BACKGROUND:Three-dimensional facial stereophotogrammetry, a convenient, noninvasive and highly reliable evaluation tool, has in recent years shown great potential in plastic surgery for preoperative planning and evaluating treatment efficacy. However, it requires manual identification of facial landmarks by trained evaluators to obtain anthropometric data, which takes much time and effort. Automatic 3D facial landmark localization has the potential to facilitate fast data acquisition and eliminate evaluator error. OBJECTIVES:The aim of this work was to describe a novel deep-learning method based on dimension transformation and key-point detection for automated 3D perioral landmark annotation. METHODS:After transforming a 3D facial model into 2D images, High-Resolution Network is implemented for key-point detection. The 2D coordinates of key points are then mapped back to the 3D model using mathematical methods to obtain the 3D landmark coordinates. This program was trained with 120 facial models and validated in 50 facial models. RESULTS:Our approach achieved a satisfactory mean [standard deviation] accuracy of 1.30 [0.68] mm error in landmark detection with a mean processing time of 5.2 [0.21] seconds per model. Subsequent analysis based on these landmarks showed mean errors of 0.87 [1.02] mm for linear measurements and 5.62° [6.61°] for angular measurements. CONCLUSIONS:This automated 3D perioral landmarking method could serve as an effective tool that enables fast and accurate anthropometric analysis of lip morphology for plastic surgery and aesthetic procedures.

Background The depressor anguli oris muscle (DAO) is a pivotal treatment target when creating a harmonic jawline. However, evidence of its live morphology remains scarce. Objectives In this study we aimed to reevaluate the DAO with a facile ultrasound analysis and thereby guide safer and more effective botulinum toxin type A (BTX-A) injection. Methods A prospective ultrasound assessment was conducted in 41 patients. Morphology of the DAO and its relative position to neighboring structures were appraised at the ubiquitous facial landmark, the labiomandibular fold (LMF). Three-dimensional images were captured before and after the patient received the BTX-A injection based on sonographic evidence. Results The skin-to-muscle depths of the DAO on average (measured from the medial to lateral border) were 5.26, 5.61, and 8.42 mm. The DAO becomes thinner and wider from zone 1 to zone 3 (P < .001). Overlapping lengths of the DAO and the depressor labii inferioris increased from zone 1 to zone 3: 4.74, 9.68, 14.54 mm (P < .001). The medial border of the DAO was located at 4.33, 6.12, 8.90 mm medial to the LMF (zone 1-3), and no muscle fibers of the DAO were observed in zone 1 or zone 2 in nearly one-third of patients. Improvement of the mouth corner downturn angle upon receiving BTX-A injection at zones 2 and 3 were 88.3%, 32.3%, and 14.7% for the neutral, maximum smile, and down-turning mouth corner expressions. Conclusions This work established an informative ultrasound portrait of the DAO and structures in the perioral region, which suggested the LMF as a convenient landmark for locating the DAO. Injection at the middle and lower thirds of the LMF at a 4- to 5-mm depth is recommended.

Background: Minimally invasive access and fast recovery are trends of gynecomastia surgery. We placed great importance on liposuction and modified original pull-through technique. The purpose of this study was to present a refined surgical strategy for gynecomastia in grade I and II. Methods: The refined strategy embraced enhanced liposuction to remove the intraglandular fat sufficiently, followed by open resection of gland using the pull-through and bottom-up technique with adjuvant liposuction in the end. Surgical data were recorded and satisfactory questionnaires with 5-point scales were administered during follow-up. Results: Between January 2017 and May 2022, 165 patients underwent enhanced liposuction combined with the pull-through and bottom-up technique for gland excision. Age ranged from 12 to 56 years. The median length of surgery was 100 min. A median of 300 ml of fat was aspirated and a median of 20.8 g of gland was excised. Seventy-seven patients (46.7%) responded the questionnaires at least 6 months postoperatively, and the average overall satisfaction was 4.68 +/- 0.52 points. Thirteen sides of breasts developed complications with a rate of 4.0%. Conclusion: Enhanced liposuction combined with pull-through and bottom-up technique proved effective to treat grade I and II gynecomastia with minimal scarring and high satisfaction. The refined strategy was simple and safe, and would obtain optimal outcomes even for inexperienced surgeons. (c) 2023 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

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

BackgroundThe lips are one crucial determinant of facial attractiveness. Current studies investigating lip attractiveness were mostly conducted in Caucasians, and the results could not directly apply to Asians. Aside from lip proportions, lip contours play an important role in attractiveness but it is unclear how people perceive different lip contours. The aim of this study was to investigate the aesthetic perception of various lip shapes by Chinese to identify the most attractive lip morphology for women and men, respectively.Methods303 Chinese participants were invited to rate the attractiveness of identical lip images with different contours and proportions in a young female and a young male. Stratified analyses were performed to assess the effect of gender, age and occupation on the preference of lip shapes.ResultsThe lips that were rated to be most attractive had a flat upper vermilion border, an M-shaped oral fissure and a U-shaped lower vermilion border in both genders. Most respondents considered an upper-to-lower vermilion proportion of 1:1 to be more attractive, regardless of the gender of the lip models, and the lip thickness-to-width proportions of 1:2 and 1:2.5 were perceived most attractive for female and male, respectively.ConclusionsThis study adds to our understanding of how lip contours contribute to attractiveness and that Chinese have distinctive aesthetic preferences for lip morphology, which possibly stem from racial characteristics and cultural differences. With such knowledge, practitioners may better tailor the treatment strategy when performing lip rejuvenation procedures.Level of Evidence IIIThis 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.

The efficient management of skin wounds for rapid and scarless healing represents a major clinical unmet need. Nonhealing skin wounds and undesired scar formation impair quality of life and result in high healthcare expenditure worldwide. The skin-colonizing microbiota contributes to maintaining an intact skin barrier in homeostasis, but it also participates in the pathogenesis of many skin disorders, including aberrant wound healing, in many respects. This review focuses on the composition of the skin microbiome in cutaneous wounds of different types (i.e. acute and chronic) and with different outcomes (i.e. nonhealing and hypertrophic scarring), mainly based on next-generation sequencing analyses; furthermore, we discuss the mechanistic insights into host-microbe and microbe-microbe interactions during wound healing. Finally, we highlight potential therapeutic strategies that target the skin microbiome to improve healing outcomes.

Level of Evidence V 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 .

Purpose Erythrodermic psoriasis (EP) is a severe form of psoriasis that affects multiple organs, including the cardiovascular system. However, few studies have focused on this condition.This study is aimed to assess the prevalence and factors associated with heart failure in EP patient, and to the measure the serum concentrations of fibroblast growth factor 23 (FGF23), a potential predictor of chronic heart failure. Methods We retrospectively studied patients with EP hospitalized at Peking Union Medical College Hospital between January 2005 to October 2021. The prevalence of heart failure and associated factors was measured. In addition, peripheral blood samples were collected from 17 patients and matched with samples from eight healthy controls, and their serum concentrations of FGF23 were measured by ELISA. Results We studied 225 patients with EP, with a male: female ratio of 2.7:1 and a mean age of 47.6 ± 16.7 years. Twenty-five (11.1%) participants were diagnosed with heart failure during their hospital stay. The patients with EP and heart failure were older (58.2 years vs. 46.2 years, p = 0.001); had a higher prevalence of a history of coronary heart disease (32.0% vs. 21.5%, p < 0.001), fever (48.0% vs. 23.0%, p = 0.007), infection (56.0% vs. 35.5%, p = 0.046); higher hsCRP concentration (43.2 mg/L vs. 8.2 mg/L, p = 0.005); and higher prevalence of anemia (60.0% vs. 22.0%, p < 0.001), hypoalbuminemia (64.0% vs. 42.0%, p = 0.037), and hyperlipidemia (40.0% vs. 20.0%, p = 0.023) than those without heart failure. The serum FGF23 concentration was significantly higher in patients with EP than controls (493.1 pg/ml vs. 277.8 pg/ml, p = 0.027), and was significantly lower after treatment (395.7 pg/ml vs. 463.1 pg/ml, p = 0.022). Conclusions Clinicians should be aware of the risk of heart failure in patients with EP, and especially those of advanced age and with a history of coronary heart disease, severe systemic symptoms, high concentrations of inflammatory biomarkers, and poor nutritional status.

Background Establishing facial anthropometric reference values is essential for diagnosis of deformity, assessment of aging, and planning for aesthetic and reconstructive treatment.Objectives This study aimed to provide detailed perioral anthropometric data in relation to sex and age in Chinese persons with a standardized 3-dimensional protocol.Methods Three-dimensional facial photographs were obtained of 60 male and 64 female healthy Chinese participants ages 20 to 35 and 50 to 65 years old, as well as 2 acromegaly patients, with the VECTRA 3D camera. A standardized evaluation was performed to locate 37 perioral landmarks and generate corresponding measurements, including 26 linear distances, 5 ratios, 2 curvatures, 4 areas, and 9 angles. Measurements of different age groups and of different genders were compared, as were measurements of healthy individuals with those of acromegaly patients.Results Sex discrepancy was noted in philtrum length, width, and area, lip width, and vermilion and cutaneous upper lip area; these were larger in Chinese males than females. However, vermilion heights were similar in both genders. With age, philtrum and cutaneous upper lip height and area, lip width, and angles related to cupid's bow significantly increased, whereas vermilion height and mouth corner angles decreased, and philtrum width, vermilion areas, and lip protrusion remained unchanged. Compared to healthy Chinese patients, acromegaly patients had a larger value for most measurements. Perioral rejuvenation based on detailed 3-dimensional anthropometry showed good results.Conclusions Chinese males have wider but not thicker lips than females, and aging features thin, flattened, and wide vermilions with a lengthened philtrum in both genders. These data can serve as a reference standard for disease diagnosis, aesthetic procedures, and reconstructive lip surgeries.

目的 观察中国人群的鼻背纹分型并探讨相应的精准化治疗策略.方法 回顾性分析自 2021年 7 月至 2022 年9月,于中国医学科学院北京协和医院整形美容外科治疗鼻背纹的 238 例患者,女性 201 例,男性 37 例.术前在标准拍摄条件下拍摄皱鼻照片,进行鼻背纹分型.选择 6 个常规注射点注射A型肉毒毒素,根据个体的分型调整注射点的注射剂量.术后 3～5 周进行随访,采用面部皱纹评分评估治疗效果以及有无并发症发生.结果 纳入患者中复合型 88 例(37.0%),横纹型 70 例(29.4%),斜纹型 52 例(21.8%),竖纹型 28 例(11.8%).面部皱纹评分:术前为(2.50±0.50)分,术后为(1.03±0.54)分,治疗前后评分差异具有统计学意义(P＜0.05).术后14例患者出现了淤青,9例患者出现微笑时唇部的轻微不对称,其他患者无其他严重并发症发生.结论 中国人的鼻背纹可分为复合型、横纹型、斜纹型以及竖纹型.精准化鼻背纹治疗策略具有良好的临床效果.

A Chinese woman in her late 20s presented with a 20-year history of progressive skin laxity. What is your diagnosis?

Three-dimensional (3D) stereophotogrammetry has been widely used in anthropometry for both medical and esthetic purposes. However, no studies have assessed its reliability on measuring the lower eyelid by 3D imaging. This study aimed to establish a standardized 3D anthropometric protocol for lower eyelid region and validate its reliability. Fifty-eight participants (116 eyes) were recruited with mean age of 39.14 ± 11.25 years. Two sets of VECTRA 3D images were taken for each subject, and each set of images was individually measured twice by two raters. Twenty-seven landmarks were identified in the lower eyelid region, and then 19 linear, 4 curvilinear, 7 angular and 2 areal metrics were assessed for intrarater, interrater and intramethod reliability. High reliability was found in this 3D imaging-based lower eyelid anthropometry. The mean absolute difference within 2 intrarater measurement were 0.22 and 0.08 units, the technical errors measurement were 0.31 and 0.15 units, the relative errors of measurement were 0.90 www.springer.com/00266 .

The non-invasive three-dimensional (3D) stereophotogrammetry is widely used in anthropometry for medical purpose. Yet, few studies have assessed its reliability on measuring the perioral region. This study aimed to provide a standardized 3D anthropometric protocol for the perioral region. 38 female and 12 male Asians were recruited (mean age 31.6 ± 9.6 years). Two sets of 3D images using the VECTRA 3D imaging system were acquired for each subject, and two measurement sessions for each image were performed independently by two raters. 25 landmarks were identified, and 28 linear, 2 curvilinear, 9 angular and 4 areal measurements were evaluated for intrarater, interrater, and intramethod reliability. Our results showed high reliability of 3D imaging-based perioral anthropometry by mean absolute difference (0.57 and 0.57 unit), technical error measurement (0.51 and 0.55 unit), relative error of measurement (2.18 www.springer.com/00266 .

Background: Erythrodermic psoriasis (EP) remains challenging to manage because it is rare and has complex complications. Although acitretin is recommended as an appropriate choice for EP, there is a lack of large-scale evidence. Objectives: This study aims to assess the efficacy and safety of acitretin as systemic monotherapy in EP patients. Design: We retrospectively analyzed data from patients with EP who received at least 3 months of acitretin as systemic monotherapy during hospitalization and out-patient follow-up from January 2005 to May 2021 at the Peking Union Medical College Hospital, China. Methods: The efficacy was clinically evaluated after 1, 2, 4, and 12 weeks of treatment, which was classified as a good response (>75% of lesions cleared), partial response (50%–75% cleared), moderate response (25–50% cleared), or no response (<25% cleared). Safety was assessed on the basis of physical examination results and significant changes in laboratory examination results after 12 weeks of treatment. Results: Overall, 81 patients (79.0% men; mean age, 47.9 years) were included. The acitretin dose ranged from 20 to 60 mg/day (0.3 to 0.8 mg/kg/day). The rates of good, partial, and moderate responses were 0.0%, 2.5%, and 42.0% at 1 week; 3.7%, 34.6%, and 61.7% at 2 weeks; 29.6%, 58.0%, and 12.4% at 4 weeks; and 85.2%, 13.6%, and 1.2% at 12 weeks after treatment initiation, respectively. EP patients transformed from psoriasis vulgaris showed a higher good/partial response rate compared with that of EP patients that developed from pustular or articular psoriasis (44.6% vs. 14.3%, p = 0.035). Patients with concurrent infection showed a lower rate of good/partial response compared with that of those without concurrent infection (16.7% vs. 44.4%, p = 0.049). Adverse effects were seen in 45 (55.6%) patients in 12 weeks, and dyslipidemia ( n = 31; 38.3%), xerosis ( n = 24; 29.6%), and elevated liver enzymes ( n = 6; 7.4%) were most commonly reported. Twenty-three patients were followed up for over 3 years, and six (26.1%) patients had EP recurrence. Conclusions: Acitretin as a systemic monotherapy showed satisfactory effectiveness for EP, especially in patients developed from psoriasis vulgaris and without infection.

Bullous pemphigoid is an autoimmune blistering disorder that primarily occurs in elderly patients. Reports indicate that BP coexists with various hematological diseases, including acquired hemophilia A, hypereosinophilic syndrome, aplastic anemia, autoimmune thrombocytopenia, and hematological malignancies. Early identification of these comorbidities contributes to a better control and reduced mortality. This article details the atypical clinical manifestations of BP when associated with hematological diseases, specific diagnostic strategies, underlying mechanistic connections, and possible treatments. Cross-reactivity between autoantibodies and exposed abnormal epitopes, shared cytokines and immune cells, together with genetic susceptibility are the most common connections between BP and hematological diseases. Patients were most often successfully treated with oral steroids combined with medications specifically targeting the hematological disorders. However, the individual comorbidities require specific considerations.

Bullous pemphigoid (BP) can be comorbid with a variety of immune diseases, such as immune skin diseases (psoriasis, vitiligo, alopecia areata and various other immune bullous diseases) , immune digestive diseases (inflammatory bowel disease, primary biliary cirrhosis) , autoimmune thyroid diseases, autoimmune rheumatic diseases (rheumatoid arthritis, dermatomyositis, scleroderma and systemic lupus erythematosus) , immune renal diseases (immune nephropathy, renal allograft rejection) and acquired hemophilia A. The above comorbidities markedly affect the quality of life of and treatment options for patients. This review elaborates on currently reported immune diseases associated with BP and their concomitant mechanisms.

Background Bullous pemphigoid (BP) is a senile chronic autoimmune bullous skin disease with a high relapse rate, which significantly impairs patients’ quality of life and contributes to disease mortality. This observational case-control study explores the gene polymorphisms of cytokines and their clinical significance in Chinese patients with BP. Methods IL-1α (rs1800587), IL-1β (rs16944, rs1143627, rs1143634), IL-4 (rs2243250), IL-6 (rs1800795), IL-10 (rs1800896, rs1800871, rs1800872), IL-13 (rs1800925, rs20541), TNF-α (rs1799964, rs1800630, rs1799724, rs361525), IFN-γ (rs1799964, rs1800630, rs361525, rs1800629, rs4248160, rs1800750), and TGF-β1 (rs2317130, rs1800469, rs4803457) genes were genotyped in the healthy controls and BP patients, respectively. Expression of these cytokines in serum was measured. Medical profiles of patients, including baseline characteristics and prognosis, were statistically analyzed. Results We found that IL-1 β and IL-13 concentrations were higher in the BP patients’ sera compared to those in the controls. For IL-13, significant differences were found in the nucleotide ratio/genotype/haploid frequency/haplotype, respectively. IL-13 (rs20541, rs1800925) is related to gender, and the IL-13 genotype was significantly associated with recurrence. Conclusions BP is associated with IL-13 gene polymorphism and IL-13 concentration is elevated in blood circulation in patients with BP. Our results support that IL-13 is relevant in the pathogenesis of BP, suggesting that IL-13 could potentially represent a promising target for BP therapy and a prognostic marker.

BackgroundType I interferonopathies are a group of rare autoimmune diseases characterised by excessive activation of type I interferon that leads to disturbances in immune function. Three prime repair exonuclease 1 (TREX1) is an important exonuclease and plays an important role in DNA damage repair. TREX1 mutations are associated with many type I interferonopathies. Studies have been published on the effectiveness of tofacitinib in the treatment of type I interferonopathies. The aim of this study is to identify the pathogenic variation in a Chinese family with type I interferonopathies and to observe the therapeutic effects of tofacitinib.MethodsA Chinese family with two members with type I interferonopathies was investigated. Whole exome sequencing and Sanger sequencing were applied for mutation screening using peripheral blood DNA of the patient and her family members. Sequencing results were analysed using bioinformatics software tools including VarCards and PolyPhen-2. Close clinical follow-up and observation were used to record changes in the disease before and after treatment with tofacitinib.ResultsCompound heterozygous variants of TREX1 were observed in the patient's genome. One was a missense variant (NM_016381; c.C227T; p.Ala76Val) from the patient's father, and the other was a frameshift variant (NM_016381; c.458dupA; p.Gln153Glnfs*3) from the patient's mother. One of the proband's elder brothers with similar skin lesions also carried these two variants. This brother of the proband had more serious cutaneous involvement with the comorbidity of cerebral palsy. These TREX1 variants have not been reported in previous studies and are predicted to be highly pathogenic. The proband was given tofacitinib that led to a marked improvement.ConclusionsWe identified two novel complex heterozygous variants in the TREX1 gene, which may underlie the molecular pathogenesis of the type I interferonopathies observed in members of this family. Tofacitinib could be an alternative treatment for this disease.

BACKGROUND:Acromicric dysplasia is a rare heritable short-stature syndrome with joint stiffness and varying degrees of cutaneous hardness. Stiff skin syndrome is a rare connective tissue disorder characterized by diffusely thick and hard skin from the time of birth. Heterozygous point mutations in the FBN1 have been proposed as the predominant cause of both diseases. METHODS:By performing skin biopsy, X-ray imaging, electrocardiography, as well as whole-genome sequencing and Sanger sequencing, we diagnosed an 8-year-old Chinese boy as acromicric dysplasia with severe skin stiffness caused by a heterogeneous mutation in the FBN1. RESULTS:The patient presented with skin tightness, wrist and ankle stiffness, short stature and limbs, several deformed joints in the extremities, cone-shaped epiphyses, and distinct facial features. He also had a patent foramen ovale and frequent respiratory infections. Skin biopsy showed thickened dermis and excessive collagen aggregation. Alcian blue staining indicated dermal mucopolysaccharide deposition. Mutation analysis revealed a heterozygous missense mutation, c.5243G>A (p.Cys1748Tyr), in exon 42 of the FBN1. CONCLUSION:This is a report about acromicric dysplasia with stiff skin syndrome-like severe cutaneous presentation caused by a single hotspot mutation, further revealing the gene pleiotropy of FBN1.