Craniofacial Surgery

Pediatric Blood Management Protocol in Cranial Vault Surgery Background: Cranial vault surgeries are invasive, extensive procedures with blood transfusions being frequently required. Previous interventions have been described to attempt to decrease the transfusion burden. The objective of this study is to determine if a Pediatric Blood Management (PBM) team can reduce transfusion requirements in children undergoing cranial vault surgery. Methods: A protocol was developed which involved preoperative optimization of hemoglobin (Hb), intraoperative use of tranexamic acid, cell saver technology, and blood sparing operative techniques. Patients were preoperatively screened with basic laboratory testing. Retrospective data on 20 consecutive patients who underwent craniofacial surgery prior were used as controls. Prospective data on patients was collected. Results: Groups were similar in age and weight. Postoperative Hb measurements were similar, with the control group 10.9 ± 2.2 g/dL and the intervention arm 9.6 + 2.7 g/dL. Discharge Hb concentrations also were similar with 9.6 ± 1.6 g/dL and 9.7 ± 2.5 g/dL in the control and PBM group, respectively. The rate of transfusion decreased from 80% to 42% after protocol implementation (P = 0.007). During the last 6 months of data collection, the transfusion rate decreased further to 17%. Furthermore, 4 patients were found to have von Willebrand disease preoperatively with only 1 requiring a transfusion. Conclusions: The authors found that the institution of a PBM team reduced the transfusion burden of patients, including complex patients with von Willebrand disease. The use of a multimodal approach to hematologic management optimized patients for their procedures and helped minimize exposure to transfusion associated complications. Address correspondence and reprint requests to John A. Girotto, MD, FACS, 230 Michigan St NE, Grand Rapids, MI 49503; E-mail: John.Girotto@helendevoschildrens.org Received 5 November, 2018 Accepted 12 March, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Dermal-Fat Graft for Facial Contouring in Patients With Craniofacial Microsomia Craniofacial microsomia (CFM) is a variable craniofacial malformation, related to the development of the structures originated from the first and second brachial arches, affecting skeletal tissue, soft tissue, and neuromuscular components. In the situation of subcutaneous tissue and chewing muscles hypoplasia, free tissue transfer is a treatment option. Dermal-fat graft allows easy modeling during surgery, volumetric gain and improvement of asymmetry. The aim of this study was to evaluate the facial contour and the percentage of symmetry after the use of dermal-fat graft in patients with CFM, who had already submitted to osteotomies, attended at the Associate Center for Cleft Lip and Palate (CAIF) during 2001 to 2018. For analysis, the authors selected 17 patients who fulfilled the above prerequisites. The symmetry study was done by the analysis of preoperative and postoperative photographs in the Image J software. Two standard points were used: nasal base and upper lip limit. On the nasal base, the preoperative analysis showed a hypoplastic side with a median of 93.00% of the normal side size, rising to 97.78% in the postoperative period. On the upper lip limit, the preoperative analysis showed a median of 87.80% and, in the postoperative period, 98.15%. Analysis of the interaction between the operative moments and the modified Pruzansky classification showed that there were no significant differences between grades. Long-term evaluation demonstrated that the use of a dermal-fat graft for correction of facial symmetry was effective and close to 100%, regardless of the degree of hypoplasia of the patient. Address correspondence and reprint requests to Renato da Silva Freitas, MD, PhD, Plastic Surgery Unit – Hospital de Clínicas (UFPR), Rua General Carneiro, 181, Curitiba, Parana 80060–900, Brazil; E-mail: dr.renato.freitas@gmail.com Received 21 February, 2019 Accepted 18 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.

Composite Nasoseptal Flap for Palate Reconstruction Palatal fistulae represent a pathological connection from the oral cavity through the hard or soft palate to the nasal cavity and can present a significant reconstructive dilemma. Surgical correction of palatal fistulae is often limited by prior treatment, including ablative procedures and radiotherapy, or previous reconstructive attempts. In light of these challenges, the nasoseptal flap represents an excellent adjacent source of vascularized tissue which may be suitable for palatal fistula repair with minimal donor site morbidity, low associated risks, and a short recovery period. The purpose of this study was to fully understand the potential utility of this reconstructive option, including the ability to harvest a composite flap including both septal cartilage and contralateral mucoperichondrium. In this single institution prospective study consisting of a series of 5 cadaver dissections, primary outcome measures were the anterior reach of the flap as compared to the anterior nasal spine and the size of the palatal defect that the nasoseptal flap could be used to successfully reconstruct. Composite flaps were successfully harvested in continuity with a disc of septal cartilage and contralateral mucoperichondrium, providing structural integrity to the reconstruction and the ability to anchor the flap to the native hard palate mucosa. The nasoseptal flap's maximum anterior reach was within 2.0 cm (standard deviation of 0.1 cm) from the anterior nasal spine and could reliably reconstruct palate defects of 2.5 cm or less. The nasoseptal flap provides a viable regional option for reconstructing defects of the hard palate. Prospective clinical trials are needed to investigate long-term reconstructive and functional outcomes of the composite nasoseptal flap in palatal reconstruction. Address correspondence and reprint requests to Joseph Zenga, MD, Department of Otolaryngology-Head & Neck Surgery, Division of Head and Neck Surgical Oncology and Reconstruction, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226; E-mail: jyzenga@mcw.edu Received 22 December, 2018 Accepted 24 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Total and Unilateral Peak Nasal Inspiratory Flow and Unilateral Visual Analogue Scale: Rationale in Indication and Outcomes of Septoplasty? Septoplasty is one of the most frequently performed procedures in otorhinolaryngology. Proper selection of patients for septoplasty as well as examination is essential for good outcome of surgery. The aim of this study was to evaluate the suitability of combination of 2 simple, cheap, and easily performed examinations for indication and outcomes of septoplasty to evaluate the effectiveness in this type of surgery. Seventy patients were enrolled from 2 tertiary centers from the period of April 2017 to March 2018, who all underwent septoplasty for nasal septal deviation. Total and unilateral peak nasal inspiratory flow (PNIF), unilateral visual analogue scale, and nasal endoscopy for indication and outcomes of septoplasty were performed. Furthermore, assessment of possible correlation between subjective and objective data before and 3 months after septoplasty was done. Statistical analysis was carried out on the obtained data. Postoperatively the total and both unilateral PNIF measurements increased significantly compared with corresponding preoperative values and similarly means of visual analogue scale scores on both sides decreased 3 months after the procedure. No significant correlation was seen between objective and subjective outcomes neither before the surgery, nor postoperatively. The study confirmed the suitability of using PNIF as a simple and inexpensive tool that can be a reasonable alternative to rhinomanometry and which is able to reflect changes after septoplasty. Simultaneously, along with the expected improvement in the total PNIF and unilateral PNIF on deviated side, a slight but significant improvement in PNIF values on the nondeviated side was also demonstrated. Address correspondence and reprint requests to Petr Schalek, MD, PhD, ENT Department of Third Medical Faculty, Charles University and University Hospital Královské Vinohrady, Šrobárova 50, 100 34 Prague, Czech Republic; E-mail: schalekp@hotmail.com Received 24 November, 2018 Accepted 25 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Scalp Arteriovenous Malformation Resection With Novel Technique of Endovascular and Surgical Devascularization A 26-year-old female patient referred to our emergency service with complaint of increase headache and swelling of the left upper eye led. External examination of the head revealed left frontal scalp and left eye led swelling, which was soft and pulsatile. Brain computed tomography (CT) scan and magnetic resonance imaging showed left frontal soft tissue and left periorbital swelling with crowded left intraorbital contents. Brain CT angiography showed vascular mass lesion in the left frontal subcutaneous lesion. Six-vessel cerebral angiography showed left frontal scalp arteriovenous malformation (AVM) supplied from the right and left superficial temporal arteries from the external carotid artery and from the left supraorbital artery arising from the ophthalmic artery of the internal carotid artery. By endovascular technique, bilateral superficial temporal arteries were occluded with Onyx 18 (Micro-Therapeutics, Inc., Irvine, CA). The patient was operated after 2 days. Left eye-brow incision was performed and the supraorbital artery was exposed, ligated, and cut. Left fronto-temporal skin incision was performed and the AVM totally excised. No intraoperative nor postoperative complications seen. Follow-up cerebral angiography showed total resection of the AVM. Address correspondence and reprint requests to Bashar Abuzayed, MD, Consultant Neurosurgeon., The Specialty Hospital, PO Box: 930186. Amman. Jordan; E-mail: sylvius@live.com Received 18 March, 2019 Accepted 19 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Artificial Intelligent Model With Neural Network Machine Learning for the Diagnosis of Orthognathic Surgery Diagnosis and treatment planning are the most important steps in the orthognathic surgery for the successful treatment. The purpose of this study was to develop a new artificial intelligent model for surgery/non-surgery decision and extraction determination, and to evaluate the performance of this model. The sample used in this study consisted of 316 patients in total. Of the total sample, 160 were planned with surgical treatment and 156 were planned with non-surgical treatment. The input values of artificial neural network were obtained from 12 measurement values of the lateral cephalogram and 6 additional indexes. The artificial intelligent model of machine learning consisted of 2-layer neural network with one hidden layer. The learning was carried out in 3 stages, and 4 best performing models were adopted. Using these models, decision-making success rates of surgery/non-surgery, surgery type, and extraction/non-extraction were calculated. The final diagnosis success rate was calculated by comparing the actual diagnosis with the diagnosis obtained by the artificial intelligent model. The success rate of the model showed 96% for the diagnosis of surgery/non-surgery decision, and showed 91% for the detailed diagnosis of surgery type and extraction decision. This study suggests the artificial intelligent model using neural network machine learning could be applied for the diagnosis of orthognathic surgery cases. Address correspondence and reprint requests to Tae-Woo Kim, DDS, PhD, Department of Orthodontics, School of Dentistry, Dental Research Institute, Seoul National University, 101 Daehakro, Jongro-Gu, Seoul 110-749, Republic of Korea; E-mail: taewoo@snu.ac.kr Received 3 December, 2018 Accepted 22 April, 2019 This study was supported by grant no 05-2016-0014 from the Seoul National University Dental Hospital Research Fund. 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.

Clinical Characteristics and Microsurgery Treatment of Anterior Cranial Fossa Dural Arteriovenous Fistula Anterior cranial fossa dural arteriovenous fistulas (DAVFs) represent 6% of all intracranial DAVFs and have a high risk of intracranial hemorrhage. To analyze the clinical characteristics and microsurgery treatment of anterior cranial fossa DAVFs, a retrospective review of 21 patients with anterior cranial fossa DAVFs undergoing microsurgery was performed, including 8 bleeding patients and 13 non-bleeding patients. The Glasgow coma scale (GCS) scores were used to evaluate the conscious states of 8 bleeding patients before and after operation. All patients had no obvious complications and the clinical symptoms were improved after operation. No abnormal fistulas and drainage veins were detected by digital subtraction angiography postoperatively. The GCS scores of 8 bleeding patients showed that the conscious states became better than pre-operation. Of the 21 patients, 9 patients were followed up without recurrence. Taken together, microsurgery is an effective method for the treatment of anterior cranial fossa DAVFs and it is very important for the improvement of bleeding patients’ conscious states. Address correspondence and reprint requests to Handong Wang, PhD, Department of Neurosurgery, Jinling Hospital, 305 East Zhongshan Road, Nanjing 210002, Jiangsu Province, P.R. China; E-mail: njhdwang@hotmail.com Received 11 September, 2018 Accepted 30 April, 2019 This work was supported by Grants from the National Natural Science Foundation of China (No. 81672503 and 81702484). The authors declare that they have no conflict of interests. 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.

Role of Autologous Fat Injection in Neglected Patients With Anterior Plagiocephaly Anterior plagiocephaly is a type of non-syndromic craniosynostosis requiring surgery. In this study, the authors have presented 15 neglected patients with anterior plagiocephaly. Two of patients had moderate plagiocephaly whereas others had mild plagiocephaly. A total of 38 procedures (fat injections) were performed on these patients. Following procedures, 2 of patients were under corrected, 2 of who were over corrected, and others were adequate corrected. One of the patients developed fat necrosis. None of them showed persistent over correction. Authors believe that autologous fat transplantation is a safe and effective method, in patients with anterior plagiocephaly who have not been operated, to improve patients’ appearance and, subsequently, their self-esteem as well as their social function. Address correspondence and reprint requests to Abdoljalil Kalantar-Hormozi, MD, Department of Plastic and Craniofacial Surgery, Medical College of Shahid Beheshti University of Medical Science (SBMU), 15 Khordad Hospital, Azodi Street, Karim Khan Blvd, Tehran, Iran; E-mail: kalantarj@yahoo.com Received 18 January, 2019 Accepted 25 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Comparison of Patient Satisfaction Between Composite and Dorsum Augmentation-Only Nasal Reconstructions With Diced Cartilage Graft Wrapped in Fascia The comparison of patient satisfaction with the use of diced cartilage graft wrapped in fascia (DCF) graft in composite versus dorsum augmentation-only reconstructions (DAOR), technical hints and complications in our series, affecting the end-result and the patient satisfaction (PS) has been presented. Between 2013 and 2018 the DC-F graft is used in 32 rhinoplasty cases. Nine of patients have had composite reconstruction (CR). The DAOR has been needed for 23 of patients. The follow-up period has been 2 months to 3 years. The authors have obtained satisfactory results in 24 cases but some untoward progress in 8 cases. A questionnaire was prepared and asked all patients for the assessment of the satisfaction from appearance, breathing, self-esteem, and positive psychological effect. The learning curve for rhinoplasty should be calculated for, hump reduction, crooked nose, augmentation rhinoplasty, and so on. separately which is also relevant for the use of a DC-F graft. Placing the DC-F over a straight platform, choosing the accurate graft and fascia material wisely, proper tailoring of DC-F, sliding it under the skin-superficial musculoaponeurotic system properly etc. determine the quality of the end result and the degree of PS. Operating on the DAOR are relatively more comfortable compared to CRs but responses to our questionnaire denote higher degrees of satisfaction in CR cases. Utilization of the DC-F graft in secondary rhinoplasties for dorsum augmentation provides satisfactory results. The degree of PS with the DC-F reconstruction seems to have an adverse correlation with the extent of deformities that you start with. Address correspondence and reprint requests to Aret Çerçi Özkan, MD, Incirli Caddesi Bayrak Apt. No 89/7 Bakirköy, Istanbul, PK. 34147 Türkiye, Turkey; E-mail: aretmd@hotmail.com Received 1 February, 2019 Accepted 22 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Transcranioplasty Ultrasound Through a Sonolucent Cranial Implant Made of Polymethyl Methacrylate: Phantom Study Comparing Ultrasound, Computed Tomography, and Magnetic Resonance Imaging Background: Current methods of transcranial diagnostic ultrasound imaging are limited by the skull's acoustic properties. Craniotomy, craniectomy, and cranioplasty procedures present opportunities to circumvent these limitations by substituting autologous bone with synthetic cranial implants composed of sonolucent biomaterials. Objective: This study examined the potential to image the brain using transcranioplasty ultrasound (TCU) through a sonolucent cranial implant. Materials and Methods: A validated adult brain phantom was imaged using computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound without an implant. Next, for experimental comparison, TCU was performed through a sonolucent implant composed of clear polymethyl methacrylate. Results: All imaging modalities successfully revealed elements of the brain phantom, including the bilateral ventricular system, the falx cerebri, and a deep hyperdense mass representing a brain tumor or hematoma. In addition, ultrasound images were captured which closely resembled axial images obtained with both CT and MRI. Conclusion: The results obtained in this first-ever, preclinical, phantom study suggest TCU is now a viable immediate and long-term diagnostic imaging modality deserving of further clinical investigation. Address correspondence and reprint requests to Chad Gordon, DO, FACS, Division of Neuroplastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, JHOC, 8th Floor, 601N. Caroline St., Baltimore, MD 21287; E-mail: cgordon@jhmi.edu Received 11 February, 2019 Accepted 24 April, 2019 There was no external funding used for this study. CG is a consultant for Stryker and Longeviti Neuro Solutions. JH and CG are stockholders of Longeviti Neuro Solutions. None of the other authors have any conflicts to report. © 2019 by Mutaz B. Habal, MD.