Publications by authors named "Tanvaa Tansatit"

81 Publications

The Crest Injection Technique for Glabellar Line Correction and the Paracentral Artery.

Plast Reconstr Surg Glob Open 2021 Dec 8;9(12):e3982. Epub 2021 Dec 8.

Faculty of Medicine, Siam University, Bangkok, Thailand.

The glabella is a zone that carries a high risk of blindness after performing filler injections. The arteries beneath the glabellar lines were investigated by meticulous dissections in 30 geriatric embalmed cadavers with latex injections into the arterial system. The results showed that the supratrochlear artery, a direct branch of the ophthalmic artery, ascended from the muscular layer of the medial eyebrow along the medial canthal vertical line of the intercanthal vertical zone (53 in 60 hemifaces, or 88%). The dominant single paracentral artery from the radix artery was found within the radix vertical zone (eight out of 30 glabellae, or 27%). Among these, the dominant paracentral artery was near the midline in two cadavers and arose along the radix vertical line in six cadavers. The dominant paracentral artery may be the cause of ocular complications during injections of glabellar lines between the medial eyebrows, especially at the radix vertical lines. The supratrochlear artery might cause ocular complications when an injection is performed close to the medial eyebrows. Pinching to create a skin crest and evert glabellar line for a precise injection is recommended to temporarily occlude the paracentral artery.
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http://dx.doi.org/10.1097/GOX.0000000000003982DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8654445PMC
December 2021

Anatomical Study of the Dorsal Nasal Artery to Prevent Visual Complications during Dorsal Nasal Augmentation.

Plast Reconstr Surg Glob Open 2021 Nov 16;9(11):e3924. Epub 2021 Nov 16.

Faculty of Medicine, Siam University, Bangkok, Thailand.

Dorsal nasal augmentation is a common injection associated with ocular complications. Digital compressions on both sides of the nose are recommended during injection. Considering the reported incidences of visual complications, this preventive technique may need an adjustment for more effectiveness to prevent blindness. Therefore, the dorsal nasal arteries (DNAs) were studied by conventional dissections in the subcutaneous and fibromuscular tissues of the nasal dorsum in 60 embalmed cadavers. The results showed that among the 60 faces, 32 faces had bilateral DNAs (53.3%), 23 had dorsal nasal plexus with minute arteries (38.3%), and five had a single dominant DNA (8.3%). The DNA originated from one of the four arterial sources, which influenced the location and course of the artery. These sources included the ophthalmic angular arteries in 21 faces (56.8%), terminal ophthalmic arteries in two faces (5.4%), lateral nasal arteries in 11 faces (29.7%) and facial angular arteries in three faces (8.1%). Consequently, the dominant dorsal nasal artery running close to the midline found in 8% of the cases could make side compressions during nasal dorsum augmentation less effective from preventing ocular complications. However, an adjustment of digital compressions which combines pinching and side compressions is suggested to improve the safety.
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http://dx.doi.org/10.1097/GOX.0000000000003924DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8594662PMC
November 2021

A Cadaveric Study of Dye Spreading: Determining the Ideal Injection Pattern for Masseter Hypertrophy.

Dermatol Surg 2021 10;47(10):1354-1358

Division of Dermatology, Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.

Background: Masseter hypertrophy is the main cause of an asymmetrical and squared lower facial contour in the Asian community. Botulinum toxin injection technique is crucial to treat this condition.

Objective: To improve injection techniques for masseter hypertrophy by elucidating the distribution of the injections within the masseter.

Methods: Thirty masseter muscles were divided into 6 groups of 5 muscles each. Each group received one 0.2- or 0.3-mL injection at Point A, B, or C according to a three-point technique. Muscle dimensions and dye of the primary and secondary dye spreading were measured.

Results: The average muscle length, width, and thickness were 69.87, 33.50, and 11.23 mm, respectively. The average primary longitudinal and horizontal spreading was 36.56 and 15.60 mm, respectively. No statistically significant difference was found between 0.2- and 0.3-mL injections at each point.

Conclusion: The three-point technique best fits in the safe zone and should be the standard injection technique for masseter hypertrophy. Injection at Points B and C may create secondary spreading that affect the risorius muscle and the parotid gland which are the cause of asymmetrical smiling and xerostomia, respectively. The dosage should be adjusted according to the muscle volume and not only the thickness.
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http://dx.doi.org/10.1097/DSS.0000000000003171DOI Listing
October 2021

Achieving the Most Effective Hanging Points at the Lower End of the Face for Thread Lifting: Quantitative Measurement of Tissue Resistance in Different Facial Layers.

Plast Reconstr Surg Glob Open 2021 Jul 15;9(7):e3701. Epub 2021 Jul 15.

Department of Anatomy, Faculty of Medicine, and The Chula Soft Cadaver Surgical Training Center, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.

The thread lift procedure is a minimally invasive alternative to facelift surgery. The hanging point, which the terminal end of the thread is hooked into, is an important component. If it is loose and cannot stabilize the passage when the inserted thread is pulled, the lifting effect will fail. Therefore, the aim of this study was to elucidate the ability of the tissue to support the thread attachment in the different facial layers while performing this procedure. Twenty hemi-faces of 10 soft cadavers, which were divided into 45 blocks, were used to measure the tissue resistance in the midface area. The resistance of the soft tissue in the four facial layers in each block was measured while a 22G cannula connected with a force gauge was passed through it. The results showed that the tissue resistance in the sub-SMAS was higher than the SMAS and subcutaneous layers in the blocks located in the nasolabial and perioral regions. This was also significantly greater than the resistance in the subcutaneous layer in the three medial blocks below the oral commissure ( < 0.05). However, the low resistance of the sub-SMAS was found in the blocks located in the buccal and lower parotidomasseteric regions. Thus, it was preferable that the hanging point was based in the deep plane (sub-SMAS and SMAS layers) of the nasolabial, perioral, and upper parotidomasseteric regions. Moreover, the sub-SMAS layer within the buccal and lower parotidomasseteric regions should be avoided due to the loose attachment in the buccal capsule and subplatysmal fat.
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http://dx.doi.org/10.1097/GOX.0000000000003701DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8341254PMC
July 2021

The analgesic efficacy of anterior femoral cutaneous nerve block in combination with femoral triangle block in total knee arthroplasty: a randomized controlled trial.

Korean J Anesthesiol 2021 12 29;74(6):496-505. Epub 2021 Jun 29.

Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Background: Ultrasound-guided femoral triangle block (FTB) can provide motor-sparing anterior knee analgesia. However, it may not completely anesthetize the anterior femoral cutaneous nerve (AFCN). We hypothesized that an AFCN block (AFCNB) in combination with an FTB would decrease pain during movement in the immediate 12 h postoperative period compared with an FTB alone.

Methods: Eighty patients scheduled to undergo total knee arthroplasty were randomized to receive either FTB alone (FTB group) or AFCNB with FTB (AFCNB + FTB group) as part of the multimodal analgesic regimen. The primary outcome was pain during movement at 12 h postoperatively. Secondary outcomes included numeric rating scale (NRS) pain scores, incidence of surgical incision site pain, intravenous morphine consumption, immediate functional performance, patient satisfaction, and length of hospital stay.

Results: The NRS pain scores on movement 12 h postoperatively were significantly lower in the AFCNB + FTB group than in the FTB group (mean difference: -2.02, 95% CI: -3.14, -0.89, P < 0.001). The incidence of pain at the surgical incision site at 24 h postoperatively and morphine consumption within 48 h postoperatively were significantly lower (P < 0.001), and quadriceps muscle strength at 0° immediately after surgery was significantly greater in the AFCNB + FTB group (P = 0.04).

Conclusions: The addition of ultrasound-guided AFCNB to FTB provided more effective analgesia and decreased opioid requirement compared to FTB alone after total knee arthroplasty and may enhance immediate functional performance on the day of surgery.
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http://dx.doi.org/10.4097/kja.21120DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8648511PMC
December 2021

Commentary on: Deployment of the Ophthalmic and Facial Angiosomes in the Upper Nose Overlaying the Nasal Bones.

Aesthet Surg J 2021 11;41(12):NP1986-NP1988

Department of Anatomy, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

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http://dx.doi.org/10.1093/asj/sjaa397DOI Listing
November 2021

Commentary on: Safe Glabellar Wrinkle Correction With Soft Tissue Filler Using Doppler Ultrasound.

Aesthet Surg J 2021 08;41(9):1090-1093

Chakri Naruebodindra Medical Institute, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand.

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http://dx.doi.org/10.1093/asj/sjaa326DOI Listing
August 2021

Cadaveric Dissections to Determine Surface Landmarks Locating the Facial Artery for Filler Injections.

Aesthet Surg J 2021 05;41(6):NP550-NP558

Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand.

Background: The facial artery is a high-risk structure when performing filler injections at the nasolabial fold, buccal, and mandibular regions.

Objectives: This study aimed to establish reference landmarks locating the course of the facial artery and its essential branches.

Methods: Thirty-one embalmed cadavers were enrolled in this study. The course of the facial artery was observed in regard to the following reference points: masseter insertion, oral commissure, and common bony landmarks. The corner of the mouth was utilized as the landmark to measure the turning point of the facial artery.

Results: Seven points were established to identify the course and turning point of the facial artery. These included the anterior masseteric, lateral mental, infraorbital, medial canthal, basal alar, post-modiolar (PMP), and supra-commissural (SCP) points. The course of the facial artery deviates at least twice at the lateral mental points and at the SCP or PMP. The facial artery appeared more medially when the artery turned at the PMP and SCP. It presented through the lateral channel if the turning point was solely at the PMP. Wherever the facial artery deviates, it can be divided into 3 segments: the mandibular, buccal, and nasolabial segments. The arterial course may deviate laterally from the mouth corner towards PMP. The nasolabial segment may also deviate laterally to the basal alar point at the alar grove for 0.5 to 1 cm.

Conclusions: The deviation of facial artery closely relates with mandibular, buccal, and nasolabial segments. It is essential in avoiding arterial injury for physicians and surgeons who perform procedures in these areas.
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http://dx.doi.org/10.1093/asj/sjaa235DOI Listing
May 2021

Localization and Topography of the Arteries on the Middle Forehead Region for Eluding Complications Following Forehead Augmentation: Conventional Cadaveric Dissection and Ultrasonography Investigation.

J Craniofac Surg 2020 Oct;31(7):2029-2035

Department of Anatomy, Faculty of Medicine, and The Chula Soft Cadaver Surgical Training Center, Chulalongkorn University and King Chulalongkorn Memorial Hospital.

Forehead augmentation with filler injection is one of the most dangerous procedures associated with iatrogenic intravascular injection resulting in the severe complications. Nonetheless, few studies have determined the explicit arterial localization and topography related to the facial soft tissues and landmarks. Therefore, this study aimed to determine an arterial distribution and topography on the middle forehead region correlated with facial landmarks to grant an appropriate guideline for enhancing the safety of injection. Nineteen Thai embalmed cadavers were discovered with conventional dissection and 14 Thai healthy volunteers were investigated with ultrasonographic examination on the middle forehead. This study found that at the level of mid-frontal depression point, the transverse distance from the medial canthal vertical line to the superficial and deep branches of supraorbital artery were 9.1 mm and 15.1 mm, respectively. Whereas the depths from the skin of these arteries were 4.1 mm and 4.3 mm, respectively. Furthermore, the frontal branch of superficial temporal artery was detectable in 42.1% as an artery entering the forehead area. At the level of lateral canthal vertical line, the vertical distance of frontal branch was 31.6 mm, and the depth from skin of the artery was 2.7 mm. In conclusion, a proper injection technique could be performed based on an intensive arterial distribution and topography, and ultrasonographic examination before the injection is also suggested in order to restrict the opportunity of severe complications.
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http://dx.doi.org/10.1097/SCS.0000000000006644DOI Listing
October 2020

The Novel Costotransverse Foramen Block Technique: Distribution Characteristics of Injectate Compared with Erector Spinae Plane Block.

Pain Physician 2020 06;23(3):E305-E314

Department of Anatomy, Chulalongkorn University, Bongkok, Thailand.

Background: The costotransverse foramen (CTF) is a space continuous with the paravertebral space. We hypothesized that injections passing through the CTF will result in a successful injectate spread to the paravertebral space.

Objectives: We investigated patterns of dye spread to assess characteristics of neural blockade following ultrasound-guided CTF and erector spinae plane (ESP) injection in an anatomic and clinical study.

Study Design: Prospective cadaveric study, and case studies.

Setting: University hospital.

Methods: Six soft cadavers were studied. The boundaries of the CTF and the needle pathway of CTF injection were identified in the first cadaver. The CTF and ESP injections were performed on either the left or right sides of the T4 vertebral level in cadavers 2 to 6. Fifteen milliliters of 0.2% methylene blue was injected in each block, and the spread of dye was assessed by anatomic dissection. We also report 2 case studies of CTF and ESP blocks.

Results: Cadaver studies of CTF injection demonstrate that with injection to the inferior aspect of the base of the transverse process, the dye mainly passes anteriorly through the CTF into the paravertebral space, with minimal track-back to the deep back muscles. Consistent sensory blockade was achieved in 2 case studies. With the ESP injection, the spread of dye was observed cephalocaudad to the fascia of the erector spinae muscle, with no dye spreading within the paravertebral space in all cadavers.

Limitations: Prospective case series.

Conclusions: CTF block was consistently associated with a mainly anterior spread of injectate into the paravertebral space that involved the thoracic spinal nerves, and minimal posterior spread of injectate to the deep back muscles.

Key Words: Thoracic vertebrae, rib cage, paraspinal muscle, nerve block, joints.
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June 2020

Clinical implications of the arterial supplies and their anastomotic territories in the nasolabial region for avoiding arterial complications during soft tissue filler injection.

Clin Anat 2021 May 6;34(4):581-589. Epub 2020 Jul 6.

Department of Anatomy, Faculty of Medicine, and The Chula Soft Cadaver Surgical Training Center, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.

Introduction: The nasolabial fold (NLF) causes particular concern during aging in the middle face region. However, arterial complications of filler injections at this site have been continually reported during recent years. The aim of this study was to investigate the arterial locations and their anastomotic pathways related to filler injection sites in the NLF.

Materials And Methods: Thirty hemi-faces of 15 embalmed Thai cadavers were dissected. Three anatomical landmarks of NLFs were assigned: the inferior margin level (NLF1), the mid-philtral horizontal line level (NLF2), and the inferior alar level (NLF3). Ten hemi-faces of five soft embalmed Thai cadavers underwent a modified Sihler's staining procedure to investigate the arterial anastomoses.

Results: The artery closest to all of the landmarks was the facial artery. It was located inferomedial to NLF1 in 28%, and the mean distances along the X- and Y-axes were 3.53 ± 2.11 mm and 3.53 ± 1.75 mm, respectively. It was also located medial to NLF2 in 52.1% with an X-axis distance of 4.93 ± 1.53 mm. Several arteries were located close to NLF3, including the facial (33.3%), lateral nasal (33.3%), and infraorbital (30.0%) arteries. Anastomoses of the nasolabial arteries served to connect both the external-external and internal-external carotid systems.

Conclusions: Several arteries are located close to NLF1-NLF3. To prevent arterial injury, the locations and anastomotic pathways, as possible sources of severe complications, should be recognized prior to NLF filler injection.
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http://dx.doi.org/10.1002/ca.23617DOI Listing
May 2021

Three-Dimensional Evaluation of the Depressor Anguli Oris and Depressor Labii Inferioris for Botulinum Toxin Injections.

Aesthet Surg J 2021 05;41(6):NP456-NP461

Department of Oral Biology, Division in Anatomy and Developmental Biology, Human Identification Research Institute, BK21 PLUS Project, Yonsei University College of Dentistry, Seoul, South Korea.

Background: Botulinum toxin type A (BoNT-A) injection administered at an inappropriate site or depth can produce an unwanted change in facial animation because the depressor anguli oris (DAO) and depressor labii inferioris (DLI) muscles are partially overlapped. Therefore, simple BoNT-A injection guidelines, based on 3-dimensional (3D) facial anatomic references and landmarks, would be very useful.

Objectives: The aim of this study was to establish novel BoNT-A injection guidelines that include the soft tissue thickness at the lower perioral region. Data were acquired with a 3D scanning system combined with dissections in order to obtain accurate injection sites and depths for the DAO and DLI.

Methods: 3D scans of the facial skin, superficial fat, and facial muscle surface were performed in 45 embalmed cadavers. The thicknesses of the skin and subcutaneous layer were calculated automatically from superimposed images at each of 5 reference points (P) in the perioral region.

Results: In every case (100%), P3 and P5 were located in the DLI and DAO areas, respectively (45/45). Therefore, we defined P3 as the "DLI point" and P5 as the "DAO point." The soft tissue thicknesses at the DLI and DAO points were 6.4 [1.7] mm and 6.7 [1.8] mm, respectively.

Conclusions: The P3 and P5 described in this study are effective guidelines that only target the DLI and DAO. Clinicians, specifically, can easily use facial landmarks, such as the cheilion and pupil, to assign the DLI and DAO points without any measurement or palpation of the modiolus.
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http://dx.doi.org/10.1093/asj/sjaa083DOI Listing
May 2021

Translucent and Ultrasonographic Studies of the Inferior Labial Artery for Improvement of Filler Injection Techniques.

Plast Reconstr Surg Glob Open 2019 Sep 30;7(9):e2399. Epub 2019 Sep 30.

Department of Anatomy, Faculty of Medicine, and The Chula Soft Cadaver Surgical Training Center, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.

Lower lip augmentation by filler injection is an aesthetic procedure essential for achieving a feminine look and to enhance attractiveness. Complications as a result of injury to the inferior labial artery can result in undesirable outcomes.

Methods: The translucent technique was used to study the origin of the inferior labial artery in 11 cadavers. Ultrasonography of the inferior labial artery was also performed in 20 volunteers, which provided supplemental data to this study, in relation to establishing recommendations for filler injection.

Results: Five different types of inferior labial artery were described. These types were found in various combination patterns. Types 2, 4, and 5 are more vulnerable to arterial injury during filler injection. Ultrasonography revealed a depth of 6 mm and an arterial position at the vermillion border as the dangerous injection plane.

Conclusion: The origins and courses of the inferior labial artery are classified into 5 types. These types are often found in combination with each other in different faces, resulting in large anatomical variation between people. Types of combination influence severity of lower lip necrosis when arterial injury occurs. The physician should be aware of these anatomical variations during aesthetic treatments and reconstructive procedures to avoid the dangers of accidental arterial injury.
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http://dx.doi.org/10.1097/GOX.0000000000002399DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6908380PMC
September 2019

Implication of Location of the Ascending Mental Artery at the Chin Injection Point.

Plast Reconstr Surg 2020 01;145(1):51e-57e

From the Department of Anatomy, Faculty of Medicine, and the Chula Soft Cadaver Surgical Training Center, Chulalongkorn University and King Chulalongkorn Memorial Hospital; the Department of Basic Medical Science, Faculty of Medicine Vajira Hospital, Navamindradhiraj University; and the Department of Anatomy and Human Biology, University of Birmingham.

Background: Facial proportions can be improved by means of chin augmentation in patients with a receding chin. The ascending mental artery is the main arterial supply to the top of the chin, and arterial occlusion of this artery can result in soft-tissue infarction. This study aims to measure the topographic anatomy of the ascending mental artery at the chin injection area, using a three-dimensional camera.

Methods: Thirty-one embalmed cadaveric faces were dissected at the chin. The midline of the inferior margin of the mandibular protuberance was marked with a pin. A variation in size between the two opposite ascending mental arteries was noticed. The depth of the artery from the skin surface and distance from the midline were measured using a three-dimensional camera.

Results: There were 19 dominant ascending mental arteries on the right and 12 on the left. The dominant ascending mental arteries enter the chin paracentrally, approximately 6 mm (mean ± SD, 5.64 ± 4.34 mm) from the midline, within the muscular plane, and at a depth of 4.15 ± 1.95 mm from the skin. Furthermore, the artery formed an anastomosis with the sublingual artery, within the floor of the mouth.

Conclusion: Every aesthetic physician should recognize the course of the ascending mental artery and use the appropriate techniques to avoid vascular injury during chin augmentation using filler injections.
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http://dx.doi.org/10.1097/PRS.0000000000006394DOI Listing
January 2020

Anatomical and Ultrasonography-Based Investigation to Localize the Arteries on the Central Forehead Region During the Glabellar Augmentation Procedure.

Clin Anat 2020 Apr 21;33(3):370-382. Epub 2019 Nov 21.

Department of Anatomy, Faculty of Medicine, and The Chula Soft Cadaver Surgical Training Center, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.

Glabellar augmentation is one of the most popular cosmetic procedures but can entail severe complications caused by inadvertent intravascular injection of filler. Nevertheless, few studies have investigated the arteries on the glabellar and central forehead regions. The aim of this study was to correlate the topography and location of the arteries in this area with anatomical landmarks to propose a safety guideline. Two methods were used to investigate the glabellar and central forehead areas: dissection of 19 Thai embalmed cadavers, and ultrasonographic examination of 14 healthy Thai volunteers. At the level of the glabellar point, the horizontal distances from the midline to the arteries were 4.7 mm (central artery), 7.8 mm (paracentral artery), and 14.7 and 19.2 mm (superficial and deep branches of supratrochlear artery). The depths from the skin of the arteries were 3.1 mm (central artery), 4.8 mm (paracentral artery), and 4.2 and 5.9 mm (superficial and deep branches of supratrochlear artery). The periosteal artery was detected in 71.1% as a branch of either the superior orbitoglabellar or the supratrochlear artery. It ran in the supraperiosteal layer for a short course and penetrated the periosteum above the superciliary ridge or above the medial eyebrow, adhering tightly to the bony surface. This study suggests a safe injection technique for the glabella based on a thorough knowledge of arterial distribution and topography and color Doppler ultrasonographic examination prior to the injection, which is recommended to minimize the risk of severe complications. Clin. Anat. 33:370-382, 2020. © 2019 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ca.23516DOI Listing
April 2020

Three-Dimensional Territory and Depth of the Corrugator Supercilii: Application to Botulinum Neurotoxin Injection.

Clin Anat 2020 Jul 13;33(5):795-803. Epub 2019 Nov 13.

Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 PLUS Project, Yonsei University College of Dentistry, Seoul, South Korea.

This study aimed to determine the three-dimensional (3D) territory and depth of the corrugator supercilii muscle (CSM) using a 3D structured-light scanner. Thirty-two hemifaces from Korean and Thai embalmed cadavers were used in this study, and 35 healthy young Korean subjects also participated. A 3D analysis of the CSM territory and depth was performed using a structured-light 3D scanner. The most frequently observed locations of the CSM identified in the cadaver were confirmed in healthy young subjects using a real-time two-dimensional B-mode ultrasonography system. The CSM was present in all of the cadavers and healthy young subjects at the intersection point between the vertical line passing through the medial canthus and the horizontal line passing through the glabella (Point #6). The CSM was located on the medial side of the lateral limbus in most cases. The most-medial and most-lateral origin points were at depths of 5.7 ± 1.4 mm (mean ± SD) and 6.6 ± 1.4 mm, respectively; the corresponding depths of the insertion points were 5.4 ± 1.4 mm and 5.6 ± 2.1 mm, respectively. The origin and insertion points of the CSM were at similar depths. The injection depth should be around 4 mm for botulinum neurotoxin (BoNT) injections into the CSM. Point #6 could be regarded as an effective target point for managing the glabellar frown line and preventing palpebral ptosis when injecting BoNT into the CSM. Clin. Anat., 33:795-803, 2020. © 2019 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ca.23507DOI Listing
July 2020

A novel anatomical consideration on the exposed segment of the facial artery.

Clin Anat 2020 Mar 14;33(2):257-264. Epub 2019 Oct 14.

Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Center, BK21 PLUS Project, Yonsei University College of Dentistry, Seoul, South Korea.

An understanding of the location and depth of the facial artery (FA) is essential in aesthetic surgery and various cosmetic procedures. The purpose of this study was to clarify the three-dimensional (3D) topography of the exposed segment (ES) of the FA and to provide information to help minimize complications during clinical procedures. From 50 embalmed adult cadavers, the undissected and dissected hemifaces were scanned and reconstructed using the 3D scanner. Then the topographic location of the ES was identified and measured from the superimposed the 3D images. The ES was observed in 82% of the whole specimens. The exposure patterns of the ES were examined, and classified into three types: Type I, one site exposed pattern (74%); Type II, two sites exposed pattern (8%); and Type III, nonexposed pattern (18%). The extent of the ES was located at 2.2 mm above and 4.2 mm below the cheilion (Ch)-otobasion inferius line, and 20.0 to 25.2 mm from the Ch on the lateral aspect. In the frontal view, the average distance from the mid-pupillary line to the ES was 7.1 mm, and from the lateral canthal line to the ES was 6.1 mm. The ES was 7.6 mm below the skin surface. The results of this study will help to provide safe guidelines for filler injections as well as selecting the safe regions in various clinical procedures. Clin. Anat. 33:257-264, 2020. © 2019 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ca.23495DOI Listing
March 2020

Reply: The Feasibility Determination of Risky Severe Complications of Arterial Vasculature Regarding the Filler Injection Sites at the Tear Trough.

Plast Reconstr Surg 2019 10;144(4):710e-711e

Department of Anatomy, Faculty of Medicine, Chula Soft Cadaver Surgical Training Center, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.

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http://dx.doi.org/10.1097/PRS.0000000000006035DOI Listing
October 2019

Anatomical and ultrasound-based injections for sunken upper eyelid correction.

J Cosmet Dermatol 2020 Feb 21;19(2):346-352. Epub 2019 Jun 21.

Area88 Plastic Surgery Clinic, Seoul, Korea.

Background: A needle or a cannula can be safely used during filler injection procedures to correct a sunken upper eyelid. To date, there are no precise injection points recommended that are based on an anatomical study.

Objective: This study systematically investigated the vascular pattern and depth of forehead arteries at the periorbital area of upper eyelid.

Methods: Twenty cadavers were dissected in this study. Additional data were obtained from 30 healthy volunteers using Doppler ultrasound imaging with high-frequency probe.

Results: The ophthalmic artery divided into two opposite primary branches: the superior and inferior orbitoglabellar arteries running along the orbital rim. After the supratrochlear artery arose from the superior orbitoglabellar artery at the medial eyebrow, the supraorbital artery either divided from this artery near the supraorbital foramen or emerged as an individual artery from the supraorbital notch. The inferior orbitoglabellar artery gave off the radix artery superior to the medial canthal tendon. The radix artery divided into two opposite branches: the dorsal nasal artery going to the nose and the paracentral artery going to the glabella. Ultrasound imaging revealed a subcorrugator space that a cannula can safely pass through. At the supraorbital foramen/notch, the supraorbital artery traveled very close to the bone. Based on the anatomical data collected, the following injection points for a needle and a cannula technique are recommended.

Conclusion: Correction of a sunken upper eyelid is a dangerous procedure which should be performed only by experienced physicians. However, with precise anatomical knowledge and correct techniques, optimal outcomes can be safely achieved.
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http://dx.doi.org/10.1111/jocd.13049DOI Listing
February 2020

Ethnic differences in platysmal perforators and its relevance for the platysma myocutaneous flap.

J Plast Reconstr Aesthet Surg 2019 Aug 16;72(8):1272-1277. Epub 2019 May 16.

Department of Medical Education, Albany Medical College, Albany, NY, USA. Electronic address:

Background: Variable flap loss rates for the platysma myocutaneous flap have been reported for the Caucasian and the Asian population, which are 10.1% and 1.6%, respectively. This study was designed to investigate ethnic differences in the number and location of platysmal perforators that influence flap survival rates.

Methods: The number and location of platysmal perforators were investigated in a total of 60 platysma muscles: bilaterally in 20 Caucasian (13 males and 7 females) and 10 Asian (5 males and 5 females) specimens using cadaveric dissections. Adjustment for inter-individual variability in platysma length and width was performed by standardizing each x-value to mandibular length and each y-value to mandibulo-clavicular distance.

Results: A total of 64% of all detected platysmal perforators were found in the medial half of the muscle following the pathway of the external carotid artery. Individuals of Caucasian ethnicity had a mean number of 7.60 ± 2.0 perforators per side, whereas individuals of Asian ethnicity had a mean number of 13.05 ± 1.76 perforators per side (p < 0.001). Individuals of Asian ethnicity had a statistically significant increased number of platysmal perforators in the medial middle (2.95 ± 1.05 vs. 1.60 ± 1.08; p < 0.001) and lower (1.60 ± 1.35 vs. 0.73 ± 0.85; p = 0.003) regions of the platysma compared to those of Caucasian individuals.

Conclusion: A significantly higher number of platysmal perforators were identified in the investigated Asian population. This provides a potential explanatory model for the reported lower platysma myocutaneous flap loss rates in the Asian population than in the Caucasian population.
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http://dx.doi.org/10.1016/j.bjps.2019.05.001DOI Listing
August 2019

Optimal location of local anesthetic injection in the interspace between the popliteal artery and posterior capsule of the knee (iPACK) for posterior knee pain after total knee arthroplasty: an anatomical and clinical study.

Korean J Anesthesiol 2019 10 30;72(5):486-494. Epub 2019 Apr 30.

Department of Orthopedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Background: This study aimed to determine the optimal location of local anesthetic injection in the interspace between the popliteal artery and posterior capsule of the knee (iPACK), using the anatomical pattern of the articular branch of tibial nerve (ABTN). We hypothesized that injection at the level of ABTN forming a popliteal plexus would mainly spread throughout the popliteal fossa without contacting the tibial or peroneal nerves.

Methods: The anatomical study included 30 soft cadavers. Ultrasound-guided dye injection was performed in legs of 10 cadavers after identifying the position of the ABTN and surrounding structures, followed by dissection to assess its spread. Clinical study was conducted in 15 patients undergoing total knee arthroplasty (TKA) with ultrasound-guided injection in the iPACK. All patients also received continuous adductor canal block. Sensorimotor function of the tibial and common peroneal nerves was determined.

Results: In the distal portion of the popliteal fossa, the tibial nerve and popliteal vessels ran superficially and closely together. The trajectory of ABTN ran lateral to the popliteal vasculature, forming a plexus towards the posterior capsule of the knee below the medial side of the upper edge of lateral femoral condyle. In cadavers, the ABTN and surrounding area of the popliteal plexus were stained with dye after injection. In the clinical study, no patients experienced complete motor or sensory blocks.

Conclusions: We described a modified iPACK technique injection at the level of the ABTN forming the popliteal plexus, and it may constitute an optional anesthetic regimen to promote early ambulation following TKA.
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http://dx.doi.org/10.4097/kja.19060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6781212PMC
October 2019

Investigation of the presence and variation of the ascending mental artery: Conventional dissections and ultrasonographic study.

J Cosmet Dermatol 2019 Dec 28;18(6):1821-1829. Epub 2019 Mar 28.

Division of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.

Background: Tongue and mouth floor infarction following filler injections for chin augmentation is a rare complication that has the increase in incidence been reported.

Objective: This study investigated the arterial anastomosis between the submental and sublingual arteries that can lead to the emboli and subsequent tongue infarction during chin augmentation.

Methods: Forty-two formaldehyde-embalmed cadavers and four soft-embalmed cadavers were dissected to verify the incidence and source of the ascending mental artery. Ultrasonographic study of the artery was performed in 10 healthy volunteers. Attention was paid to discriminate whether the ascending mental artery arose from the submental artery or the sublingual artery using the arch of the mylohyoid muscle as the discriminating landmark.

Results: Incidence of ascending mental artery from the sublingual artery was 7.1% in the studied population. All ascending mental arteries were 0.7 ± 0.2 mm in diameter at the mental protuberance and were branches of the submental artery that arose from the facial artery, except for two arteries that arose from the sublingual artery. Ultrasonographic study revealed that one left and one right sublingual artery from the lingual arteries penetrated the mylohyoid muscle near the midline to become the ascending mental artery in two volunteers. The ascending mental artery from the other side continued from the submental artery.

Conclusion: Findings from the cadaveric dissections and ultrasonographic study revealed that the ascending mental artery may be a branch that continues from the lingual artery, or communicates with the sublingual artery through the mouth floor.
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http://dx.doi.org/10.1111/jocd.12928DOI Listing
December 2019

Regional thickness of facial skin and superficial fat: Application to the minimally invasive procedures.

Clin Anat 2019 Nov 12;32(8):1008-1018. Epub 2019 Mar 12.

Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Center, BK21 PLUS Project, Yonsei University College of Dentistry, Seoul, South Korea.

Various recently introduced minimally invasive treatment modalities are now widely used for enhancing the aging face. In a special, filler is used to increase the volume of tissue, and so understanding the regional thickness and distribution of the facial superficial fat is essential for optimizing minimally invasive procedures. The aim of this study was to establish the overall facial skin and superficial fat thicknesses using a three-dimensional (3D) scanning system. From 53 adult Korean and Thai embalmed adult cadavers, the undissected and serially-dissected facial specimens were scanned and reconstructed. The facial skin and superficial fat thicknesses on seven facial regions were calculated from the superimposed images. The facial skin tended to become thicker in the order of the radix and dorsum, and the temple, supraorbital, forehead, perioral, cheek, and infraorbital areas. The skin was thinnest at radix and dorsum (1.51 ± 0.55 mm), and thickest in infraorbital region (1.97 ± 0.84 mm). The facial superficial fat thickness tended to increase in the order of the radix and dorsum, supraorbital, forehead, temple, cheek, infraorbital, and perioral regions. The superficial fat was thinnest at the radix and dorsum (1.61 ± 1.07 mm), and thickest in the perioral region (5.14 ± 3.31 mm). The facial superficial fat thickness tended to increase in the order of the radix and dorsum, supraorbital, forehead, temple, cheek, infraorbital, and perioral regions. The present findings indicate that 3D scanning system can yield crucial anatomical information about depths of the facial skin and superficial fat layers for utilization in various clinical procedures. Clin. Anat. 32:1008-1018, 2019. © 2019 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ca.23331DOI Listing
November 2019

Locational Relationship between the Lateral Border of the Frontalis Muscle and the Superior Temporal Line.

Plast Reconstr Surg 2019 02;143(2):293e-298e

From the Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, Yonsei University College of Dentistry; and the Chula Soft Cadaver Surgical Training Center and Department of Anatomy, Faculty of Medicine, Chulalongkorn University.

Background: The frontalis is a representative target muscle for botulinum neurotoxin type A injections aimed at treating horizontal wrinkles in the forehead region. However, a lack of information regarding the shape and thickness of the frontalis may lead to unexpected side effects.

Methods: This study dissected hemifaces of 44 embalmed Korean and Thai cadavers and performed ultrasound examinations on 20 Korean volunteers. Two anatomical types were identified: (1) the lateral portion of the frontalis covered the superior temporal line in type I, and (2) the lateral border of the frontalis and the superior temporal line almost coincided in type II. A horizontal line was drawn laterally from the midpoint between the metopion and the glabella, and landmarks F1, F2, and F3 were defined as points where this horizontal reference line intersected with vertical lines from the midpoint of the pupil, the lateral canthus, and the lateral orbital rim, respectively.

Results: Type I was more common than type II [84 percent (37 of 44) versus 16 percent (seven of 44)]. When the lateral border of the frontalis ran along the border, there were no cases in which the superior temporal line was not visible. The mean minimum distance in type I was 10.53 mm. The muscle thicknesses at F1, F2, and F3 were 1.80 ± 0.44 mm (mean ± SD), 1.61 ± 0.37 mm, and 0.11 ± 0.04 mm, respectively.

Conclusions: This study yielded data on the location and thickness of the lateral border of the frontalis. An anatomical study-based, ultrasound-guided injection technique can achieve reliable results when noninvasive treatment is applied to the forehead area.
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http://dx.doi.org/10.1097/PRS.0000000000005202DOI Listing
February 2019

Classification of unusual insertion of the pectoralis minor muscle.

Surg Radiol Anat 2018 Dec 10;40(12):1357-1361. Epub 2018 Oct 10.

Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 PLUS Project, Yonsei University College of Dentistry, Seoul, 03722, South Korea.

Purpose: The pectoralis minor muscle (PMi) generally originates from the third, fourth, and fifth ribs and inserts on the medial and superior margins of the anterior portion of the coracoid process. Variations in the shape and attachment point of the PMi could cause discomfort in the shoulders. The aim of this study was to observe the types of morphological insertion patterns and attachment sites of the PMi.

Methods: Seventy-four sides of fresh, embalmed Korean (42 sides; mean age 78 years) and Thai (32 sides; mean age 78 years) cadavers were dissected to analyze the morphological insertion types and attachment sites of the PMi.

Results: Unusual insertion patterns were evident in about 23% of the samples. When the portion of the PMi tendon ran over the coracoid process, the most common attachment site was the glenohumeral joint capsule. We also confirmed the attachment of the PMi to the clavicle. Costal attachments of the PMi that extend from the second rib to the fourth rib were observed frequently as well.

Conclusions: Unusual insertion patterns of the PMi are common. Some authors consider that tendon attachment to the joint capsule can cause shoulder pain. In addition, the PMi tendon could be utilized in acromioclavicular joint reconstruction. Surgeons need to be aware of the possibility of a PMi variant being found during surgery even when this is not visible in magnetic resonance or ultrasound imaging.
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http://dx.doi.org/10.1007/s00276-018-2107-0DOI Listing
December 2018

Three-Dimensional Topography of the Emerging Point of the Ophthalmic Artery.

Plast Reconstr Surg 2019 01;143(1):32e-38e

From the Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, Yonsei University College of Dentistry; and the Chula Soft Cadaver Surgical Training Center and Department of Anatomy, Faculty of Medicine, Chulalongkorn University.

Background: During periorbital noninvasive and surgical procedures, there is the risk of iatrogenic injury to the emerging point of the ophthalmic artery. This study aimed to determine the three-dimensional location of the emerging point of the ophthalmic artery and to provide clinicians with anatomical information that would help them to avoid associated complications.

Methods: Seventeen hemifaces of the emerging point of the ophthalmic artery from 10 Korean and seven Thai cadavers were dissected and scanned by a three-dimensional scanner. The emerging points of the ophthalmic artery of 30 healthy Korean volunteers were also detected using an ultrasound imaging system.

Results: The transverse distance from the medial canthus to the emerging of the ophthalmic artery was 3.8 ± 1.0 mm medially, and the vertical distance was 14.0 ± 2.9 mm superiorly. The transverse distance from the midline was 16.5 ± 1.7 mm to the emerging point of the ophthalmic artery and 20.0 ± 2.0 mm to the medial canthus. The measured depth from the skin surface to the emerging point of the ophthalmic artery was 4.8 ± 1.7 mm by means of three-dimensional scanning and 4.5 ± 1.1 mm using ultrasound detection. The vertical distance from the inferior margin of the superior orbital rim to the emerging point of the ophthalmic artery was 5.3 ± 1.4 mm.

Conclusion: These data inform clinicians about the anatomical three-dimensional location of the emerging point of the ophthalmic artery, which will help them to avoid iatrogenic injury when they are performing periorbital clinical procedures.
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http://dx.doi.org/10.1097/PRS.0000000000005081DOI Listing
January 2019

Ultrasound evaluation of arterial anastomosis of the forehead.

J Cosmet Dermatol 2018 Dec 26;17(6):1031-1036. Epub 2018 Aug 26.

Area88 Plastic Surgery Clinic, Seoul, Korea.

Background: Color Doppler ultrasound has a potential role as an imaging guide in aiding filler injections which are blinded procedures.

Objective: This study investigated the forehead arteries and provided insight into their anastomoses. This was performed by challenging their function to provide blood through these anastomoses when the main artery was temporary occluded by compression.

Methods: Three arteries were identified on each side of the forehead, the supratrochlear, the supraorbital and the superficial temporal arteries. Under ultrasound monitoring, each target artery and corresponding anastomosis was studied separately by compressions performed in a sequential and accumulative manner.

Results: Data from the current study imply that accidental cannulation of either the supratrochlear artery or the supraorbital artery can cause ophthalmic artery embolization in every case recorded. If the frontal branch of the superficial temporal artery is cannulated, the chance of blindness as a complication occurs in one fifth of volunteers. Anastomosis between both sides of the terminal branches of ophthalmic arteries creates the possibility of bilateral ocular complications when accidental cannulation occurs at one of these branches, especially the supratrochlear artery. Thus, injury to the supratrochlear artery carries a greater risk of complication than the supraorbital artery.

Conclusion: These findings emphasize that the chance of ocular complication is less when accidental cannulation occurs at the superficial temporal artery compared with injury to the supratrochlear or the supraorbital arteries as the terminal branches of the ophthalmic artery. Ultrasound can assist in the identification and evaluation of all the arteries at risk, thus avoiding the occurrence of vascular complications.
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http://dx.doi.org/10.1111/jocd.12755DOI Listing
December 2018

The Feasibility Determination of Risky Severe Complications of Arterial Vasculature Regarding the Filler Injection Sites at the Tear Trough.

Plast Reconstr Surg 2018 11;142(5):1153-1163

From the Department of Anatomy, Faculty of Medicine, and the Chula Soft Cadaver Surgical Training Center, Chulalongkorn University and King Chulalongkorn Memorial Hospital; the Department of Basic Medical Science, Faculty of Medicine Vajira Hospital, Navamindradhiraj University; the College of Health Sciences, Christian University; and the School of Life Sciences, Faculty of Health and Life Sciences, University of Liverpool.

Background: The tear trough is a significant sign of periorbital aging and has usually been corrected with filler injection. However, the arterial supply surrounding the tear trough could be inadvertently injured during injection; therefore, this study aimed to evaluate the nearest arterial locations related to the tear trough and investigate the possibility of severe complications following filler injection.

Methods: Thirty hemifaces of 15 Thai embalmed cadavers were used in this study.

Results: The artery located closest to both the inferior margin (TT1) and mid-pupil level (TT2) of the tear trough was found to be the palpebral branch of the infraorbital artery. Furthermore, at 0.5 mm along the tear trough from the medial canthus (TT3), the angular artery was identified, which was found to be a branch of the ophthalmic artery. The artery at TT1 and TT2 was located beneath both the zygomaticus major and the orbicularis oculi muscles. The distances from TT1 to the artery were measured as follows: laterally, 2.79 ± 1.08 mm along the x axis; and inferiorly, 2.88 ± 1.57 mm along the y axis. For the TT2, the artery was located inferomedially from the landmark of 4.65 ± 1.83 mm along the x axis and 7.13 ± 3.99 mm along the y axis. However, the distance along the x axis at TT3 was located medially as 4.00 ± 2.37 mm.

Conclusion: The high risk of injury to the artery at the tear trough should be considered because of the numerous arteries to this area.
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http://dx.doi.org/10.1097/PRS.0000000000004893DOI Listing
November 2018

Topography of the dorsal nasal artery and its clinical implications for augmentation of the dorsum of the nose.

J Cosmet Dermatol 2018 Aug 29;17(4):637-642. Epub 2018 Jul 29.

Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Center, Yonsei University College of Dentistry, Seoul, South Korea.

Background: Injections of filler into the nose for dorsum augmentation have a higher risk of complications due to the complicated blood supply and anastomotic channels in this area.

Objectives: The aim of this study was to determine the anatomical features and location of the dorsal nasal artery (DNA), and to provide clinical anatomical information to reduce side effects and severe complications in the perinasal area.

Methods: Using the 31 cadaveric noses in Asians, dissections and histologic examinations were performed to identify the location and depth of the vascular structures including DNA.

Results: Dorsal nasal artery ran downward at 20.3 ± 3.5 mm from the intercanthal line and the communicating branch that connected the bilateral DNAs was located 8.5 ± 3.5 mm inferior to the intercanthal line. The DNA was located at 4.4 ± 3.2 mm, 4.6 ± 4.4 mm, and 5.2 ± 4.4 mm lateral to the midline of the nose on the intercanthal, quadrisected, and bisected lines, respectively. At the level of nasal bone, DNA was located superficial to the muscular layer and it runs inferolaterally on dorsum on nose. It was running more deeply and located beneath the fibromuscular layer at the cartilaginous portion of the dorsum of nose.

Conclusions: Injection into deep fatty layer may reduce the risk of arterial injury and the consequent complications. However, in a hooked nose, the tip of the needle traveling along the deep layer approaches the superficial layer due to the convexity of the hump as it passes over it, which can increase the probability of damaging the DNA.
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http://dx.doi.org/10.1111/jocd.12720DOI Listing
August 2018
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