Craniofacial Surgery

Controversy on the Age of Hypertelorism Correction Introduction: Orbital hypertelorism (HTO) is a challenging craniofacial problem seen in association with some congenital deformities. The age of HTO correction is a matter of debate. The Aim of the work: to evaluate the outcome of HTO correction and determine the optimal timing for intervention, striving for the earliest possible intervention with the lowest relapse. Patients and methods: A standard craniofacial approach with medial bone resection, 4 walls orbital box osteotomy and orbital medialization were done for all patients. Skeletal and soft tissue procedures were done as indicated. Results: there were 10 patients aging 6 to 19 years. Seven were associated with craniofacial clefts, and 3 with craniosynostosis syndromes. HTO was severe in 8 cases and moderate in 2 cases. It was asymmetric in 2 cases. Frontoorbital remodeling was done in 3 cases with craniosynostosis. Failed surgery was reported in 2 cases. A redo surgery was done for one of them with an excellent outcome, while refused by the other. Nine patients had an excellent outcome. The mean level of satisfaction was 93.37%. Three patients had ugly facial scars. No major complications were recorded. Conclusion: The time for surgical treatment of HTO is determined by the severity of the associated deformity. If there is an urgent factor indicating intervention, early correction can be performed exceptionally; otherwise, HTO correction should be performed after the age of 6 years. Address correspondence and reprint requests to Ahmed Gaber Hassanein, MD, Address: Maxillofacial Surgery Unit, General Surgery Department, Sohag Faculty of Medicine, Sohag, Egypt; E-mail: ahmedgaber_74@yahoo.com Received 2 August, 2018 Accepted 10 April, 2019 The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Applications of Bone Morphogenetic Protein-2: Alternative Therapies in Craniofacial Reconstruction Large defects of the craniofacial skeleton can be exceedingly difficult to reconstruct since autologous bone grafts are limited by donor site morbidity and alloplastic implants have low biocompatibility. Bone morphogenetic proteins (BMPs) in craniofacial reconstruction have been used with mixed outcomes and complication concerns; however, results for specific indications have been promising. In alveolar clefts, cranial vault defects, mandibular defects, and rare Tessier craniofacial clefts, BMP-2 impregnated in collagen matrix was looked at as an alternative therapy for challenging cases. In cases where structural support was required, BMP-2 was used as part of a construct with bio-resorbable plates. Demineralized bone was added in certain cases. The authors described specific indications, detailed surgical techniques, and a review of the current literature regarding the use of BMP-2 in craniofacial reconstruction. BMP-2 is a viable option for craniofacial reconstruction to decrease donor-site morbidity or when alternatives are contraindicated. It is not recommended for routine use or in the oncologic setting but should currently be reserved as an alternative therapy for complex cases with limited options. Bone morphogenetic proteins are a promising, emerging option for complex craniofacial reconstruction. Future directions of BMP-2 therapies will become apparent as data from prospective randomized trials emerges. Address correspondence and reprint requests to James P. Bradley, MD, 1991 Marcus Avenue, #102, Lake Success, NY, 11042; E-mail: JPBradley4@mac.com Received 9 October, 2018 Accepted 20 March, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Correlation Between Speech Outcomes and the Amount of Maxillary Advancement After Orthognathic Surgery (Le Fort I Conventional Osteotomy and Distraction Osteogenesis) in Patients With Cleft Lip and Palate Background: The purpose of this study is to evaluate the factors affecting the speech outcome following Le fort I conventional osteotomy(CO) or Le Fort I distraction osteogenesis(DO) in patients with cleft lip and palate at a single institution. Method: Records of cleft lip and palate patients who underwent orthognathic surgery between 2010 and 2015 were reviewed. Data included age at orthognathic surgery, sex, cleft lip and palate type, type of orthognathic surgery, the amount of maxillary advancement, and speech assessment. Speech outcomes were classified into 2 categories. Compared with the pre and post-operative Pittsburgh Weighted speech scale scores, in case that the post-operative total score is increased the authors define it as "Speech deterioration" and if not, the authors define it as "Speech preservation." Result: The 44 patients were identified, 33 patients underwent CO and 11 patients underwent DO. The mean age was 19.4 ± 1.4. The mean period time of speech evaluation after orthognathic surgery was 1.0 ± 0.46 year. The mean amount of maxillary advancement was 7.2 ± 3.2 mm and show significant correlation with speech outcomes. (P = 0.012) . In CO group, the patients who had the maxilla 1∼5 mm advancement maintained their speech completely and 44% of patients with 6∼8 mm deteriorated their speech. In DO group, patients with 9∼10 mm maintained their speech completely, 50% of patients with 11∼12 mm deteriorated their speech and 100% of patients with 13∼16 mm deteriorated their speech. According to the relationship between the amount of maxillary advancement and speech outcomes, there was a statistically significant correlation in both CO and DO groups. (P = 0.04, 0.029). Conclusion: It was found that speech of the patients with more amount of maxillary advancement tended to get worse. Also, it was observed that there exist some stable ranges of maxillary advancement for speech safety which does not effect on speech. (1∼5 mm in CO group and 9∼10 mm in DO group). Address correspondence and reprint requests to Yountaek Koo, MD, Wonjin Plastic Surgery, Seoul, Korea, 419, Gangnam-daero, Seocho-gu, Seoul, Korea; E-mail: kooyountaek@gmail.com; Sukwha Kim, MD, Department of Plastic Surgery, Seoul National University Hospital, 101 Daehak-ro Jongno-gu, Seoul 110–744, Korea; E-mail: kimsw@snu.ac.kr Received 20 October, 2018 Accepted 1 April, 2019 The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Three-Dimension–Printed Surgical Guide for Accurate and Safe Mandibuloplasty in Patients With Prominent Mandibular Angles Performance of mandibuloplasty is highly dependent on each surgeon's experience, and reproducing the results of simulation surgery is often difficult. In order to obtain successful clinical outcomes, a fast and efficient surgery technique that minimizes operation time and risk to patients is needed. The authors designed a 3D-printed mandible fit surgical guide for use as a bridge between simulation and actual surgery. The authors enrolled 7 patients with prominent mandibular angle who visited the outpatient clinic of the Department of Plastic and Reconstructive Surgery at Asan Medical Center in Seoul, Korea between December 2013 and May 2017. The surgical guides were made with a 3D printer and simulated based on individual facial bone CT scans. The surgical guides were designed to fit the lower border of the mandible and to cover the portion planned for removal. The resulting personalized 3D-printed surgical guides were applied on both mandibular angles to the body and along the lower border of the mandible. Osteotomy of the mandibular angle and body were performed along the surgical guide. All patients recovered without any immediate postoperative complications. The use of 3D-printed surgical guide was effective in simplifying the process of mandibuloplasty. Our results demonstrate the value of 3D printing technology in mandibuloplasty. Address correspondence and reprint requests to Jong-Woo Choi, MD, PhD, Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; E-mail: pschoi@amc.seoul.kr Received 30 October, 2018 Accepted 10 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

A Novel Use of Buccal Fat Pad Flap for Immediate Reconstruction of Palatal Tumor Resection Defect Integrity of the palatal mucosa may be disrupted due to various pathological and congenital factors. In maxillofacial defects, the buccal fat pad has been used frequently to repair the palatal region and close oro-nasal communications. In this case report, the use of buccal fat pad for the closure of a surgical palatal defect is presented with a 3-year follow-up. A 75-year-old female patient visited our clinic with a complaint of a non-adaptive maxillary denture. During clinical and radiographic examination, a well-demarcated mass on the palatal mucosa extending to the soft palate of the left side was observed. Subsequent to resection of the tumor, a defect occurred on the palatal region extending toward the soft palate. The pedicled buccal fat pad was chosen for closure of the defect. The patient was followed-up at 3, 7, 14, and 30 days after surgery. Epithelization and healing of the surgical wound were uneventful. At the 3-year follow-up, functional closure of the left palatal region was observed with no recurrence. Buccal fat pad is an easily manipulated flap with predictable results for the reconstruction of medium-sized defects of the oral and maxillofacial region with minimal postoperative discomfort for the patient. Address correspondence and reprint requests to Onur Koç, DDS, PhD, Hacettepe University Faculty of Dentistry Oral and Maxillofacial Surgery Department Sihhiye, Ankara, Turkey; E-mail: onurkoc101@gmail.com Received 4 November, 2018 Accepted 20 March, 2019 The authors declare no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Lateral Osteotomy Fixation Technique in Rhinoplasty Rhinoplasty is the most challenging facial aesthetic surgical procedure according to many plastic surgeons. Nasal bone osteotomies, especially lateral osteotomies, have a complicated history. If lateral osteotomy is not stable after osteotomy during intraoperative period, stabilization is attempted with internal and external nasal splints but it is not possible to be confident about the stabilization since it is not fully fixed and cannot be observed directly. The authors presented the technique stabilization of the lateral osteotomy inferior tip with cerclage wire, if there is a stabilization problem or step-off deformity after lateral osteotomy. Address correspondence and reprint requests to Muhammet Uraloğlu, MD, Karadeniz Teknik Üniversitesi Tip Fakültesi, Farabi Hastanesi Plastik Cerrahi Anabilim Dali, Trabzon, Turkey; E-mail: uraloglu@hotmail.com Received 11 May, 2018 Accepted 29 March, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

The Trends of Pediatric Facial Fractures Due to Violence in a Level One Trauma Population Introduction: Pediatric facial fractures due to intentionally violent mechanisms represent a unique subset of facial fractures. The objective of our research is to identify how violence affects patterns of facial fractures and their management in pediatric patients. Methods: An IRB approved, retrospective study of our institution's pediatric patients ≤18 years of age who presented with ≥1 facial fracture due to violence from January 2006 to December 2015 was performed. Violence was defined as trauma intended to hurt another or self. Demographics, fractures, mechanism, concomitant injuries, and management were analyzed. Results: The 1274 patients were diagnosed with facial fractures, with 235 of these due to violence (18%). These patients of violence (POV) had 332 fractures, with an average fracture per patient of 1.4 ± .0.8. The majority (86%) were male, Non-Hispanic African American (35%), and the average age was 15.9 ± 2.8 years. The most common fracture was the mandible (50% of patients) and most common mechanism was assault (76%). The POV were older, male, and of minority race/ethnic groups when compared to patients of non-violence (PONV) (P <0.01). The POV presented with fewer concomitant injuries, were less likely to be admitted to the intensive care unit, and more often surgically managed when compared to the PONV (P <0.01). Conclusion: This study represents the largest US, single institution, Level 1 trauma center study of pediatric facial fractures. Pediatric patients with facial fractures due to a violent mechanism represent a distinct category of trauma patients with a unique profile of injuries. Address correspondence and reprint requests to Matthew R. Greives, MD, FACS, Division of Pediatric Plastic Surgery, Department of Pediatric Surgery, McGovern School of Medicine, University of Texas Health Science Center, 6431 Fannin Street, MSB 5.281, Houston, TX 77030; E-mail: Matthew.R.Greives@uth.tmc.edu Received 15 February, 2019 Accepted 8 April, 2019 The manuscript has not previously been submitted. Abstract has been presented at the American College of Surgeons South Texas Annual Meeting in Houston, TX on February 24, 2018. The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Temporal Hollowing Augmentation With Polyetheretherketone Patient-Specific Implant Temporal hollowing is a common complication of surgical dissection in the temporal region. As it is a serious cosmetic problem, the need for reconstruction is increasing. Advances in medical imaging, computer software, 3-dimensional printing technology, and biochemistry have enabled surgeons to use patient-specific implants for correction of craniofacial deformities. Titanium, polymethylmethacrylate, and polyetheretherketone are representative materials of the alloplastic implant. In this article, the authors report the first case of temporal hollowing augmentation using a polyetheretherketone patient-specific implant. Address correspondence and reprint requests to Ki Yong Hong, MD, PhD, Department of Plastic and Reconstructive Surgery, Ilsan Hospital, Dongguk University Medical Center, Dongguk-ro 27, IlSanDong-gu, GoYang-si, GyeongGi-do, 10326, South Korea; E-mail: pskyhong@gmail.com Received 26 February, 2019 Accepted 15 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Mammalian Skull Dimensions and the Golden Ratio (Φ) The Golden Ratio (Phi, or Φ = 1.618…) is a potentially unifying quantity of structure and function in nature, as best observed in phyllotactic patterns in plants. For centuries, Φ has been identified in human anatomy, and in recent decades, Φ has been identified in human physiology as well. The anatomy and evolution of the human skull have been the focus of intense study. Evolving over millenia, the human skull embodies an elegant harmonization of structure and function. The authors explored the dimensions of the neurocranium by focusing on the midline calvarial perimeter between the nasion and inion (nasioiniac arc) and its partition by bregma into 2 sub-arcs. The authors studied 100 human skulls and 70 skulls of 6 other mammalian species and calculated 2 ratios: 1) the nasioiniac arc divided by the parieto-occipital arc (between bregma and inion), and 2) the parieto-occipital arc divided by the frontal arc (between nasion and bregma). The authors report that in humans these 2 ratios coincide (1.64 ± 0.04 and 1.57 ± 0.10) and approximate Φ. In the other 6 mammalian species, these 2 ratios were not only different, but also unique to each species. The difference between the ratios showed a trend toward convergence on Φ correlating with species complexity. The partition of the nasioiniac arc by bregma into 2 unequal arcs is a situation analogous to that of the geometrical division of a line into Φ. The authors hypothesize that the Golden Ratio (Φ) principle, documented in other biological systems, may be present in the architecture and evolution of the human skull. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 Address correspondence and reprint requests to Rafael J. Tamargo, MD, Department of Neurosurgery, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Zayed Tower, Suite 6115, 1800 Orleans Street, Baltimore, MD, 21287; E-mail: rtamarg@jhmi.edu Received 7 March, 2019 Accepted 8 April, 2019 The authors have no conflict of interest to declare. © 2019 by Mutaz B. Habal, MD.

Extension of the Question Mark Temporal Craniectomy Trauma Incision to Bicoronal Incision for Delayed Cranioplasty No abstract available

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com