Craniofacial Surgery

Adding Depth to Cephalometric Analysis: Comparing Two- and Three-Dimensional Angular Cephalometric Measurements Introduction: Lateral cephalometric radiographs (LCR) have been the standard tool used for cephalometric analysis in craniofacial surgery. Over the past decade, a three-dimensional (3D) revolution in cephalometric analysis and surgical planning has been underway. To date, research has not validated whether cephalometric measurements taken from two-dimensional (2D) and 3D data sources are equivalent and interchangeable. The authors sought to compare angular cephalometric measurements taken with 2D and 3D modalities. Methods: Sixty-two head CT scans (36 females, 26 males) with an average age of 63 ± 20 years were studied. Twelve cephalometric angular measurements were taken from 3D reconstructed skulls using the software package Mimics 19.0 (Materialize; Leuven, Belgium). These same facial angles were measured from 2D lateral cephalograms reconstructed from the original CT scans using Dolphin 11.9. Measurements taken with both techniques were compared for agreement using a paired t test. Intra-class correlation coefficient assessment was used to determine inter-rater reliability. Statistical significance was set at P < 0.05. Results: Five of the 12 angular measurements (SNA, SNB, MP-FH, U1-SN, and U1-L1) demonstrated statistically significant differences (P < 0.05) between the 2D and 3D analyses. All of these differences were less than the standard deviations for the respective measure. Conclusion: The differences between angular cephalometric values obtained from 2D LCRs and 3D CT reconstructions are small. This supports the practices of using 2D and 3D cephalometric data interchangeably in most applications. Clinicians must be selective in which measures they employ to maximize accuracy and care must be taken when measuring dental inclination with lateral cephalograms. Address correspondence and reprint requests to S. Alex Rottgers, MD, Assistant Professor of Plastic Reconstructive Surgery, Johns Hopkins All Children's Hospital, Division of Plastic and Reconstructive Surgery, 601 Fifth Street South, Suite 306, St. Petersburg, FL 33701; E-mail: srottge1@jhmi.edu Received 28 November, 2018 Accepted 12 March, 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.

Risk Factors for Adult Postintubation Tracheal Stenosis Background: To identify risk factors for developing adult postintubation tracheal stenosis (TS) and determine if there were patient characteristics that could serve as prognostic indicators of clinical outcomes in this patient population. Methods: A total of 55 patients with postintubation TS admitted to our institution between February 2009 and March 2017 (TS group) and randomly selected 86 patients admitted to the intensive care unit and intubated over the same period in whom TS was ruled out (control group) were compared. Causal factors of intubation were noted. Patient-, treatment-, and procedure/cuff site-related risk factors of TS were compared. Results: Both groups did not differ from each other by means of age and gender (P = 0.640, and P = 0.724, respectively). Compared to controls, patients with TS had a significantly higher BMI (32.8 ± 7.64 kg/m2 versus 25.9 ± 6.68 kg/m2; p = 0.002) and were more likely to have diabetes (28.4% vs 9.82%; p = 0.0011). Patients who were previously intubated for more than 48 hours (P = 0.016) and patients treated with irradiation (P = 0.028) were significantly more likely to develop TS than control patients. Conclusion: Patients with TS had a significantly higher BMI, and were more likely to have diabetes compared to controls. Patients who were previously intubated for more than 48 hours and patients treated with irradiation were more likely to develop TS than control patients. Address correspondence and reprint requests to Murat Songu, MD, Department of Otorhinolaryngology, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey; E-mail: songumurat@yahoo.com Received 16 January, 2019 Accepted 27 February, 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.

Transnasal Endoscopic Retrieval of a Metallic Intraorbital Intraconal Foreign Body Facilitated by an Intraoperative Magnetic Stick Here, we report the case of an intraorbital intraconal foreign body that was successfully retrieved by a transnasal endoscopic approach facilitated intraoperatively by a magnetic stick. A 36-year-old man was admitted to our unit with a left-sided intraorbital intraconal metallic foreign body. Following 2 failed attempts via a transconjunctiva approach, we finally recovered the foreign body using transnasal endoscopic surgery. During this procedure, a magnetic stick was used to help us locate and successfully remove the foreign body, grapeshot measuring approximately 0.5 cm in diameter. Visual acuity in the injured eye increased from 0.01 preoperatively to 0.04 6 days after surgical intervention. There were no complications. We therefore propose that in selected patients, the endoscopic transnasal approach is an effective, safe and minimally invasive approach for the removal of intraorbital intraconal foreign bodies. The intraoperative use of a magnet can facilitate the successful location and removal of magnetic metallic foreign bodies. Address correspondence and reprint requests to Jianfeng Liu, MD, Department of Otolaryngology, China-Japan Friendship Hospital, Yinghuadong Street, Chaoyang District, Beijing, China 100029; e-mail: mmconfucius@163.com Received 19 February, 2019 Accepted 31 March, 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.

Unusual Cause of Facial Asymmetry: Sturge-Weber Syndrome Sturge-Weber syndrome is a rare neurocutaneous disease, also called encephalotrigeminal angiomatosis. In this study, we aimed to present a patient with Sturge-Weber syndrome who had atypical radiological findings and with dural arteriovenous fistula. The patient presented with hemifacial asymmetry. Sturge-Weber syndrome may present with atypical radiological findings and additional pathologies. Address correspondence and reprint requests to Hayri Ogul, MD, Department of Radiology, Faculty of Medicine, Ataturk University, 25240 Erzurum, Turkey; E-mail: drhogul@gmail.com Received 21 February, 2019 Accepted 20 March, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Removal of Foreign Bodies in Orbit-Zygomatic-Maxillary Complex Trauma is one of the leading causes of death worldwide. Due to its anatomy and position in the facial skeleton, the orbit becomes a region susceptible to trauma which may also involve the penetration of foreign bodies (FBs). These events can have serious repercussions depending on their extent due to the proximity of the orbit with other noble structures of the face and skull. Because of this, a system of prehospital management of traumas must be established, in order to promote a better prognosis for patients. The present study aims to report the case of a patient suffering from a motorcycle accident with multiple fragments of FBs in the region of orbit-zygomatic-maxillary complex. The emergency surgical removal of the fragments was performed by a multidisciplinary team, involving Ophthalmology and Oral and Maxillofacial Surgery and Traumatology (OMST). Wound cleansing and debridement were performed with subsequent removal of the foreign bodies by the OMST team, in addition to the reduction and fixation of related fractures. As for Ophthalmology, the evisceration of the affected eye was performed due to its anatomical and functional impairment. The patient is 12 months postoperatively, with no aesthetic or functional complaints regarding OMST. The anatomical knowledge of the traumatized region, besides the establishment of the conduct regarding the removal of possible associated foreign bodies are required so that the success of the treatment can be obtained, aiming to minimize the damages to the patient. Address correspondence and reprint requests to Edson Luiz Cetira Filho, DDS, MSc, Rua Monsenhor Furtado, 1273, Rodolfo Teófilo, Fortaleza, CE 60430-355, Brazil; E-mail: edson.cetira@hotmail.com Received 3 March, 2019 Accepted 28 March, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Head Shape Retention Following Helmet Therapy for Deformational Plagiocephaly Background: The aim of the present study was to evaluate whether any change can be expected in the 6-month period after completing treatment with a molding helmet for deformational plagiocephaly. A retrospective review of helmeted patients from a deformational plagiocephaly clinic from May 2010 to June 2011. Methods: A total of 71 individuals with 6-month follow-up after completion of molding helmet treatment were identified. About 51 males and 20 females ranged in age from 2 to 10 months at initial treatment. The main outcome measure was the amount of change in head shape in the 6-month period following molding helmet therapy. Results: During the course of helmet treatment cephalic index and cranial vault asymmetry both decreased significantly (P < 0.001). Posthelmet follow-ups revealed a further decrease in cephalic index (P < 0.001). Although the cranial vault asymmetry decreased slightly between the final helmeting visit and the follow-up visit, this change was not statistically significant (P = 0.292). Controlling for other factors, continued normalization was not significantly related to helmeting duration. Conclusion: Findings revealed both cephalic index and cranial vault asymmetry improved while in the helmet. During the 6 months following helmet treatment, cephalic index continued to improve; cranial vault asymmetry changed only insignificantly in this same period. Address correspondence and reprint requests to Sybill D. Naidoo, PhD, CPNP, 660 S Euclid, Campus Box 8238, St Louis, MO 63110; E-mail: naidoos@wustl.edu Received 4 March, 2019 Accepted 24 March, 2019 Dr Naidoo is a speaker for Hanger Clinic and Orthomerica. Dr Patel is a speaker for Hanger Clinic and a consultant for Stryker. 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.

Coexistence of Antrochoanal Polyp and Fibrous Dysplasia in the Maxilla The authors report an unusual case of coexistence of antrochoanal polyp (ACP) and fibrous dysplasia (FD) in the maxilla. To the best of our knowledge, this condition has never been reported in the literature. The complete removal of the ACP through endoscopic sinus surgery was attained and FD was ultimately diagnosed by histopathological examination. It is hypothesized that chronic inflammation or irritation due to FD has an effect on the occurrence of ACP. Address correspondence and reprint requests to Sang Chul Lim, MD, PhD, Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Medical School and Hwasun Hospital, 322, Seoyang-ro, Hwasun, Jeonnam, South Korea 58128; E-mail: limsc@jnu.ac.kr Received 14 March, 2019 Accepted 10 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

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.

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