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As the use of closed incision negative pressure therapy (ciNPT) becomes more widespread, dressing designs have evolved to address implementation challenges and meet surgeon demand. While traditional application of ciNPT was limited to the immediate suture line, a novel dressing that covers the incision and additional surrounding tissues has become available. To expand upon previous ciNPT recommendations and provide guidance on this new dressing, an expert panel of plastic surgeons convened to review the current literature, identify challenges to the implementation and sustainability of ciNPT, and use a modified Delphi technique to form a consensus on the appropriate use of ciNPT with full-coverage dressings. After three rounds of collecting expert opinion via the Delphi method, consensus was reached if 80% of the panel agreed upon a statement. This manuscript establishes 10 consensus statements regarding when ciNPT with full-coverage foam dressings should be considered or recommended in the presence of patient or incision risk factors, effective therapeutic settings and duration, precautions for use, and tools and techniques to support application. The panel also discussed areas of interest for future study of ciNPT with full-coverage dressings. High-quality, controlled studies are needed to expand the understanding of the benefits of ciNPT over the incision and surrounding tissues.

BACKGROUND An increasing number of women are choosing to undergo contralateral prophylactic mastectomy with immediate bilateral breast reconstruction. Operating on the contralateral noncancer side is not without its own set of risks. We sought to compare complication rates between the cancerous and contralateral prophylactic breasts. METHODS A retrospective review was conducted of all patients undergoing immediate postmastectomy bilateral breast reconstruction for unilateral breast cancer between January 2008 and January 2019 at a single institution. Data were collected on patient demographics, cancer and adjuvant/neoadjuvant treatments, tumor, reconstruction, hospital stay, and complications. Complications were compared between the cancerous and the noncancerous breasts. RESULTS One hundred sixty patients met the inclusion criteria of this study. Of these 160 patients, 33 (20.6%) had complications (major and minor) only to the cancerous breast, 7 (4.4%) had complications only to the noncancerous breast, and 7 (4.4%) had bilateral complications. Most patients underwent tissue expander/implant reconstruction (93.8%) with the rest (6.2%) undergoing abdominally based flap or latissimus dorsi flap reconstruction. Patients with complications were more likely to have hypertension, diabetes, exposure to radiation, and neoadjuvant chemotherapy. Complications included wound dehiscence, hematoma, cellulitis, seroma, capsular contracture, infected implant, and skin necrosis. Overall, there were significantly more complications to the cancerous breasts than the noncancerous breasts (P < 0.001). In addition, although exposure to radiation to the affected side significantly increased the likelihood of complications to that side (P < 0.0001), patients who were not exposed to any radiation were also more likely to have complications to the cancer side than to the noncancer side (P = 0.00065). However, after controlling for the effects of radiation, there was no significant difference in complications between the cancer side and the prophylactic side when stratifying by specific complications. CONCLUSIONS Although contralateral prophylactic mastectomy with immediate bilateral reconstruction is not without added risk when compared with a unilateral procedure, this study shows that the incidence of complications to the noncancerous breast is less than that to the cancerous breast. This information can be used to help counsel patients with unilateral breast cancer on their treatment options and associated risks.

Background In this study we aimed to review the outcomes of nipple-sparing mastectomy (NSM) in the setting of expanded criteria: previous breast surgery/irradiation, neoadjuvant chemotherapy (NAC), post-NSM irradiation, and to assess conversion to acceptable criteria after NAC. Patients and Methods In this single-institution institutional review board-approved retrospective review, we identified patients who underwent NSM after previous breast intervention or NAC from January 2010 to February 2017. Clinicopathologic features, previous breast surgeries, response rate, complications, and recurrences were recorded. Results Sixty-three patients underwent 106 NSMs. Among 63 patients, 39 (61.9%) received NAC, 30 (47.6%) previous lumpectomy, 4 (6.3%) with cosmetic implants, 4 (6.3%) with mastopexy, 5 (7.9%) with previous radiation therapy, and 21 (33%) underwent post-NSM radiation therapy. Transient epidermolysis occurred in 24 patients (38.1%), with 16 patients (66.6%) having complete flap recovery and nipple loss in 8 patients (12.6%). All 10 patients with central disease on pre-NAC imaging converted to acceptable criteria, with 9 having successful NSM. At mean 67.2-month follow-up, 56 patients (88.9%) were disease-free, 5 (7.9%) experienced a systemic recurrence, and 2 (3.2%) a local recurrence. Conclusion NSM is oncologically acceptable in this patient cohort. Patients with large central tumors who undergo NAC should be reconsidered after completion of chemotherapy because many might convert to successful nipple-areolar preservation.

The use of sunscreen is essential for protection against photoaging and skin cancer. There is no global consensus on rating systems for sunscreens but it is essential to understand what makes a product broad-spectrum. In addition, physicians should have a general understanding that high-quality successful sunscreens should not only provide broad-spectrum ultraviolet A/B protection but should also be formulated so that they are easy to apply, are water resistant, and are photostable in order to increase user compliance.

Radiofrequency energy has a wide range of medical applications, including noninvasive treatment of wrinkles and body contouring. This technology works by differential heating of skin and soft tissue layers causing dermal remodeling or adipolysis, ultimately leading to observable effects. This article reviews the physics of radiofrequency as applied clinically.

Breast implants are frequently used for both cosmetic breast augmentation and breast reconstruction after mastectomy. Three companies currently offer FDA-approved breast implants (Allergan, Mentor, and Sientra), but their product offerings—including permanent breast implants, breast tissue expanders, sizers, and post-operative warranty—can be difficult to compare because of brand names and company-specific jargon. The ability to have a brand-agnostic understanding of all available options is important for both the surgical trainee as well as the surgeon in clinical practice. After a brief review of the history of breast implant devices, this review utilizes a unique conceptual framework based on variables such as fill material, shape, relative dimensions, and surface coating to facilitate a better understanding of the similarities and differences between the different company’s offerings. Specifically, we identify which types of devices are offered by all three companies, those that are offered by only one company, those that have very limited product offerings, and those combinations that are not available at all. Finally, clinical implications are drawn from this framework that can be used by both cosmetic and reconstructive surgeons to counsel patients about all available options. Importantly, this project is entirely independent of any company’s funding, support, or input. 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 .

As many as 40 % of breast cancer patients undergoing axillary lymph node dissection (ALND) and radiotherapy develop lymphedema. We report our experience performing lymphatic–venous anastomosis using the lymphatic microsurgical preventive healing approach (LYMPHA) at the time of ALND. This technique was described by Boccardo, Campisi in 2009. LYMPHA was offered to node-positive women with breast cancer requiring ALND. Afferent lymphatic vessels, identified by injection of blue dye in the ipsilateral arm, were sutured into a branch of the axillary vein distal to a competent valve. Follow-up was with pre- and postoperative lymphoscintigraphy, arm measurements, and (L-Dex®) bioimpedance spectroscopy. Over 26 months, 37 women underwent attempted LYMPHA, with successful completion in 27. Unsuccessful attempts were due to lack of a suitable vein (n = 3) and lymphatic (n = 5) or extensive axillary disease (n = 1). There were no LYMPHA-related complications. Mean follow-up time was 6 months (range 3–24 months). Among completed patients, 10 (37 %) had a body mass index of ≥30 kg/m2 (mean 27.9 ± 6.8 kg/m2, range 17.4–47.6 kg/m2), and 17 (63 %) received axillary radiotherapy. Excluding two patients with preoperative lymphedema and those with less than 3-month follow-up, the lymphedema rate was 3 (12.5 %) of 24 in successfully completed and 4 (50 %) of 8 in unsuccessfully treated patients. Our transient lymphedema rate in this high-risk cohort of patients was 12.5 %. Early data show that LYMPHA is feasible, safe, and effective for the primary prevention of breast cancer-related lymphedema.

BACKGROUND: Closure with dermal sutures is time consuming, may increase the risks of infl ammation and infection secondary to foreign body reaction, exposes the surgeon to possible needlestick injuries, and has variable cosmetic outcomes depending on each surgeon’s technique. The absorbable INSORB dermal stapler is hypothesized to be faster and more cost effective than sutures for dermal layer closures and provides a safer and more consistent result. METHODS: This is a prospective, randomized, controlled study. Patients undergoing bilateral breast reconstruction with tissue expanders had one incision randomized to dermal closure with absorbable dermal staples. The contralateral side was closed with dermal sutures. During the expansion period, wounds were assessed by a blinded plastic surgeon using the 13-point Vancouver Scar Scale. At the time of implant exchange, both scars were excised and examined for histologic signs of infl ammation. RESULTS: Eleven patients (22 incisions) were enrolled in the study. The dermal stapler was four times faster than standard suture closure, reducing closure time by 10.5 minutes (p

Although autogenous bone grafting remains the standard in the reconstruction of bone defects, disadvantages may include limited amount of bone and donor-site morbidity. Tissue engineering approaches can potentially obviate these problems. Fat contains a population of stem cells that can be isolated and differentiated into various cell lines, including osteocytes, adipocytes, and myocytes, depending on the culture conditions. In this study, the authors used osteogenically differentiated fat-derived stem cells to repair rat palatal bone defects.Fat-derived stem cells were isolated, differentiated into osteocytes in osteogenic medium, and seeded onto poly-L-lactic acid scaffolds. Rat palatal bone defects were surgically made and animals divided into four groups according to the type of implant for bone repair: group I, empty defect; group II, poly-L-lactic acid without cells; group III, poly-L-lactic acid with undifferentiated fat-derived stem cells; and group IV, poly-L-lactic acid with osteogenically differentiated fat-derived stem cells. Palates were harvested at 6 or 12 weeks after implantation (n = 8 per group at each time interval). Hematoxylin and eosin staining, immunohistochemical staining for osteocalcin, and histomorphometric measurements of new bone were performed.Defects in groups I, II, and III had no bone and were primarily filled with fibrous tissue. In contrast, there was substantial bone regeneration in group IV, which was statistically significant by histomorphometry compared with groups I, II, and III. Newly formed bone in group IV stained positive for osteocalcin.The authors successfully reconstructed palatal bone defects using absorbable three-dimensional scaffolds seeded with osteogenically differentiated fat-derived stem cells. This study demonstrates the feasibility of reconstructing bony defects with fat-derived stem cells.

Background: The treatment of diabetic wounds remains a difficult challenge. The present study investigates whether platelet-derived growth factor (PDGF) lentiviral gene therapy can improve diabetic wound healing in the diabetic db/db mouse. Methods: PDGFcDNA was cloned and lentiviral vectors were constructed with either the PDGF-B or green fluorescence protein (GFP) gene. A 2 X 2-cm full-thickness dermal wound was made on each db/db mouse. Animals were divided into three groups, with eight animals in each group as follows: group I, empty wound; group II, lentiviral PDGF; and group III, lentiviral GFP. Lentiviral vectors were injected into the wounds and healing was assessed at 21 days. Harvested wounds were assessed for residual epithelial gap, granulation tissue area, PDGF expression, collagen formation (picrosirius red), and angiogenesis (CD31 staining). Results: Lentiviral vectors were constructed and transfected dermal fibroblasts demonstrated in vitro production of PDGF mRNA as measured by reverse-transcriptase polymerase chain reaction. Immunohistochemistry for PDGF confirmed successful in vivo transfection of the PDGF gene. At 21 days, reepithelialization and granulation tissue area were similar in all groups. However, there was a statistically significant increase in angiogenesis and substantially thicker, more coherently aligned collagen fibers in the PDGF group compared with controls. Conclusions: PDGF lentiviral vectors were successfully transfected into the regenerated dermis in diabetic wounds. Although reepithelialization was similar among the groups, there was enhanced angiogenesis and collagen deposition in the lentiviral PDGF group. These results demonstrate that lentiviral PDGF transfection of the diabetic wound enhances PDGF production, improves vascularization and collagen organization, and has potential clinical applications in diabetic wound treatment.

The treatment of diabetic wounds is a considerable clinical challenge. In this study, mouse dermal fibroblasts retrovirally transduced with the human platelet-derived growth factor B (PDGF-B) gene were used to treat diabetic mouse wounds. The PDGF-B gene was obtained from human umbilical vein endothelial cells, cloned into retroviral vectors, and introduced into diabetic mouse C57B1/ks-db/db dermal fibroblasts. In vitro results demonstrated production of PDGF-B protein by these transduced cells at steady-state levels of 1000 ng PDGF-B/10(6) cells/24 hours, and expression of PDGF-B mRNA. These cells were seeded onto polyglycolic acid scaffold matrices and used to treat diabetic mouse 20-mm x 20-mm full-thickness excisional dorsal skin wounds. Measurement of the residual epithelial gap at 21 days showed significantly accelerated healing (P < 0.05) of wounds treated with PDGF-transduced cells (epithelial gap 10.46 +/- 1.20 mm) compared with untreated wounds (14.66 +/- 0.591 mm), wounds treated with polyglycolic acid alone (14.80 +/- 0.575 mm), or wounds treated with negative control LNCX-transduced cells (13.76 +/- 0.831 mm). Immunohistochemical staining showed intense staining for PDGF in wounds treated with PDGF-B-transduced cells. This study demonstrates the promising potential for gene therapy in diabetic wound healing.

Adipose tissue contains a population of pluripotent stem cells capable of differentiating along multiple mesenchymal cell lineages. In this study the authors isolated these fat-derived stem cells successfully from Lewis rats and induced differentiation along adipogenic and osteogenic lineages in vitro and in vivo. Induction was stimulated by exposing stem cells to lineage-specific induction factors. Adipocyte-inducing media contained dexamethasone, insulin, and isobutyl-methylxanthine. Osteoblast inducing media contained dexamethasone, beta-glycerophosphate, and ascorbic acid. Undifferentiated stem cells were maintained in minimal essential media alpha and fetal bovine serum. At 10 days, cells cultured in adipogenic media differentiated into adipocytes in vitro, as evidenced by positive Oil red O staining of lipid vacuoles. At 21 days, cells cultured in osteogenic media differentiated into osteoblasts in vitro as demonstrated by Alizarin red staining of a calcified extracellular matrix and immunohistochemical staining for osteocalcin. Differentiated cells were seeded at a density of 5 x 106 cells onto 15 x 15-mm polyglycolic acid grafts and implanted subcutaneously into three groups of Lewis rats: Group I contained undifferentiated stem cell grafts, group II contained adipocyte grafts, and group III contained osteoblast grafts. At weeks 4 and 8, in vivo fat formation was demonstrated in group II rats, as confirmed by Oil red O staining. At 8 weeks, group III rats demonstrated in vivo bone formation, as confirmed by the presence of osteocalcin on immunohistochemistry and the characteristic morphology of bone on hematoxylin-eosin staining. Group I rats demonstrated no in vivo bone or fat formation at either time interval. These results demonstrate the ability to isolate pluripotent stem cells from adipose tissue, to induce their differentiation into osteoblasts and adipocytes in vitro, and to form bone and fat subsequently in vivo. This is the first published report of in vivo bone formation from fat-derived stem cells. These cells may eventually serve as a readily available source of autologous stem cells for the engineering of bone and fat.

Provided are mammalian cells comprising a recombinant sonic hedgehog (SHH) gene such that a recombinant SHH protein can be expressed by the cell. Also provided are matrices suitable for applying to a tissue defect. Additionally provided are tissue regeneration compositions. Methods of regenerating tissue at the site of a tissue defect in a mammal are also provided.

Dermal lymphatic malformations are rare congenital hamartomas of superficial lymphatics characterized by high recurrence rates after excision. The standard therapy for a single lesion is surgical excision with wide margins, which reduces recurrence but can have a potentially unacceptable aesthetic outcome. A case of a 24-year-old woman with a 6 cm × 5 cm dermal lymphatic malformation on her right thigh, diagnosed by clinical history, physical examination, magnetic resonance imaging and pathological findings, is reported. The patient underwent wide local excision with split-thickness skin grafting. After pathological examination revealed negative margins, the patient underwent tissue expander placement and excision of the skin graft with primary closure. The lesion did not recur, and the patient achieved a satisfactory aesthetic result. The present case represents the first report of the use of tissue expanders to treat dermal lymphatic malformations in the lower extremity and demonstrates a safe, staged approach to successful treatment.

Sternal wound infections following pediatric open-heart procedures occur infrequently. Four of our last 600 consecutive pediatric open-heart median sternotomies (1991 to 1996) required muscle flap reconstruction for treatment of deeply infected sternotomy wounds. Risk factors included multiple sternotomies, previous superficial infection, and immunocompromised states. Two patients were closed with bilateral pectoralis muscle flaps. The 2 other patients were closed with vertical rectus abdominis muscle flaps; 1 including an attached skin paddle. While the pectoralis major muscle flap is the first flap of choice utilized in adult patients, in pediatric patients a different hierarchy of flap selection is often necessary. The chest wall often has multiple scars from previous procedures, limiting use of the pectoralis muscle. In small infants the pectoralis muscle can be thin and inadequate for large sternal defects. All patients achieved healed wounds. Muscle flap reconstruction of pediatric sternal wounds can be an effective one-stage treatment for deep sternal wound infections with sternal instability.

A 71-year-old woman, one year following a fleur-de-lis abdominoplasty and incisional hernia repair, presented with two chronic, draining peri-umbilical sinuses. Her immediate postoperative course was complicated by a superficial surgical site infection with central skin breakdown that was treated with vacuum assisted closure (VAC). After the wound had closed completely, two midline sinus tracts developed. A CT scan demonstrated an 8x3x1.6cm thick-walled collection along the anterior abdominal wall containing numerous air bubbles. Surgical debridement revealed a cavity containing an 8x3x1.6cm block of well incorporated VAC foam. With the increasing clinical use of VAC wound therapy, this image serves as an important reminder to include gossypiboma in the differential diagnosis for patients with chronic wound problems who have previously received VAC treatment.

Acromioclavicular (AC) joint cysts are an uncommon presentation of full-thickness rotator cuff tears. It is important to understand the relationship between AC joint cysts and rotator cuff tears because there is a high recurrence rate if the cyst is treated without addressing the rotator cuff tear. We present a case of a patient with a very large AC joint cyst associated with a significant softtissue deformity, a large full-thickness rotator cuff tear, and AC joint degeneration. We present this case because the pathology required a unique approach to the shoulder to manage the large soft-tissue mass.

Background: In the United States, the inferior pedicle Wise pattern technique of reduction mammaplasty has been well established as a safe and reliable method of reducing breast size while maintaining nipple-areolar vascularity and sensation. Nonetheless, the typical inverted-T scar of the Wise pattern reduction is a consistent source of patient and surgeon dissatisfaction with the operation, which has led to the increased popularity of limited-incision techniques of breast reduction. Objective: In this study, it was our goal to evaluate patient preferences for breast reduction scar location. Methods: A retrospective chart review was undertaken that identified 121 patients who underwent bilateral Wise pattern reduction mammaplasty between July 1999 and June 2004. The patients were asked to rate their satisfaction with the surgery on a 1 to 10 scale and to rate the extent, if any, to which they were bothered by their scars. Those patients who were bothered by their scars were asked to delineate which part of the scar bothered them most—the horizontal component, the vertical component, or the areolar component. A statistical analysis of the results was performed with a standard two-tailed t test and a χ2 analysis. Results: Of the 121 surveys mailed out, 27 surveys were undeliverable. Fifty-seven of the remaining 94 surveys were returned, for a response rate of 61%. Although 49 of the respondents (86%) were highly satisfied with their surgery, 37 patients (65%) indicated dissatisfaction with their scars. Forty-one patients (72%) responded to the question asking which of the scars was most bothersome. Of these 41 respondents, 10 were bothered by all scars equally. Among the remaining 31 patients, 20 (65%) indicated that the horizontal component bothered them most—a statistically significant proportion ( P < .001). Twenty-three of 46 patients (50%) who responded to the questions asking which scar they would erase if they were able to do so indicated that they would erase the vertical scar, which was also statistically significant ( P < .001). Conclusions: Our survey confirms the widespread satisfaction reported by patients who have undergone Wise pattern breast reduction surgery. However, it also demonstrates that a statistically significant number of patients are bothered by their scars. These results underscore the importance of developing techniques that minimize breast reduction scars and suggest that short-scar options would be welcomed by women considering breast reduction surgery.

Advanced glycation end products (AGEs) accumulate in diabetic wounds as a result of the glycosylation of various proteins. Interaction of AGEs with the receptor for AGEs (RAGE) results in an exaggerated inflammatory response and compromised collagen production. These changes lead to impaired wound healing. A soluble form of RAGE (sRAGE) has been shown to bind AGEs and thereby blunt their pathogenetic effects. Using genetically diabetic C57BLks-db/db mice, the authors applied sRAGE topically to standardized full-thickness wounds to improve diabetic wound healing. They measured various parameters of wound healing such as neovascularization, reepithelialization, collagen formation, and granulation tissue area. Their results showed a statistically significant increase in granulation tissue area and microvascular density in the sRAGE group compared with untreated wounds. There was a trend toward a smaller epithelial gap in the sRAGE-treated group that did not reach statistical significance. The authors conclude that sRAGE may be a powerful treatment of accelerating diabetic wound healing.

The healing of ischemic wounds is a particularly difficult clinical challenge. In this study, rabbit dermal fibroblasts transduced retrovirally with human platelet-derived growth factor B (PDGF-B) and human vascular endothelial growth factor 121 (VEGF121) genes were used to treat wounds in a rabbit ischemic ear model. The PDGF-B and VEGF121 genes were obtained from human umbilical vein endothelial cells (HUVECs) by reverse transcription-polymerase chain reaction, cloned into retroviral vectors under control of the beta-actin promoter, and introduced into primary rabbit dermal fibroblast cells. In vitro results demonstrated that rabbit dermal fibroblasts are transduced and selected readily using retroviral vectors, and are engineered to secrete PDGF-B and VEGF121 at steady-state levels of 150 ng per 10(6) cells per 24 hours and 230 ng per 10(6) cells per 24 hours respectively. These cells were then seeded onto polyglycolic acid (PGA) scaffold matrices and used to treat ischemic rabbit ear wounds. Immunohistochemistry showed intense staining for PDGF-B and VEGF121 in the wounds treated with these transduced cells compared with the control treatment groups. For the relatively more ischemic distal ear wounds, granulation tissue deposition was increased significantly in the wounds treated with PDGF-B- and VEGF121-transduced cells compared with wounds treated with PGA alone. These results demonstrate that gene augmentation of rabbit dermal fibroblasts with the PDGF-B and VEGF121 genes introduced into this ischemic wound model via PGA matrices modulates wound healing, and may have clinical potential in the treatment of ischemic wounds.

Periosteum has been demonstrated to have cell populations, including chondroprogenitor and osteoprogenitor cells, that can form both cartilage and bone under appropriate conditions. In the present study, periosteum was harvested, expanded in cell culture, and used to repair critical size calvarial defects in a rabbit model. Periosteum was isolated from New Zealand White rabbits, grown in cell culture, labeled with the thymidine analog bromodeoxyuridine for later localization, and seeded into resorbable polyglycolic acid scaffold matrices. Thirty adult New Zealand White rabbits were divided into groups, and a single 15-mm diameter full-thickness calvarial defect was made in each animal. In group I, defects were repaired using resorbable polyglycolic acid implants seeded with periosteal cells. In group II, defects were repaired using untreated polyglycolic acid implants. In group III, the defects were left unrepaired. Rabbits were killed at 4 and 12 weeks postoperatively. Defect sites were then studied histologically, biochemically, and radiographically. In vitro analysis of the cultured periosteal cells indicated an osteoblastic phenotype, with production of osteocalcin upon 1,25(OH)2 vitamin D3 induction. In vivo results at 4 weeks showed islands of bone in the defects repaired with polyglycolic acid implants with periosteal cells (group I), whereas the defects repaired with untreated polyglycolic acid implants (group II) were filled with fibrous tissue. Collagen content was significantly increased in group I compared with group II (2.90 +/- 0.80 microg/mg dry weight versus 0.08 +/- 0.11 microg/mg dry weight, p < 0.006), as was the ash weight (0.58 +/- 0.11 mg/mg dry weight versus 0.35 +/- 0.06 mg/mg dry weight, p < 0.015). At 12 weeks there were large amounts of bone in group I, whereas there were scattered islands of bone in groups II and III. Radiodensitometry demonstrated significantly increased radiodensity of the defect sites in group I, compared with groups II and III (0.740 +/- 0.250 OD/mm2 versus 0.404 +/- 0.100 OD/mm2 and 0.266 +/- 0.150 OD/mm2, respectively, p < 0.05). Bromodeoxyuridine label, as detected by immunofluorescence, was identified in the newly formed bone in group I at both 4 and 12 weeks, confirming the contribution of the cultured periosteal cells to this bone formation. This study thus demonstrates a tissue-engineering approach to the repair of bone defects, which may have clinical applications in craniofacial and orthopedic surgery.