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1.
Journal of Sun Yat-sen University(Medical Sciences) ; (6): 343-350, 2019.
Article in Chinese | WPRIM | ID: wpr-817783

ABSTRACT

@#【Abstract】 【Objective】To investigate the differential expression of long non-coding RNA-1708(lncRNA-1708)in osteogenic differentiation of human bone marrow mesenchymal stem cells(hBMSC)and its effect on osteogenic differentiation of hBMSC.【Methods】Purchased 3 groups of hBMSC from different sources and cultured in vitro. qRT-PCR was used to detect the expression of lncRNA-1708 after osteogenic differentiation of three groups of hBMSC,and the relationship between lncRNA-1708 and hBMSC osteogenic differentiation was analyzed. LncRNA-1708 overexpressing lentivirus and lncRNA-1708 interferenced plasmid were transfected respectively,to obtain stable hBMSC cell line. After 14-day osteogenic differentiation on transfected hBMSC,RT-PCR was used to detect the expressions of runt-related transcription factor 2(RUNX2)and alkaline phosphatase(ALP)mRNA,and alkaline phosphatase staining was made.【Results】The expression of lnc-1708 decreased after osteogenic differentiation of hBMSC for 7 d(P < 0. 001).Two cell lines,which respectively express high lncRNA-1708 and low lncRNA-1708,were constructed successfully. In lnc-1708-overexpressed BMSC,the mRNA levels of osteogenic markers RUNX2 and ALP were both significantly down-regulated(0.46±0.03 vs.1.00±0.02,0.15±0.07 vs. 1.02±0.28,P < 0.01). On the contrary,in the lnc-1708-silencing BMSC,the expressions of RUNX2 and ALP mRNA level were significantly up-regulated(1.62±0.18 vs. 1.00±0.04,1.58±0.11 vs. 1.01±0.18,P < 0.01).【Conclusion】LncRNA-1708 may have an inhibitory effect on osteogenic differentiation of hBMSC.

2.
Journal of Regional Anatomy and Operative Surgery ; (6): 263-266, 2015.
Article in Chinese | WPRIM | ID: wpr-500167

ABSTRACT

Objective To discuss the clinical manifestation and treatment of the complications caused by injected polyacrylamde hydro-gel( PAAG) for breast augmentation. Methods This retrospective research was performed among 212 patients who undergoing breast aug-mentation with injected polyacrylamde hydrogel. The clinical manifestation and treatment outcome of the complications were analyzed and summarized,which is aim to search an effective treatment method. Results For the 212 patients,the main complications were breast multi-ple indurations (131 cases),fever (9 cases),infection (14 cases),breast pain (65 cases),PAAG displacement (28 cases) and secondary deformity or asymmetry (25 cases). 152 cases experienced one clinical symptom,the rest patients simultaneously undergone no less than two clinical symptoms. Patients were received open operation with periareolar incision ( surgery group) or vacuum absorption by needle ( aspira-tion group) for dislodging PAAG. No significant difference was found in wound healing,breast shape satisfaction and pain anesis between the two groups. Whilethe surgery group was better than the aspiration group in efficiency for taking out PAAG and the incidence of reoperation, with statistical significance. Conclusion A plenty of complications occurred after breast augmentation with injected polyacrylamde hydrogel, the method of open operation with periareolar incision is a better way for eliminating PAAG and treating the complications.

3.
Chinese Journal of Medical Education Research ; (12): 1254-1256, 2015.
Article in Chinese | WPRIM | ID: wpr-484208

ABSTRACT

Plastic and Aesthetic surgery is a science which creates beauty by combining know-ledge and art. Combined with the professional characteristics of plastic surgery, we reformed the cur-riculum content and teaching mode of continuous education, including a established interactive theoret-ical learning model based on Journal club, the strengthening of clinical practice integrated with multiple related disciplines, the expanding the knowledge of Sociology, Psychology and Ethics, and the construc-tion of a long-term platform of network resources. Therefore, a comprehensive and specialized continu-ous education model in the department of plastic and aesthetic surgery was ultimately formed, whose preliminary assessment was favorable, and could be helpful in the cultivation of high-quality plastic and aesthetic surgeons in the future.

4.
Journal of Regional Anatomy and Operative Surgery ; (6): 591-593, 2014.
Article in Chinese | WPRIM | ID: wpr-499959

ABSTRACT

Objective To explore an effective and hidden incision scar method for epicanthus correction. Methods 80 patients of bi-lateral single eyelid with epicanthus were divided into group A,group B and group C. Twenty-five patients with 50 eyes of group A received“Z” plasty correction of epicanthus,25 cases with 50 eyes of group B received the traditional“Y-V” plasty correction of epicanthus,30 cases with 60 eyes of group C treated with modified “Y-V” plasty correction of epicanthus. The curative effective was observed. Results Three groups were followed up for 6~24 months, the appearances of 25 patients in group A were significantly improved,of whom 2 cases had uni-lateral recurrence,8 cases with obvious postoperative scar. The eyelid shapes of patients in group B were natural after surgery,12 cases with obvious scar. all patients in group C were found no postoperative hypertrophic scars. Conclusion The three surgical treatment were effec-tive for epicanthus,but the design approaches of“Z” plasty correction and“Y-V” plasty correction are more complex,and postoperative scar is obvious,meanwhile the modified “Y-V” plasty correction is simple with incision hidden good shape scar formation.

5.
Chinese Journal of Plastic Surgery ; (6): 274-277, 2012.
Article in Chinese | WPRIM | ID: wpr-271286

ABSTRACT

<p><b>OBJECTIVE</b>To evaluate the feasibility of 3-Dimensional (3-D) model reconstruction of penis and surrounding structures based on magnetic resonance images, which may provide the model building method for modeling surgery of individual penoplasty.</p><p><b>METHODS</b>Magnetic resonance (MR) images of penis with different imaging parameters were evaluated. With the surface rendering construction, the 3D virtual model was established by Amira software.</p><p><b>RESULTS</b>The anatomical details imaging is better in T2-weighted fast spin-echo images with 3.0 mm slice thickness. The established model based on the MR images can show the soft-tissue, suspensory ligament of the penis. The suspensory ligament stretches between the pubic symphysis and the corpora cavernosa. The penile roots attach to inferior ramus of pubis.</p><p><b>CONCLUSIONS</b>MR imaging provides enough anatomical information for modeling. It can be used for the development of model surgery system of individual penoplasty.</p>


Subject(s)
Adult , Humans , Male , Imaging, Three-Dimensional , Magnetic Resonance Imaging , Models, Anatomic , Penis
6.
Chinese Journal of Plastic Surgery ; (6): 427-431, 2011.
Article in Chinese | WPRIM | ID: wpr-246912

ABSTRACT

<p><b>OBJECTIVE</b>To establish a model of individually forecasting the penile length gained after penis lengthening.</p><p><b>METHODS</b>A total of 322 patients were diagnosed congenital penile shortness and received partial suspensory ligament release in our department from Oct. 1988 to Apr. 2011. The patients were divide into two groups as Modeling Group (n = 200) and Checking Group (n = 122). Then a two-dimensional model of the suspensory-ligament-release penis lengthening is established. In the Modeling Group, a statistical analysis of the penile length in flaccid and erectile state before and after penis lengthening was carried out, and a forecasting predictive function of increased penile length was derived. Then the predictive accurate rate was tested in the Checking Group.</p><p><b>RESULTS</b>There was a significant linear correlation between the increased length in flaccid and erectile state (correlation coefficient = 0.921, P < 0.01), there was also a similar relationship between the extension rate of erection before and after the operation (correlation coefficient = 0.803, P < 0.01). According to the significant linear correlations showing above, two regression forecasting models were established. A predictive function of increased flaccid length was derived from the two regression forecasting models. The effectively forecasting rates were 84.5% (169/200, the Modeling Group) and 87.7% (107/122, the Checking Group) when the absolute value of forecasting error was less than 1.5 cm.</p><p><b>CONCLUSIONS</b>The discovered significant correlation and the established forecasting function provide us a model of roughly and individually forecasting the penile length gained after penis lengthening.</p>


Subject(s)
Adolescent , Adult , Humans , Male , Middle Aged , Young Adult , Forecasting , Ligaments , General Surgery , Penis , Congenital Abnormalities , General Surgery , Plastic Surgery Procedures , Methods , Surgical Flaps , Urologic Surgical Procedures, Male , Methods
7.
Chinese Journal of Burns ; (6): 205-209, 2011.
Article in Chinese | WPRIM | ID: wpr-257856

ABSTRACT

<p><b>OBJECTIVE</b>To investigate modulatory role of Rac1 protein in epidermal stem cell (ESC) migration during wound healing, in order to provide a reference for enriching basic theory of wound healing and guiding clinical application.</p><p><b>METHODS</b>Constitutively active mutant of Rac1 protein (Rac1Q61L) or dominant negative isoform of Rac1 protein (Rac1T17N) was transfected into ESC using a retroviral vector FUGW, and retroviral vector FUGW transfected into ESC in singles was used as blank control. The cells were divided into 3 parts according to the random number table and treated as follows. First, equal numbers of cells were inoculated into 24-well plates coated with collagen I (20 µg/mL), collagen IV (20 µg/mL) or fibronectin (10 µg/mL). Cells adhered to above matrices were quantitated using CytoTox 96 colorimetric kit. Second, 1000 cells adhered to collagen IV, after being stained with tetramethyl rhodamine isothiocyanate-phalloidin, were collected for observation of cell morphology and comparison of spreading area under confocal laser scanning microscope. Third, ESC with density of 2 × 10(5) cells per well were placed in upper compartment of Transwell chamber, DK-SFM culture medium alone or that containing stromal cell derived factor 1 (SDF-1) was added into lower compartment of Transwell chamber. Migration of ESC was observed using inverted phase contrast microscope, and the result was denoted as migration rate. Lastly, ESC with density of 7.5 × 10(5) cells per well was inoculated into 6-well plates for 12 hours, and treated with 4 µg/mL mitomycin C for 2 hours. The remaining scratch width of monolayer was respectively measured 6 hours or 12 hours after scratching to calculate the percentage of remaining scratch width. Data were processed with t test.</p><p><b>RESULTS</b>Compared with that of blank control, the number of Rac1Q61L-transfected cells adhered to collagen I was significantly increased (t = 5.302,P < 0.05), while the number of Rac1T17N-transfected cells adhered to collagen I, IV, and fibronectin were all obviously decreased (with t value respectively 13.741, 15.676, 8.256, P values all below 0.05). Confocal laser scanning microscope showed that spreading area of Rac1Q61L-transfected ESC (with laminate pseudopodia on edge) and Rac1T17N-transfected ESC was respectively larger and smaller as compared with that of blank control. With SDF-1 effect, the migration rate of Rac1T17N-transfected ESC was decreased by 78.0% and Rac1Q61L-transfected ESC was increased by 43.4% as compared with that of blank control. Without SDF-1 effect, the migration rate of Rac1T17N-transfected ESC was decreased by 55.2%, while the migration rate of Rac1Q61L-transfected ESC was close to that of blank control. Six or 12 hours after scratching, the percentage of remaining scratch width in Rac1Q61L-transfected ESC was lower as compared with that in blank control [(39 ± 9)% vs. (43 ± 5)%, (6 ± 5)% vs. (18 ± 7)%, with t value respectively 1.027, 4.389, with P value respectively above and below 0.05], while that in Rac1T17N-transfected ESC [(81 ± 9)%, (71 ± 11)%, respectively] was obviously higher as compared with that in blank control (with t value respectively 11.386, 11.726, P values all below 0.05).</p><p><b>CONCLUSIONS</b>Rac1 protein may control the migration of ESC by regulating its adhesion, spreading, and chemotaxis, and it plays an active role in wound healing accelerated by ESC.</p>


Subject(s)
Humans , Cell Movement , Cell Proliferation , Epidermis , Cell Biology , Epithelial Cells , Mutation , Stem Cells , Cell Biology , Transfection , Wound Healing , rac1 GTP-Binding Protein , Genetics , Metabolism
8.
Chinese Journal of Plastic Surgery ; (6): 369-372, 2010.
Article in Chinese | WPRIM | ID: wpr-268672

ABSTRACT

<p><b>OBJECTIVE</b>To investigate the expression and the role of secreted frizzled-related protein 2 (SFRP2) in the earlobe keloid and find a valid way to treat the keloid with gene therapy.</p><p><b>METHODS</b>The expression of SFRP2 mRNA and protein was tested with in situ hybridization and Western Blot Analysis method in the different period of earlobe keloid.</p><p><b>RESULTS</b>The SFRP2 mRNA and protein expression at the keloid edge was significantly high in 12 month group than in 3 or 6 month groups (P < 0.01), but not than in 24 month group. The SFRP2 expression started to decrease in the keloid center 12 month later (P < 0.01). The SFRP2 expression was always higher in edge than in center during all the period (P < 0.05, P < 0.01).</p><p><b>CONCLUSIONS</b>The results suggest that SFRP2 may play an important role in the development of keloid, especially at the keloid edge. The high SFRP2 expression in endothelial cells and surrounding tissue is also important. It may be a new way for gene therapy of keloid by decreasing the SFRP2 expression.</p>


Subject(s)
Adolescent , Adult , Female , Humans , Male , Middle Aged , Young Adult , Ear , Keloid , Metabolism , Membrane Proteins , Metabolism
9.
Chinese Journal of Burns ; (6): 212-215, 2010.
Article in Chinese | WPRIM | ID: wpr-305601

ABSTRACT

<p><b>OBJECTIVE</b>To study the promotion effect of stromal cell-derived factor 1 (SDF-1) on the migration of epidermal stem cells (ESC) in the healing process of frostbite-wound model ex vivo.</p><p><b>METHODS</b>A three-dimensional model of full-thickness frostbite of skin was constructed (with slot-like wound) out of skin equivalent. The expression of SDF-1 in wound stroma was observed with immunohistochemistry staining on post injury days (PID) 3 and 7. The model frostbite wounds were divided into control group (treated with PBS 50 microL per wound), SDF-1 group (treated with 100 ng/mL SDF-1, 50 microL per wound), and AMD3100 group [treated with 100 ng/mL AMD3100 (50 microL per wound) for 30 minutes, and then SDF-1 50 microL was added per wound]. The redistribution of ESC around wound was observed.</p><p><b>RESULTS</b>The expression of SDF-1 in wound stroma increased gradually on PID 3 and 7. Compared with those in control and AMD3100 groups, there were more ESC and epithelial cell layers, and more integrin beta(1)-positive cells appeared at the basal layer of wound in SDF-1 group, and some of the positive cells migrated upward to epidermis.</p><p><b>CONCLUSIONS</b>SDF-1 contributes to wound repair through promoting ESC to migrate toward and gather around wound edge. This may be one of the mechanisms of ESC participating in wound repair.</p>


Subject(s)
Humans , Cell Movement , Chemokine CXCL12 , Metabolism , Epidermis , Cell Biology , Frostbite , Metabolism , Therapeutics , Stem Cells , Cell Biology , Wound Healing
10.
Chinese Journal of Medical Aesthetics and Cosmetology ; (6): 398-400, 2010.
Article in Chinese | WPRIM | ID: wpr-383116

ABSTRACT

Objective To evaluate the histologic changes in the dermis and the changes of the rate of type Ⅲ and type Ⅰ collagen by the radiofrequency device. Methods The effects of radiofrequency current on the dermis were observed. Ten rabbits were treated by radiofrequency, and the histologic change in the dermis were observed by H-E staining and Sirius red staining. Results After RF treatment, the fibers in the dermis appeared more compact and the quantity of the type Ⅲ (red) and type Ⅰ (green) collagen were both increased. The fibers in the dermis appeared more compact and the rate of type Ⅲ and type Ⅰ collagen was increased. It was also found that a significant proliferation of dermal collagen was observed in 8 days after treatment. As time went by, the proliferation of dermal collagen was more pronounced, and the rate of type Ⅲ was increased. Conclusion The radiofrequency current can increase the quantity of collagen in the dermis and increase the rate of type Ⅲ and type Ⅰ collagen, which may be one of the key mechanisms of facial rejuvenation by RF.

11.
Chinese Journal of Burns ; (6): 118-121, 2008.
Article in Chinese | WPRIM | ID: wpr-347627

ABSTRACT

<p><b>OBJECTIVE</b>To investigate the inhibitory effects of genistein on tyrosine protein kinase (TPK)-mitogen activated protein kinase (MAPK) signal transduction pathway in hypertrophic scar fibroblasts (HSFb), in order to explore the molecular mechanism of inhibition of scar hyperplasia by genistein.</p><p><b>METHODS</b>HSFbs were isolated from human hypertrophic scar tissues and cultured in vitro. The cells were treated by genistein in different concentrations (25, 50, 100 micromol/L, respectively), followed by basic fibroblast growth factor (bFGF) stimulation. The activity of TPK was assessed with [gamma-32P] ATP substrate incorporation. The phosphorylation protein expression levels of main signal molecules in TPK-Ras-MAPK pathway including c-Raf, MEKl/2, extracellular signal regulated kinase (ERK), p38MAPK, c-Jun N-terminal kinase (JNK) were determined by Western blot. HSFbs treated with dimethylsulfoxide (DMSO) were used as control group.</p><p><b>RESULTS</b>After being treated with genistein in concentration of 25, 50, 100 micromol/L, the activity of TPK in HSFbs was depressed significantly [(7.15 +/- 0.35) x 10(5), (5.62 +/- 0.88) x 10(5), (5.62 +/-0.88) x 10(5) 10(5) pmol x min(-1) x mg(-1), respectively] when compared with that in control group [(8.92 +/- 0.28) x 10(5) pmol x min(-1) x mg(-1), P < 0.05]. Compared with those in control group,the phosphorylation protein expression levels of c-Raf, MEK1/2, ERK1/2 and p38 MAPK were lowered in different degree (P < 0.05 or P < 0.01) after genistein treatment. The phospho-JNK levels after treatment with genistein were similar to that of control group. Under the condition of pretreatment with genistein, the activities of TPK and signal pathway protein expressions in HSFb showed a downward trend after stimulation with bFGF.</p><p><b>CONCLUSION</b>Genistein can effect the proliferation and activation of HSFb by inhibiting the phosphorylation of receptor of TPK signal transduction pathway (TPK --> Raf --> MEK --> ERK/p38).</p>


Subject(s)
Adolescent , Adult , Child , Female , Humans , Male , Young Adult , Cell Proliferation , Cells, Cultured , Cicatrix, Hypertrophic , Metabolism , Pathology , Fibroblasts , Metabolism , Genistein , Pharmacology , Mitogen-Activated Protein Kinases , Metabolism , Phosphorylation , Protein-Tyrosine Kinases , Metabolism , Signal Transduction
12.
Chinese Journal of Plastic Surgery ; (6): 335-338, 2008.
Article in Chinese | WPRIM | ID: wpr-325848

ABSTRACT

<p><b>OBJECTIVE</b>To observe the effects of Genistein on TGF-beta1 expression and the intracellular free Ca2+ concentration in human hypertrophic scar fibroblasts, and to discuss the mechanism of the anti-fibrosis effect.</p><p><b>METHODS</b>Fibroblasts were derived from human hypertrophic scar tissue and cultured in vitro. Genistein in different concentrations (25, 50, 100 micromol/L) was administrated to the fibroblasts, respectively. After 48 hours of co-culture, the expression of TGF-beta1 mRNA and protein were examined by RT-PCR and Western-Blot assay respectively. The intracellular free Ca2+ concentration in hypertrophic scar fibroblasts pretreated by Genistein was determined by laser confocal scanning microscopy with or without the stimulation of bFGF.</p><p><b>RESULTS</b>Genistein inhibited the expression of TGF-beta1 in hypertrophic scar fibroblasts on a concentration-dependent manner. bFGF significantly elevated the intracellular free Ca2+ concentration, however its stimulating effect was remarkably alleviated when the fibroblasts were pre-treated by Genistein.</p><p><b>CONCLUSIONS</b>Genistein can reduce the expression of TGF-beta1 and block the accumulation of intracellular free calcium induced by growth factors. It maybe one of the possible mechanisms of Genistein's antifibrosis effect.</p>


Subject(s)
Humans , Calcium , Cells, Cultured , Cicatrix, Hypertrophic , Metabolism , Fibroblasts , Metabolism , Genistein , Pharmacology , Transforming Growth Factor beta1 , Metabolism
13.
Chinese Journal of Medical Aesthetics and Cosmetology ; (6): 159-162, 2008.
Article in Chinese | WPRIM | ID: wpr-382144

ABSTRACT

Objective To observe the effects of genistein on PCNA expression and cell cycle in fibroblasts derived from human hypertrophic scar in order to explore the mechanism of its inhibition on hypertrophic scar (HS) fibroblast proliferation. Methods The human hypertrophic scar fibroblasts were cultured in vitro. Genistein with various concentrations (25, 50, 100 μmol/L) was co-cultured in the medium for 48 hours. The expression of PCNA was detected with immunocytochemical staining method and the cell cycle was measured with flow cytometry. Results Genistein could significantly decrease PCNA expression in HS fibroblasts, especially when its concentration at 50 μmol/L or 100 μmol/L. The cell percentage of G0~G1 phase decreased with drug′s concentration, and G2~M percentage increased conversely, implying the suspension of mitosis. In 100 μmol/L group, most cells blocked at S phase and a hypodiploid apoptosis peak could be observed ahead of G1 phase. Conclusion Genistein can inhibit the proliferation of human hypertrophic scar by blocking cell division as well as decreasing DNA synthesis.

14.
Chinese Journal of Plastic Surgery ; (6): 300-303, 2007.
Article in Chinese | WPRIM | ID: wpr-314230

ABSTRACT

<p><b>OBJECTIVE</b>To analyze 3D digitized image of the adult penis, providing morphological data for plastic plerosis of the adult penis diagnosis and the surgery planning.</p><p><b>METHODS</b>200 adult penis were measured at the length and perimeter of the resting state and erection, and the relation among the erectile angle and length, perimeter were analyzed by the Angel Digital Image Studio software.</p><p><b>RESULTS</b>Penis increase with the age and stature growing. But the length increases in not the same ratio with the stature . With the erectile angle increasing, penile hardness is becoming strong, but penile volume do not marked change.</p><p><b>CONCLUSIONS</b>The digitized model of the penis and adjacent structure offer unique insights into the complex penis anatomy, providing morphological data for preoperative design and postoperative effective evaluation of the penile plastic plerosis.</p>


Subject(s)
Adolescent , Adult , Humans , Male , Middle Aged , Young Adult , Imaging, Three-Dimensional , Penis
15.
Microbiology ; (12)1992.
Article in Chinese | WPRIM | ID: wpr-683943

ABSTRACT

An actinomycetes which produced soluble blue pigment was isolated from the soil sample in Nanjing,China.Based on its cell chemical characteristics and 16S rDNA sequence we found that its cell wall contained L-diaminopimelic acid and glycine,the whole cell hydrolysates contained glucose and ribose,whole cell contained fatty acid from C14 to C17 with 12-methyltetradecanoic(anteiso-15) and 14-methylpentadentadecanoic acid(iso-16) as the major components.The results shown that,it belongs to the genus Streptomyces.Phylogenetic tree of 16S rDNA sequences indicated that all strains were clustered into 9 branches.All strains that could produce blue pigment were clustered into 2 branches,they were S.coelicolor、S.cyaneus.The isolate closely related to Streptomyces indigocolor with a similarity of 99.4% fell into S.cyaneus branch.

16.
Journal of Third Military Medical University ; (24)1983.
Article in Chinese | WPRIM | ID: wpr-565033

ABSTRACT

Objective To investigate the application of computer-aided 3D reconstruction and rapid prototyping(RP) technique in the correction of prominent mandibular angle.Methods Computer tomography scanning and 3D reconstruction were performed on 15 square face patients with prominent mandibular angles,then their actual mandible models were made by RP techniques.Surgical programs were made according to the model,including partial mandibular angle osteotomy,outer mandible table sagittal splitting osteotomy,chin augmentation with autogenous mandibule bones,and so on.In 15 cases,mandibular angle partial cutting was performed in 5 cases,sagittal splitting osteotomy in 6 cases,and mandibular angle partial cutting combined with splitting osteotomy in 4 cases.The autogenous mandibule bones were transplanted for chin augmentation in 3 chin microsomia patients.All the cases were treated according to the position and range set by the RP model.Results All the mandibular models produced by RP techniques were real and complete,which could directly and precisely show the state of the mandible.The operations completed smoothly and accomplished with the expected outcomes designed before operation.In all cases,the width of lower face was efficiently reduced and the face was symmetrical after operation.The follow-up period ranged from 3 months to 1 year in 12 patients,during which their facial appearances were in good condition and the results were satisfactory.Conclusion RP techniques is helpful in precise representation of the state of mandible,which providing ideal surgical models for accurate evaluation of prominent mandibular angle,design of surgical procedures as well as surgery instruction.It can provide good assistance to facial contour plastic surgery.

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