Craniofacial Surgery

The Surgical Treatment of a Large Cortical Atherosclerotic Middle Cerebral Artery Aneurysm Presenting With Parietal Lobe Infarction Distal MCA aneurysms are rarely seen in daily neurosurgical practice and they are, more commonly associated with infectious processes. Here, the authors present a 65-year-old, patient who had an atherosclerotic M4 segment located aneurysm. It was confirmed, that the aneurysm was not related with any infectious process. The patient had, presented clinically by a parietal infarction and she had been successfully operated. The neuronavigation system for this particular case aided us for a precise localization of the aneurysm and gave a chance for a smaller craniotomy. Address correspondence and reprint requests to Gulden Demirci Otluoglu, MD, Merdivenkoy Mah. 23 Nisan Sk. No: 17, 34732. Kadiköy, Istanbul, Turkey; E-mail: guldendemirci@gmail.com Received 16 April, 2019 Accepted 4 May, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Anatomical Location of the Infraorbital Foramen in Infant Dry Skulls: Implications for Cleft Surgery Background: Infraorbital foramen (IOF) is an important anatomical landmark in cleft lip surgery. The location of IOF within the maxilla of infants is different from adults. However, little information about anatomy of IOF in infants exists in the literature. This study aims to determine the location of IOF in infant dry skulls based on key surgical landmarks. Methods: All dry skulls under age 2 years old were selected from the Hamann-Todd Human Osteological Collection at the Cleveland Museum of Natural History (Cleveland, OH). Specimens without cranial bones or complete maxilla were excluded. Seven anatomical measurements were taken on each side of the face for each individual skull (14 measurements for each skull). Anatomical landmarks used for the measurements included infraorbital rim, aperture piriformis, alveolar ridge, zygomaticomaxillary buttress, anterior nasal spine (ANS), and inferolateral corner of the aperture piriformis. Results: Twenty-seven halves of 14 dry skulls were included in the final analysis. The mean age of specimens was 0.57 years. Mean distances from infraorbital foramen to infraorbital rim, aperture piriformis, alveolar ridge, zygomaticomaxillary, and ANS buttress were 4.11 ± 0.82, 9.4 ± 1.62, 12.7 ± 2.71, 11.7 ± 1.54, and 18.4 ± 2.11 mm, respectively. Conclusion: This study also shows that the infraorbital foramen in infants is located at the level of the ANS or within 2 mm higher and that the distance between the infraorbital rim and foramen is only 3 to 4 mm. These findings should be applied to the cleft population with discretion. Address correspondence and reprint requests to Fatma Betul Tuncer, MD, 30 N 1900 E Rm, Salt Lake City, UT 84132; E-mail: fatma.tuncer@hsc.utah.edu, fbetultuncer@gmail.com Received 17 February, 2019 Accepted 22 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

The Characteristics of Lower Eyelid "Reverse Ptosis" After Reconstruction of Orbital Floor Wall Fracture Using Transconjunctival Approach The purpose of this study was to evaluate the changes of lower eyelid position and the incidence of reverse ptosis after reconstruction of orbital floor fracture. The authors retrospectively reviewed the clinical records of patients who received reconstruction of orbital floor wall fractures between 2014 and 2017. Digital photographs were taken preoperatively, and at 1 week, 1 month, and 3 months postoperatively. Main measurements were marginal reflex distance 2 (MRD 2), which was measured by analyzing the digital photographs using ImageJ software. Among 264 patients with orbital wall fracture, The authors enrolled 32 eyes (18 right eyes and 14 left eyes) of 32 patients (21 males and 11 females) with a mean age of 32.1 years (range, 16–57 years). 7 (21.9%) of 32 patients had reverse ptosis at postoperative 3 months. When MRD2 of affected eye was compared based on the fellow eye, 7 patients with reversed ptosis showed a definite MRD 2 decrease (>1 mm) of affected eye from postoperative 1 month. Age showed a significant negative correlation with the difference of MRD2 between affected and fellow eye at postoperative 1 and 3 months (r = −0.378, P = 0.033 and r = −0.372, P = 0.036, respectively). Postoperative complications were not observed in all patients. The transconjunctival access in orbital floor wall surgery is a safe and useful surgical approach. However, some may have a reverse ptosis postoperatively, especially older patients. Reverse ptosis is a major clinical finding that should not be overlooked in post-operative follow-up. Address correspondence and reprint requests to Sehyun Baek, Department of Ophthalmology, Korea University College of Medicine, 73, Inchon-ro, Seongbuk-gu, Seoul 02841, Korea; E-mail: shbaek6534@korea.ac.kr Received 8 October, 2018 Accepted 8 May, 2019 Conception and design of the study, conduct of study, collection and management of data, data analysis, data interpretation, preparation, review, and approval of the manuscript by JP, SK, and SB. The study was approved by the Institutional Review Board of Korea University Guro Hospital. The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Brow Ptosis: Is Transblepharoplasty Internal Browpexy Suitable for Everyone? Purpose: Transcutaneous internal browpexy can provide patients with mild-to-moderate lateral brow ptosis, stabilization and modest lift of the lateral brow. Questions regarding effectiveness of this procedure and appropriate indications remain. Methods: The authors measured consecutive patients who underwent upper eyelid blepharoplasty with transblepharoplasty internal browpexy (TIB) September 2014 to December 2017. Pre- and postoperative brow elevation was assessed based on before and after photographs of each patient. Patient photographs were assessed for medial and lateral brow elevation, brow contouring and asymmetry. Optimal lateral brow elevation was classified as bilateral symmetrical and above the supraorbital rim for women, and symmetrical and at the supraorbital rim for men. Results: A total of 239 patients underwent bilateral TIB and 39 underwent unilateral TIB (517 eyelids in total). Pre- and post-operative measurements were taken in 98 patients (41%), with an average elevation of the lateral brow position of 2.54 mm. Six patients had an underlying infection in the first postoperative week that resolved completely. Three patients underwent a second stage direct brow lift repair and 3 needed unrecognized ptosis repair as a second stage. Conclusions: Transblepharoplasty internal browpexy is an important tool that can be used in most patients with lateral and central brow ptosis, asymmetric brow ptosis and irregular contour of the brow. Additionally, browpexy adds to the success and longevity of upper blepharoplasty, while preventing early recurrence of lateral upper eyelid hooding. Patients with significant ptosis, heavy brows, medial greater than lateral ptosis, and post-facial palsy may not be good candidates for this procedure. Address correspondence and reprint requests to Arie Y. Nemet, MD, Department of Ophthalmology, Meir Medical Center, Kfar Sava, Israel; E-mail: nemet.arik@gmail.com Received 27 December, 2018 Accepted 24 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.

Incidence of Preventable Nonfatal Craniofacial Injuries and Implications for Facial Transplantation Introduction: The number of patients who may benefit from evaluation for face transplantation in the United States (US) remains largely unknown. The goal of our study was to better delineate the pool of patients who might benefit from face transplant evaluation based on the characteristics and mechanisms of injury of previously reported face transplant recipients. Methods: The authors utilized data from the National Electronic Injury Surveillance System-All Injury Program in this study. The US Census Bureau data were used for population estimates. Inclusion and exclusion criteria were determined based on the characteristics of face transplant recipients to date, and the mechanisms of injury they sustained ultimately necessitating face transplantation. Statistical significance was reached if P <0.05. Results: The estimated annual incidence of preventable craniofacial injuries from firearms (44,266–58,299; 31.7% increase), burns (5712–19,433; 240.2% increase), and animal attacks (5355–14,666; 173.9% increase) increased from 2005 to 2014, whereas the estimated annual incidence of craniofacial injuries from machinery (3927–2933; 25.3% decrease) decreased between 2005 and 2014. The authors estimate the annual incidence rate to fall between 32.1 per 100,000 and 58.1 per 100,000 among individuals aged 20 to 64 in the US. Conclusion: In this study, the authors estimate the annual incidence rate of individuals aged 20 to 64 in the US who may benefit from face transplant evaluation and believe that this quantification has the potential to initiate actionable discussions regarding geographical and financial factors affecting access to care in this patient population. Address correspondence and reprint requests to Eduardo D. Rodriguez, MD, DDS, Hansjörg Wyss Department of Plastic Surgery, Helen L. Kimmel Professor of Reconstructive Plastic Surgery NYU Langone Health, 305 East 33rd Street, New York City, NY, 10016; E-mail: Eduardo.Rodriguez@nyumc.org Received 7 November, 2018 Accepted 8 May, 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.

Application of a Layered Muscle Flap Technique for the Reconstruction of the Cupid's Bow and Vermilion in the Repair of Secondary Cleft Lip Deformities In the repair of unilateral cleft lip, the Cupid's bow, and vermilion on the affected side are sometimes lowered excessively. Methods involving skin and mucosa flaps have been used to correct this issue, but they pose some risk of scarring. The authors here describe a layered muscle flap technique that was based on the anatomical research of nasal-labial muscles, especially the levator labii superioris alaeque nasi muscle. This technique can be used to suspend the Cupid's bow and vermilion in secondary unilateral cleft lip repair. Forty-five patients with secondary unilateral cleft lip with excessively lowered Cupid's bows and vermilion on the affected side were included in this study, which lasted 3 years. These patients were treated using the layered muscle flap surgical technique. The heights of specific bilateral landmarks were measured on patient photos and used to define the symmetry of bilateral Cupid's bow and vermilion. The comparison between post-operative and pre-operative symmetries was used to evaluate the post-operative results, and most of them were satisfactory. The results were also mostly well retained in follow-up investigations. This layered muscle flap technique could be effective in selected cases. Address correspondence and reprint requests to Bin Guo, MD, Department of Stomatology, General Hospital of Chinese People's Liberation Army, No. 28, Fuxing Road, Haidian District, Beijing, China; E-mail: guobin0408@126.com Received 17 August, 2018 Accepted 8 May, 2019 This work did not receive funding from any of the following organizations: National Institutes of Health (NIH); Wellcome Trust; Howard Hughes Medical Institute (HHMI) and other(s). 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.

Patient-Specific Reconstruction Utilizing Computer Assisted 3D Modelling for Partial Bone Flap Defect in Hybrid Cranioplasty Purpose: Decompressive craniectomy is a life-saving procedure in the setting of malignant brain swelling. Patients who survive require cranioplasty for anatomical reconstruction and cerebral protection. Autologous cranioplasty remains the commonest practice nowadays, but partial bone flap defects are frequently encountered. The authors, therefore, seek to develop a new technique of reconstruction for cranioplasty candidate with partial bone flap defect utilizing computer-assisted 3D modeling and printing. Methods: A prospective study was conducted to evaluate the outcome of a new reconstruction technique that produces patient-specific hybrid polymethyl methacrylate-autologous cranial implant. Computer-assisted 3D modeling and printing was utilized to produce patient-specific molds, which allowed real-time reconstruction of bone flap with partial defect intra-operatively. Results: Outcome assessment for 11 patients at 6 weeks and 3 months post-operatively revealed satisfactory implant alignment with favorable cosmesis. The mean visual analog scale for cosmesis was 91. Mean implant size was 50cm2, and the mean duration of intra-operative reconstruction was 30 minutes. All of them revealed improvement in quality of life following surgery as measured by the SF-36 score. Cost analysis revealed that this technique is more cost-effective compared to customized cranial prosthesis. Conclusion: This new technique and approach produce hybrid autologous-alloplastic bone flap that resulted in satisfactory implant alignment and favorable cosmetic outcome with relatively low costs. Address correspondence and reprint requests to Peh Hueh Low, MBBS, MS, Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, 16150 Kelantan, Malaysia; E-mail: peh.hueh@gmail.com; Dasmawati Mohamad, PhD, School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, 16150 Kelantan, Universiti Sains Malaysia, Malaysia; E-mail: dasmawati@usm.my Received 22 March, 2019 Accepted 7 May, 2019 This study was supported by the Universiti Sains Malaysia (USM) Research University Grant (RUT grant) (1001/PPSG/852004) from Universiti Sains Malaysia (USM), Kubang Kerian, Kelantan, Malaysia. The third author was supported by USM fellowship scheme. The authors of this manuscript have no affiliations with or involvement in any organization or entity with any financial or non-financial interest in the subject matter or materials discussed in this manuscript. 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.

The Healthcare Cost of Mandibular Nonunions The aim of this retrospective cohort study was to compare the costs and characteristics between isolated mandible fractures and mandibular nonunions. From October 2015 to December 2016, the National Inpatient Sample (NIS) was searched for patients admitted with a primary diagnosis of a mandible fracture. The sample was divided between those admitted for an initial evaluation of an isolated fracture and a fracture nonunion. Demographic descriptors, injury characteristics, and inpatient factors were recorded. A total of 1432 patients were included in the final sample, of whom 51 (3.6%) were admitted for a nonunion. Nonunion patients were significantly older (P < 0.01), and nonunions were more often localized to the body (24 vs 11%; P = 0.02). Compared to that of isolated fractures, a greater proportion of nonunions required open reduction and internal fixation (86 vs 59%; P < 0.01) and bone grafting (37 vs 1.4%; P < 0.01), and nonunions imparted +32.6% greater hospitals costs (median: $10,680 vs 14,162; P < 0.01). In conclusion, compared to isolated mandible fractures, mandibular nonunions occurred in older patients, had a higher frequency in body of the mandible, and utilized significantly more hospital resources per admission. Address correspondence and reprint requests to Kevin C. Lee, DDS, MD, 630 West 168th Street, New York, NY 10032; E-mail: kcl2136@cumc.columbia.edu Received 4 March, 2019 Accepted 25 April, 2019 There are no conflicts of interest declared by any of the authors. 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.

Evaluation of the Foramen Magnum Area Calculated by Different Methods: A Radioanatomic Study Purpose: The main objective of the study was to evaluate the probable diversity in the area of the foramen magnum (FM) calculated by different measuring methods. Methods: The study was conducted on 24 dry skulls, present in the collection of the Anatomy Department, Faculty of Medicine, Mersin University. The area of FM was calculated by different measurement methods including automatic field setting, Teixeria and Radinsky formulas obtained from anatomic (ASM), photographic (PSM) and radiologic (RSM) skull measurements. Results: The areas of FMs calculated by Teixeria formula in RSM, PSM, and ASM were as follows: 857.96 ± 99.97 mm2, 796.68 ± 105.08 mm2, and 820.86 ± 96.40 mm2, respectively. The areas calculated by Radinsky formula in RSM, PSM, and ASM were as follows: 851.37 ± 99.68 mm2, 792.63 ± 104.18 mm2, and 814.85 ± 94.99 mm2, respectively. Lastly, the areas calculated by the automatic field setting of RSM and PSM software were as follows: 799.75 ± 103.38 mm2 and 752.83 ± 105.60 mm2, respectively. Conclusion: Statistical significance was observed between the areas of FM obtained from RSM, ASM, and PSM when calculated by the automatic field setting, Teixeria formula, and Radinsky formula. The authors think that considering the amorphous shape of FM, the automatic field setting of the software should be used to obtain the most accurate numerical data related to the area of FM. Address correspondence and reprint requests to Orhan Beger, Mersin University Faculty of Medicine, Department of Anatomy, Ciftlikkoy Campus, 33343, Mersin, Turkey; E-mail: obeger@gmail.com Received 27 February, 2019 Accepted 12 May, 2019 The authors declare no conflict 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.

Surgical Management of Large Odontogenic Cysts of the Mandible Introduction: Odontogenic cysts are defined as those cysts that arise from odontogenic epithelium and occur in the tooth-bearing regions of the jaws. Cystectomy, marsupialization, or decompression of odontogenic cyst are the most common treatments proposed for this pathology. The aim of this study is to retrospectively evaluate the result of decompression based on the volumetric reduction of the cystic cavity and new bone formation by cone beam computerized tomography (CBCT). Methods: The 16 patients affected by a large odontogenic mandibular cyst were enrolled in the study. All the patients underwent a surgical decompression of the cyst followed by the enucleation after a follow-up ranging from 6 to 9 months according to the volume's reduction and new bone formation. All the patients were evaluated with a CBCT before and after the surgical decompression to measure and analyze the percentage of reduction of the cystic volume before proceeding with the enucleation. Results: The decompression of the cyst showed a reduction of the cystic volume ranging from 38.2% to 54.4% proportionally to the treatment duration. The highest percentage of volume reduction observed was 54.4% in 1 patient followed-up for 9 months, before the surgical enucleation. Conclusion: In our experience, the decompression seems to be the most suitable technique for the primary treatment of large odontogenic cyst of the jaws followed by the enucleation after 6 to 9 months. The CBCT is an objective method to evaluate the cystic volume reduction after the decompression and helps the surgeon with the surgical planning. Address correspondence and reprint requests to Giovanni Dell'Aversana Orabona, Via Pansini 5, Naples, Italy; E-mail: dellaversana@unina.it Received 2 April, 2019 Accepted 9 May, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

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

6948891480

alsfakia@gmail.com