Korean J Otorhinolaryngol-Head Neck Surg 2018;61(5): The Concepts of Virtual Reality Fig. 1. A conceptual illustration of virtual reality for su

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1 Review Korean J Otorhinolaryngol-Head Neck Surg 2018;61(5): / pissn / eissn Virtual Reality in Endoscopic Sinus Surgery and Facial Plastic & Reconstructive Surgery Yong Gi Jung 1,2 and Jung-yon Ko 2 1 Department of Otorhinolaryngology-Head and Neck Surgery, 2 Virtual Reality Laboratory, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea 부비동내시경수술과안면성형재건술에적용가능한가상현실기술 정용기 1,2 고정연 2 성균관대학교의과대학삼성창원병원이비인후과학교실, 1 가상현실연구소 2 Received March 24, 2018 Accepted April 18, 2018 Address for correspondence Yong Gi Jung, MD, PhD Department of Otorhinolaryngology- Head and Neck Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, 158 Paryong-ro, Masanhoewon-gu, Changwon 51353, Korea Tel Fax ent.jyg@gmail.com With the recent development of information and communication technology, social interest in virtual reality (VR) is increasing rapidly. VR technology is expanding into applications such as games, movies, entertainment, healthcare, education/media, manufacturing, and construction. In the healthcare, VR is used for surgical training, medical education, rehabilitation medicine, pain control, and treatment for psychiatric disorder, but the market size of VR in healthcare is not big compared to VR application in other industries. However, as the demand for high-quality medical care increases and the training time of the resident physicians is reduced, the demand for VR in the healthcare is expected to increase rapidly. Especially, the nose and paranasal sinus are composed of complicated osseous structures, which makes it difficult to understand the exact anatomy and requires highly skilled techniques to perform accurate and safe surgery. For this reason, nose and sinus are a suitable field to apply VR technology. In this review article, we describe the overview of VR technology used in healthcare, the status and prospects of VR in endoscopic sinus surgery and facial plastic surgery. Korean J Otorhinolaryngol-Head Neck Surg 2018;61(5): Key Words Education ㆍ Paranasal sinuses ㆍ Plastic surgery ㆍ Simulation training ㆍ Virtual reality. 서 론 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2018 Korean Society of Otorhinolaryngology-Head and Neck Surgery 227

Korean J Otorhinolaryngol-Head Neck Surg 2018;61(5):227-34 The Concepts of Virtual Reality Fig. 1. A conceptual illustration of virtual reality for surgery and anatomy training.

2 Korean J Otorhinolaryngol-Head Neck Surg 2018;61(5): The Concepts of Virtual Reality Fig. 1. A conceptual illustration of virtual reality for surgery and anatomy training. The medical images are reconstructed three - dimensionally by a computer and transmitted to the HMD, and the user manipulates the 3D model through the HMD and the motion controller. The HMD incorporates a gyro sensor to recognize and reflect the movement of the user's head. HMD: head mounted display. 228

3 VR in Nasal Surgery Jung YG, et al. Fig. 2. A Google card board which the user folds the paper and creates it directly. It has made a great contribution to the growth of VR by making it possible to experience VR at very low price of less than 10$. A picture was Adapted from Google cardboard. Available from: VR: virtual reality. Virtual Reality in Medicine - - Table 1. Current and emerging applications of virtual reality in medicine Application Medical/dental surgical training Pre-surgical planning Computer-aided surgery systems Interactive 3d diagnostic imaging Radiation treatment planning and control Medical education 3D visualization for telemedicine Telesurgery Rehabilitation and sports medicine Disability solutions Neurological evaluation Psychiatric and behavioral healthcare Description Training and rehearsing a surgical procedure using surgical instruments linked to a realistic simulation-may or may not include haptic feedback. Using 3D radiological images and computer workstation tools to design and plan an operative procedure. Using 3D images overlaid in real-time on the operating field to facilitate surgery. Tools for data analysis and quantitative comparisons-capturing and manipulating medical imaging data in a 3D format. Collaborative environments. Design of radiation treatment procedure to match patients anatomy precisely. 3D design and control systems. Case histories, 3D anatomy lessons and virtual cadavers, procedure training, emergency room ward simulation, palpation training, etc. Radiological image tele-consultation and second opinions, shared data for tumor review boards, remote patient examination, and specialty consults. Computer-assisted surgery at a distance. Predictive algorithms, 3D surgical planning. Simulated environments for evaluation and rehabilitation-occupational therapy, physical therapy, ergonomics, orthopedics, and sports medicine. Augmented reality environments for treatment of autism and other cognitive impairments. Environmental control systems. Standardized simulated environments for evaluation of cognitive processing, stroke deficits, memory disorders, movement disorders, and higher-functions. Evaluation and treatment of cognitive and behavioral disorders: phobias, anxiety, social affect disorders, attention deficiency hyperactive disorder, post-traumatic stress disorder, and addiction treatment. Adapted from Greenleaf W. Medical applications of virtual reality. Available from:

Korean J Otorhinolaryngol-Head Neck Surg 2018;61(5):227-34 - Technical Steps to Implement VR Fig. 3.

4 Korean J Otorhinolaryngol-Head Neck Surg 2018;61(5): Technical Steps to Implement VR Fig. 3. Digital imaging and communication in medicina segmentation tool (InVesalius, CTI, Campinas, Brazil) for acquiring 3D model from computed tomography images. The Maxillary sinus is set as a region of interest. 230

VR in Nasal Surgery Jung YG, et al. Virtual Reality in Sinus Surgery - A B Fig. 4.

Virtual reality image made with a 3D model of a maxillary sinus, a view from the inside

The created maxillary sinus virtual reality images are viewed using the window mixed

5 VR in Nasal Surgery Jung YG, et al. Virtual Reality in Sinus Surgery - A B Fig. 4. Maxillary sinus 3D model from thin sectioned computed tomography images (A). Virtual reality image made with a 3D model of a maxillary sinus, a view from the inside of a maxilla. The maxillary sinus natural ostium can be identified (B). Fig. 5. The created maxillary sinus virtual reality images are viewed using the window mixed reality (Microsoft, Redmond, WA, USA) device Odyssey (Samsung electronic company, Seoul, Korea)

Korean J Otorhinolaryngol-Head Neck Surg 2018;61(5):227-34 Virtual Reality in Facial Plastic and Reconstructive Surgery - Fig. 6.

Each joint has a motor, so it shows pre-programmed recoil action according to the movement of the user. Adapted from 3D Systems. Available from: https://ko.3dsystems.

6 Korean J Otorhinolaryngol-Head Neck Surg 2018;61(5): Virtual Reality in Facial Plastic and Reconstructive Surgery - Fig. 6. Most commonly used haptic devices, Touch (3D systems, Rock Hill, SC, USA). Each joint has a motor, so it shows pre-programmed recoil action according to the movement of the user. Adapted from 3D Systems. Available from: com. Fig. 7. VR camera for facial plastic and reconstruction surgery (360 round, Samsung electronic company, Seoul, Korea) which is installed in Samsung Changwon Hospital operating room. With 17 lenses, it is possible to record high-resolution images and implement VR environment. VR: virtual reality. 232

7 VR in Nasal Surgery Jung YG, et al. Technological Limitations and the Future of Virtual Reality REFERENCES 1) Aïm F, Lonjon G, Hannouche D, Nizard R. Effectiveness of virtual reality training in orthopaedic surgery. Arthroscopy 2016;32(1): ) Philibert I, Friedmann P, Williams WT; ACGME Work Group on Resident Duty Hours. New requirements for resident duty hours. JAMA 2002; 288(9): ) Bakker NH, Fokkens WJ, Grimbergen CA. Investigation of training needs for functional endoscopic sinus surgery (FESS). Rhinology 2005;43(2): ) Li L, Yu F, Shi D, Shi J, Tian Z, Yang J, et al. Application of virtual reality technology in clinical medicine. Am J Transl Res 2017;9(9): ) Hyoun JW. [Virtual reality technology trends in medical field]. [online] 2016 [cited 2018 Feb 28]. Available from: filedown.do?seq= ) Erin Carson. 9 industries using virtual reality. [online] 2015 [cited 2018 Feb 28]. Available from: 9-industries-using-virtual-reality/. 7) Alaker M, Wynn GR, Arulampalam T. Virtual reality training in laparoscopic surgery: a systematic review & meta-analysis. Int J Surg 2016;29: ) Yiannakopoulou E, Nikiteas N, Perrea D, Tsigris C. Virtual reality simulators and training in laparoscopic surgery. Int J Surg 2015;13: ) Greenleaf W. Medical applications of virtual reality. [online] 2004 [cited 2018 Feb 28]. Available from: MI/Discussion86-1/VR%2520Med%2520overview.pdf. 10) Reznick R, Regehr G, MacRae H, Martin J, McCulloch W. Testing technical skill via an innovative bench station examination. Am J Surg 1997;173(3): ) Arora A, Khemani S, Tolley N, Singh A, Budge J, Varela DA, et al. Face and content validation of a virtual reality temporal bone simulator. Otolaryngol Head Neck Surg 2012;146(3): ) Zhao YC, Kennedy G, Hall R, O Leary S. Differentiating levels of 233

8 Korean J Otorhinolaryngol-Head Neck Surg 2018;61(5): surgical experience on a virtual reality temporal bone simulator. Otolaryngol Head Neck Surg 2010;143(5 Suppl 3):S ) Arora H, Uribe J, Ralph W, Zeltsan M, Cuellar H, Gallagher A, et al. Assessment of construct validity of the endoscopic sinus surgery simulator. Arch Otolaryngol Head Neck Surg 2005;131(3): ) Keerl R. [Value of multimedia educational software in training of the paranasal sinus surgeon]. Laryngorhinootologie 2000;79(1): ) Edmond CV Jr, Wiet GJ, Bolger B. Virtual environments. surgical simulation in otolaryngology. Otolaryngol Clin North Am 1998;31 (2): ) Rudman DT, Stredney D, Sessanna D, Yagel R, Crawfis R, Heskamp D, et al. Functional endoscopic sinus surgery training simulator. Laryngoscope 1998;108(11 Pt 1): ) Fried MP, Sadoughi B, Gibber MJ, Jacobs JB, Lebowitz RA, Ross DA, et al. From virtual reality to the operating room: the endoscopic sinus surgery simulator experiment. Otolaryngol Head Neck Surg 2010;142(2): ) Varshney R, Frenkiel S, Nguyen LH, Young M, Del Maestro R, Zeitouni A, et al. Development of the McGill simulator for endoscopic sinus surgery: a new high-fidelity virtual reality simulator for endoscopic sinus surgery. Am J Rhinol Allergy 2014;28(4): ) Kim Y, Kim H, Kim YO. Virtual reality and augmented reality in plastic surgery: a review. Arch Plast Surg 2017;44(3): ) Olsson P, Nysjö F, Hirsch JM, Carlbom IB. A haptics-assisted craniomaxillofacial surgery planning system for restoring skeletal anatomy in complex trauma cases. Int J Comput Assist Radiol Surg 2013;8 (6): ) Wang Q, Chen H, Wu W, Jin HY, Heng PA. Real-time mandibular angle reduction surgical simulation with haptic rendering. IEEE Trans Inf Technol Biomed 2012;16(6): ) Mischkowski RA, Zinser MJ, Kübler AC, Krug B, Seifert U, Zöller JE. Application of an augmented reality tool for maxillary positioning in orthognathic surgery - a feasibility study. J Craniomaxillofac Surg 2006;34(8): ) Wu F, Chen X, Lin Y, Wang C, Wang X, Shen G, et al. A virtual training system for maxillofacial surgery using advanced haptic feedback and immersive workbench. Int J Med Robot 2014;10(1): ) Lin Y, Wang X, Wu F, Chen X, Wang C, Shen G. Development and validation of a surgical training simulator with haptic feedback for learning bone-sawing skill. J Biomed Inform 2014;48: 정답및해설 1. 답 해설ㅋ모세혈관종 (capillary hemangioma), 유사한용어로화농성육아종 (pyogenic granuloma) 은혈관종의한형태로급속하게성장하며쉽게출혈하는경향을보인다. 피부와입안점막에서잘발생하며비강점막에서는비교적드물게발생한다. 모든연령층에서발생가능하나 30 대에흔하며여성, 특히가임여성에서호발한다. 임신시프로게스테론, 에스트로겐의상승으로상피세포가과증식하여발생률이증가할수있다. 흔한증상으로는비폐색, 비출혈, 비루가있다. 유두종혹은비용으로오진하기쉽고, 악성종양또는혈관섬유종등과감별해야한다. 혈관섬유종과는다르게혈관색전술없이단순절제가가능하다. 234

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<353420B1C7B9CCB6F52DC1F5B0ADC7F6BDC7C0BB20C0CCBFEBC7D120BEC6B5BFB1B3C0B0C7C1B7CEB1D7B7A52E687770> Journal of the Korea Academia-Industrial cooperation Society Vol. 13, No. 2 pp. 866-871, 2012 http://dx.doi.org/10.5762/kais.2012.13.2.866 증강현실을 이용한 아동교육프로그램 모델제안 권미란 1*, 김정일 2 1 나사렛대학교 아동학과, 2 한세대학교 e-비즈니스학과