and who require breast tissue exceeding the amount of tissue that can be transferred with S-DIEP flap.

In this review, we discuss in detail our current procedure for treating craniosynostosis using multidirectional cranial distraction osteogenesis (MCDO). The MCDO method allows all phenotypes of skull deformity to be reshaped by distraction osteogenesis, except in patients who are 5 months of age or younger and patients with posterior cranial vault problems. We report the results of clinical data of 36 children with craniosynostosis who underwent MCDO between 2005 and 2014 in our institute. This method has the following benefits, such as a high flexibility of reshaping, shorter treatment period and less invasive secondary intervention. We also discuss the other distraction osteogenesis techniques that are used to treat craniosynostosis and compare them with MCDO. The preferred procedure for correction of craniosynostosis may depend on the patient's age, the extent of deformity, and the extent of correction achievable by surgery. We can arrange the combinations of various methods according to the advantage and disadvantage of each technique.

INTRODUCTION: Although deep inferior epigastric perforator (DIEP) flap is associated with decreased abdominal morbidity, motor nerve damage during flap elevation cannot be ignored. We compared abdominal morbidity after elevation of DIEP flap with lateral row perforators (L-DIEP) and medial row perforators (M-DIEP) to determine the perforators associated with less abdominal morbidity. METHODS: Women who underwent breast reconstruction with DIEP flaps (n = 49) were included in this study. Among them, M-DIEP and L-DIEP were harvested in 27 and 22 patients, respectively. Pre- and postoperative trunk flexor muscle ability (at 3 and 6 months after surgery) was measured prospectively in all patients using an isokinetic dynamometer. The patients were also investigated for postoperative pain, stiffness, activity, bulging, and lumbago. RESULTS: At 3 months after surgery, a significant decrease in trunk flexor muscle ability was observed in the patients of the L-DIEP group, but they recovered well after further 3 months. However, the recovery tended to be weak. Similar results were obtained with respect to pain, stiffness, activity, bulging, and lumbago between the two groups at 6 months after surgery. CONCLUSIONS: Dominant perforators for DIEP flap elevation should be chosen by considering flap viability. However, surgeons should be aware that elevation with L-DIEP is associated with a high risk of nerve injury, and may in turn result in short-term decreases in trunk flexor muscle ability. Therefore, precautionary methods should be taken by the surgeons to preserve the motor nerve with atraumatic dissection, especially during elevation with L-DIEP.

The natural mandible has 2 arcs, the marginal arc and the occlusal arc. The marginal arc is situated along the lower margin of the mandible and affects the contour of the lower third of the face. The occlusal arc is situated along the dental arc and affects the stability of prosthodontics. The gap between these 2 arcs widens in the molar area. Our developed concept of "double arc reconstruction" involves making these 2 arcs for the reconstructed mandible. For the double-barrel fibula reconstruction, 2 bone segments are used to make both arcs. For reconstructions using the iliac crest, the double arc is made by inclination of the top of the bone graft toward the lingual side. Ten patients underwent double arc reconstruction: 2 underwent reconstruction with the double-barrel fibula, and 8 underwent reconstruction with the iliac crest. Four patients had a removable denture prosthesis, 1 had an osseointegrated dental implant, and 5 did not require further prosthodontic treatment. The shape of the reconstructed mandible after double arc reconstruction resembles the native mandible, and masticatory function is good with the use of a dental implant or removable denture prosthesis, or even without prosthodontics.

BACKGROUND: In breast reconstruction, symmetry is a vital issue. However, when the original breast is unusually shaped or the patient desires augmentation at the time of reconstruction, obtaining symmetrical breasts becomes difficult. OBJECTIVES: The authors performed shaping of unaffected breasts by Brava-assisted autologous fat grafting to enhance breast symmetry, and evaluated the clinical results to validate this new approach. METHODS: Brava-assisted autologous fat grafting was performed to the unaffected breasts of 12 patients who had undergone unilateral breast reconstruction. The procedure was used for augmentation in six patients and to correct ptosis, volume, and tuberous breast deformity in three, two, and one patient, respectively. Clinical outcomes were assessed in all 12 patients. RESULTS: All patients could complete fat grafting within two sessions (one session in nine patients and two sessions in three patients). The mean volume of grafted fat per session was 211 cc in all patients. The mean retention rate of grafted fat was 58.9% in the 10 patients for whom the retention rate could be calculated using preoperative and postoperative magnetic resonance imaging (MRI). Postoperative MRI revealed small benign foci in two patients (16.7%), which were not palpable and did not become a clinical problem. A postoperative mammography revealed a small agglutinate calcification in one patient, which was determined to be benign through biopsy. CONCLUSIONS: Shaping the unaffected breast by autologous fat grafting combined with Brava is predictable, effective, and feasible as an aesthetic adjunct to unilateral breast reconstruction to achieve breast symmetry. LEVEL OF EVIDENCE: 4 Therapeutic.

The purpose of this study was to investigate the correlation between the oculocardiac reflex (OCR) and blepharoptosis surgery for safe eyelid surgery. Fifty-four consecutive patients with bilateral aponeurotic blepharoptosis were enrolled in this study. Changes in electrocardiography (ECG) monitoring were recorded during surgery. Preoperative pressing on the globe and intraoperative stretching of the levator aponeurosis were also carried out and the occurrence rate of the OCR was recorded. A positive OCR was observed in 12 patients (22.2%) in the preoperative globe-pressing test, whereas a positive OCR was observed in 22 patients (40.7%) in the levator-stretching test. The levator-stretching test did not indicate a significant difference in the rate of heart rate decrease with respect to laterality. No correlation was observed between age and the occurrence of OCR. On the other hand, there was a significant difference in the percentage of heart rate decrease between patients with positive OCR and negative OCR as determined in the globe-pressing test (mean = 13.1% vs. 5.4%). During the practical operative manoeuvre, no bradycardia was observed in any case. This study confirmed that a rapid and strong traction of levator aponeurosis induces the OCR regardless of laterality and age. Atraumatic and gentle handling are essential to prevent OCR. The preoperative globe-pressing test may be an index of the OCR in reflex-prone patients. Intraoperative ECG monitoring will be useful for early onset detection, although positive OCR was not observed in any patient during the practical surgical manoeuvre.

BACKGROUND: Although autologous fat grafting is widely accepted for breast reconstruction, its indications remain limited to minor contour deformities after reconstruction and small deformities after breast-conserving surgery. The authors describe a case series of total or nearly total breast reconstructions treated with the perioperative use of a vacuum-based external tissue expander (i.e., the Brava device) followed by autologous fat grafting. METHODS: The authors assessed the clinical outcomes and aesthetic results in six nonirradiated total mastectomy cases and eight severely deformed irradiated breast-conserving surgery cases. Total Brava wearing time and skin complications were also investigated. RESULTS: The number of fat grafting procedures required ranged from one to four, and the mean amount of fat grafted during each procedure was 256 cc (range, 150 to 400 cc). Postoperative fat lysis and cellulitis occurred in two cases (14.3 percent). Brava worked effectively for total mastectomy cases, and improvement in the total aesthetic score was significantly higher than that in the breast-conserving surgery cases. All patients wore the device for more than 8 hours/day. The most frequent skin complication was dermatitis [n = 11 (79 percent)], which occurred in all breast-conserving surgery cases. CONCLUSIONS: Brava was well tolerated by patients. Fat grafting with perioperative use of Brava is an alternative to total breast reconstruction in total mastectomy cases. However, for severely deformed breast-conserving surgery breasts treated with radiation therapy, the contracted skin was difficult to extend despite Brava use, and the results were less satisfactory. These cases also experienced a higher incidence of skin complications compared with the total mastectomy cases. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Numerous reports have demonstrated the usefulness of bioresorbable materials, but few have described severe complications caused by delayed degradation. The authors present the case of an intracranial foreign body granuloma caused by plates made of unsintered hydroxyapatite (uHA) particles and poly-l-lactide (PLLA; Super Fixsorb MX, Takiron) after cranioplasty. This 1-month-old boy presented to the authors' department with Pfeiffer syndrome. He had multiple-suture synostosis causing turribrachycephaly, Chiari malformation Type 1, and obstructive sleep apnea syndrome. At 6 months old, the child was treated with multidirectional cranial distraction osteogenesis. The uHA-PLLA plates were applied as base stones to reinforce the pins. After 16 days of distraction and 3 weeks of consolidation, the pins were removed. Seventeen months postoperatively, the plate on the right temporal bone showed passive intraosseous translocation (PIT), and by 2 years postoperatively, the plate was completely left behind in the cerebrum. At 3.5 years postoperatively, MRI disclosed a contrast-enhanced mass with surrounding brain edema at the site of the plate. The lesion was resected. The clinical history and histological specimens led to a diagnosis of foreign body granuloma surrounding the nonabsorbed resorbable plate in the dura mater. Resorbable plates are clearly useful resources in cases in which delayed absorption will not prove problematic, but careful application and follow-up is required when dealing with the growing skull given the possibility of intracranial displacement after PIT.

BACKGROUND: The authors have developed a new minimally invasive surgical procedure for simple zygoma fractures, a closed reduction and internal fixation method, that uses a cannulated cortical screw system. METHODS: From 2007 to 2012, 42 selected patients with simple zygoma fractures without ocular problems or shear at the zygomatic frontal portion were treated with this method. The mean age of the patients was 33 years (range, 13 to 77 years). RESULTS: The authors achieved good repositioning, equivalent to results achieved with conventional procedures in all cases. No notable complication occurred except for minor infection in two cases. Mean operative time was 32 minutes (range, 19 to 58 minutes). Postoperative relapse was found only in the posterior direction (p<0.001), but the distance of that was so small (mean, 0.47 mm) that it did not cause any problem clinically. CONCLUSIONS: Although further improvement might be needed, such as screw specification, the closed reduction and internal fixation method has many advantages: short operative time, less effect on soft tissue, maintenance of bone healing potential, and decreased postoperative pain and swelling. The authors concluded that this method has the potential to become a future surgical procedure for simple zygoma fractures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

BACKGROUND: Nonvascularized fat grafting has become one of the most popular options for breast contouring. However, the survival process of the grafts remains to be elucidated. In this study, we tracked the fate of nonvascularized fat grafts with in vivo bioluminescence and immunohistochemistry. METHODS: Nonvascularized fat grafts or vascularized adiposal flaps from luciferase transgenic rats were transplanted to Lewis rats. The bioluminescent signals from the grafts were monitored longitudinally. In addition, nonvascularized fat grafts from Lewis rats were engrafted to Lewis rats and the viability of the adipocytes in the grafts was evaluated with immunohistochemical staining for perilipin at postoperative week 1, 2, 3, 4, and 6. RESULTS: The bioluminescent signals from the nonvascularized fat grafts increased drastically from postoperative day 3 to 7, stayed flat from day 7 to 12, and declined from day 12 to 17, whereas those from the vascularized fat flaps remained throughout the entire postoperative period. Immunohistochemistry revealed that the survival zones with large adipocytes were decreased within 2 weeks and the regenerating zones with small adipocytes appeared after 3 weeks. CONCLUSIONS: Our study showed the process of survival and regeneration of nonvascularized fat grafts and suggested that graft-derived stromal cells proliferated within 7 days after transplantation and differentiated into adipocytes after postoperative week 3.

Reconstruction of soft-tissue defects on multiple fingers is challenging because the number of recipient vessels for free flaps is limited. We report the use of a free radial forearm flap with multiple perforator-based skin islands for the reconstruction of complex soft-tissue defects involving multiple fingers. The injuries were caused by a heat press. The flap was transferred, like "bunting," to the injured hand with an exteriorized pedicle. The technique presented here is advantageous because it simultaneously covers multiple defects and allows immediate hand therapy after the operation.

BACKGROUND: "Bare bone graft" with a vascularised iliac crest is a procedure involving no soft tissue for intraoral lining, and the intraoral defect is covered with epithelial cells through secondary healing of the exposed bone. METHODS: A vascularised iliac crest flap is transferred to a segmental mandibular defect intraorally in the position of the osteotomized stump upwardly. Granulation tissue is usually observed on the stump of the bone graft about 1 week after surgery. When sufficient granulation is observed after approximately 4 weeks, "resurfacing" is performed to prevent interference of hypergranulation tissue with epithelization. Resurfacing involves wiping the granulation tissue from the surface of the bone and covering with a plastic prosthesis fitted to the alveolus. RESULTS: A total of 11 patients underwent bare bone graft with a vascularised iliac crest. Resurfacing was performed at an average of 2.1 times for each patient. All wounds in the oral cavity were completely epithelialized from 2 weeks to 3 months after surgery. Complications with the recipient side occurred in four patients. CONCLUSIONS: Bare bone graft with the iliac crest is one favourable option for mandibular reconstruction utilising the particular shape of the bone without the attached soft tissue.

Mechanical forces influence homeostasis in virtually every tissue [1, 2]. Tendon, constantly exposed to variable mechanical force, is an excellent model in which to study the conversion of mechanical stimuli into a biochemical response [3-5]. Here we show in a mouse model of acute tendon injury and in vitro that physical forces regulate the release of active transforming growth factor (TGF)-β from the extracellular matrix (ECM). The quantity of active TGF-β detected in tissue exposed to various levels of tensile loading correlates directly with the extent of physical forces. At physiological levels, mechanical forces maintain, through TGF-β/Smad2/3-mediated signaling, the expression of Scleraxis (Scx), a transcription factor specific for tenocytes and their progenitors. The gradual and temporary loss of tensile loading causes reversible loss of Scx expression, whereas sudden interruption, such as in transection tendon injury, destabilizes the structural organization of the ECM and leads to excessive release of active TGF-β and massive tenocyte death, which can be prevented by the TGF-β type I receptor inhibitor SD208. Our findings demonstrate a critical role for mechanical force in adult tendon homeostasis. Furthermore, this mechanism could translate physical force into biochemical signals in a much broader variety of tissues or systems in the body.

The treatment of facial asymmetry is one of the most challenging activities in the field of facial plastic surgery. Asymmetry is caused from the following 3 factors which construct the "face", facial bone, soft tissue envelope, and muscle function. In order to obtain good symmetrical facial appearance, precise evaluation of theses 3 factors is required. Hemifacial microsomia, for instance, has both facial asymmetry and soft tissue deficiency, even muscle dysfunction in severe cases. The key for good outcome is as follows: 1. Consensus on the final goal should be obtained with the patient before starting the treatment. This is because minor asymmetry is getting clear as major facial asymmetry is improved. 2. Facial symmetry should be obtained at the level of facial appearance. In cases of facial bone deformity without soft tissue deficiency, the treatment plan will be created based on how much facial appearance is improved by correcting facial bone asymmetry.