Comprehensive Application of Autologous Costal Cartilage Grafts in Rhino- and Mentoplasty Background: Underdevelopment of nose and chin in East Asians is quite common. Rhinoplasty and mentoplasty are effective procedures to solve the above-depicted defects and can achieve remarkable cosmetic effects. An autologous costal cartilage graft has become an ideal material for rhinoplasty, especially for revision surgery. However, many problems in the clinical application of costal cartilage remain unresolved. This study is to investigate application strategies of autologous costal cartilage grafts in rhino- and mentoplasty. Methods: The methods involved are as follows: application of an integrated cartilage scaffold; comprehensive application of diced cartilage; and chin augmentation of an autologous costal cartilage graft. Results: In this study, satisfactory facial contour appearance was immediately achieved in 28 patients after surgery; 21 patients had satisfactory appearance of the nose and chin during the 6- to 18-month follow-up. Cartilage resorption was not observed. Two patients had nasal tip skin redness and were cured after treatment. Conclusion: This procedure can be used to effectively solve: curvature of the costal cartilage segment itself; warping of the carved costal cartilage; and effective use of the costal cartilage segment. The procedure has achieved satisfactory outcomes, and its application is worth extending to clinical practice. Address correspondence and reprint requests to Yu-Guang Zhang, MD, PhD, and Xiao-Ming Sun, MD, PhD, Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhi Zao Ju Road, Shanghai 200011, China; E-mails: zhangyg18@126.com, 817073@sh9hospital.org Received 15 January, 2019 Accepted 12 May, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Role of Intraoperative Clean Surgical Margin Determined With Lesion Size and Duration to Obtain Apropriate Histological Clean Surgical Margin in High-Risk Basal Cell Carcinoma Patients, According to National Comprehensive Cancer Network Criteria We aimed to elucidate the role of intraoperative clean surgical margin (iCSM) determined according to lesion size and duration to obtain appropriate histological clean surgical margin (hCSM) in high-risk basal cell carcinoma (BCC) patients evaluated according to National Comprehensive Cancer Network (NCCN) criteria considering the tumor size and/or location. The contribution of lesion area to determine iCSM was also evaluated. Patients with high-risk BCC requiring surgical management were included. iCSM, hCSM, and clinical variables including sec, age, longest edge, location and area, and follow-up duration were recorded. In total, 96 lesions were evaluated. Lesions were mostly located in the mask area and other face region (93.8%). Lesions located on the nose comprised 50%, 34.1%, and 26.3% in the BCC-5, BCC-7, and BCC-10 lesions, respectively. The hCSMs were positive in 11.5%, 9.1%, and 3.8% of the BCC-5, BCC-7, and BCC-10 lesions, respectively. The deep surgical margin was positive in 15.4%, 4.5%, and 7.7% of the BCC-5, BCC-7, and BCC-10 lesions, respectively. The calculated risk for the positive surgical margin if the BCC-10 lesions were done like the BCC-7 was 15.4%. No recurrence was during follow-up duration. As supported by the findings of the present study, to obtain an adequate hCSM in the high-risk BCC lesions, the iCSM determined according to NCCN recommendations may not be optimal. Nevertheless, after their categorization according to lesion size and disease duration for excision with 5-, 7-, and 10-mm iCSMs, it is possible to obtain a small but important improvement in the outcome of patients. Address correspondence and reprint requests to Nese Kurt Ozkaya, MD, Department of Plastic Reconstructive Aesthetic Surgery, Cumhuriyet University Faculty of Medicine, 58140 Sivas, Turkey; E-mail: ozkayanesekurt@gmail.com Received 4 February, 2019 Accepted 10 May, 2019 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). The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Enophthalmos: Exploration of Quantitative Treatment With Retro-Orbital Fat Globules Injection Craniomaxillofacial and plastic surgeons are often confronted with patients who present with enophthalmos caused mainly by trauma. In many patients, one-stage reconstruction repairs only the bony orbit, leaving intact the disfiguring enophthalmos. Thus, some filler is needed to restore the normal volume of the orbit. The authors describe a technique to correct such deformation safely and effectively. Data were collected from 30 enophthalmic patients (average age 36.67 ± 11.66 years) who underwent retro-ocular injections of fat globules between August 2014 and July 2018. CT helped identify a safe injection site, and specific CT measurements quantified the volume of fat globules required. There was a significant difference between the preoperative and postoperative values for lateral orbital protrusion (P < .01), superior orbital protrusion (P < .01), and orbital volume (P < .01). Most patients were satisfied with the outcome. There were no significant complications. Injecting fat globules into the retro-orbital area is an effective technique for correcting enophthalmos deformity. Address correspondence and reprint requests to Wei Wu, MD, and Ying Zhang, MD, Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, 639 Zhi Zao Ju Road, Shanghai 200011, China. Wei Wu, MD, E-mail: 2768153319@qq.com; zyinghh@163.com Received 10 April, 2019 Accepted 30 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.

Use of the One-Milliliter Syringe in Mimicking the Skin Hook for Primary Cleft Lip Repair No abstract available

Contemporary Characterization of Injury Patterns, Initial Management, and Disparities in Treatment of Facial Fractures Using the National Trauma Data Bank Background: Contemporary description of facial fracture patterns and factors associated with early operative intervention at trauma centers is lacking. The purpose of this study was to characterize injuries and initial treatment patterns of patients suffering from facial fractures. Methods: Using the National Trauma Databank from 2007 to 2015, patients suffering from facial fractures were included. Demographics, injury characteristics, and outcomes including operative interventions were assessed. Results: Over 9 years, 626,270 patients were included: 74.5% were male, 39.0% suffered traumatic brain injury (TBI), and 23.3% severe noncraniofacial injuries (chest, abdomen, and/or extremity Abbreviated Injury Score ≥3). A total of 537,594 (85.8%) patients were admitted and 184,206 (34.3%) underwent operations for their facial injuries during the index hospitalization. The frequency and patterns of fractures varied by age, sex, race, and mechanism of injury. Operative intervention rates were highest for mandible (63.2%) and lowest for orbit fractures (1.0%). Multiple regression revealed that multiple factors were independently associated with the odds of early fracture repair including: female versus male (odds ratio [95% confidence interval]: 0.96 [0.94–0.98]), age >65 versus <18 years (0.62 [0.59–0.64]), non-white race (0.95 [0.94–0.97]), uninsured versus Medicaid (0.88 [0.86–0.90]), hospital bed size (>600 vs ≤200 beds, 1.67 [1.61–1.73]), TBI (0.70 [0.69–0.71]), and C-spine injury (0.93 [0.90–0.96]). Conclusions: Facial fractures are common among many demographic cohorts, and multiple patient and injury-specific factors influenced fracture patterns and management. Early operative intervention was highest for mandible fractures and lowest for orbit fractures. Multiple factors including age, sex, insurance status, hospital characteristics, and race/ethnicity were independently associated with early operative intervention, highlighting disparities in care. Address correspondence and reprint requests to Philip J. Wasicek, MD, Division of Plastic and Reconstructive Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD 21201; E-mail: pwasicek@som.umaryland.edu Received 2 June, 2019 Accepted 18 June, 2019 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). The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Facial Rejuvenation Using a Mixture of Calcium Hydroxylapatite Filler and Hyaluronic Acid Filler Calcium hydroxylapatite filler is a popular dermal filler, as it provides long-lasting results. However, it sometimes undergoes unexpected early volume loss, due to rapid gel absorption before neocollagenesis. To compensate for this phenomenon, hyaluronic acid filler was added to calcium hydroxylapatite filler for injection as a mixture. Twenty-five patients who scored 1 or 2 on the Merz 5-point scale for the nasolabial fold and jawline were injected with 3.0 mL of the mixture. The mixture was prepared with 1.0 mL of hyaluronic acid filler, 0.5 mL of lidocaine, and 1.5 mL of calcium hydroxylapatite filler. A visual analog scale (VAS) and the 5-point global satisfaction scale (GSS) were used for objective and subjective assessments. In a subset of patients, for histologic analysis, 0.1 mL of the mixture and 0.1 mL of only calcium hydroxylapatite filler were injected into the right and left postauricular areas, respectively. The histologic analysis was performed 6 months after implantation. The mean VAS and GSS scores for both sets of wrinkles were above “fair” at every follow-up, including at short-term and long-term periods. The skin biopsies from both postauricular areas from selected patients showed increased dermal collagen bundles without inflammation. The mixture of calcium hydroxylapatite filler and hyaluronic acid filler maintained constant volume with high satisfaction, as hyaluronic acid filler compensated for the unexpected early volume loss of calcium hydroxylapatite filler. This procedure can be applied safely, and it is also convenient, because no retouching procedure is needed. Address correspondence and reprint requests to Jang Hyun Lee, MD, PhD, Department of Plastic and Reconstructive Surgery, Hanyang University Guri Hospital, 153, Gyeongchun-ro, Guri-si, Gyeonggi-do 11923, Korea, E-mail: pslee@hanyang.ac.kr; Sun Woo Lee, MD, Lee Plastic Surgery Clinic, 132, Jong-ro, Jongno-gu, Seoul 03193, Korea, E-mail: psdoctor25@empas.com Received 27 September, 2018 Accepted 24 May, 2019 This work was supported by Merz ASIA PACIFIC. 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 Readmission After Cleft Lip Repair Background: Cleft lip is the most common craniofacial malformation with an incidence of 1 in 700 live births. Our study sought to evaluate incidences and risk factors readmission following CLP repair using a well-validated national surgical database. Methods: All cleft lip repairs performed between 2012 and 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program Pediatric Database. Patient demographics, surgical variables, and reasons for readmission were analyzed and identified. A binary logistic regression was performed to identify factors independently associated with readmission following cleft lip repair. Results: The 4550 cleft lip repairs were identified with a thirty-day readmission rate of 3.8% (173 patients). A higher incidence of readmission was identified among patients with developmental delay (P ≤0.001), seizure disorder (P <0.001), structural central nervous system abnormality (P ≤0.001), steroid use within 30 days (P ≤0.001), a requirement for nutritional support (P <0.001), and ASA of 3 or higher (17.3% vs 9.9%, P <0.001). Readmitted patients were more likely to have deep incisional surgical site infections (P <0.001), deep wound dehiscence (P = 0.002), reoperation (P <0.001), pneumonia (P <0.001), and unplanned intubation (P <0.001). Multivariate regression identified seizure disorder (OR = 3.3; 95% CI = 1.3–8.3; P = 0.012) and steroid use within 30 days (OR = 3.8; 95% CI = 1.1–12.2; P = 0.030) as independently associated with readmission. The mean time of readmission was 9 days after operation. Conclusion: Patients with seizure disorder and steroid use were significantly more likely to be readmitted. Physicians should be cautious with management of patients with these risk factors. Address correspondence and reprint requests to Michael Alperovich, MD, Section of Plastic Surgery, Department of Surgery, Yale University School of Medicine, 330 Cedar Street, New Haven, CT 06510; E-mail: michael.alperovich@yale.edu Received 2 December, 2018 Accepted 15 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.

Preliminary Analysis From the Craniofacial Collaboration United Kingdom Developmental Outcomes in Children With Sagittal Synostosis The Craniofacial Collaboration United Kingdom (CC-UK) was established across the 4 Highly Specialized Craniofacial Centres (HSCCs) in the UK in 2015. This is the first wave of data to be analyzed, looking at 3-year-old children with sagittal synostosis who have had primary corrective surgery. This is a comprehensive, homogenous dataset, looking at parental measures of development and behavior. The results indicate that the majority of children are rated by their parents as falling within one standard deviation of the mean for both developmental and behavioral measures. However, there was a trend across the age groups within the sample which, although not statistically significant, indicates that more developmental difficulties may become apparent as children get older. Behavior was rated as more problematic, and the areas of greatest parental concern were Conduct (challenging or confrontational behavior) and Hyperactivity domains, where 24% of children were rated as within the clinically significant range. Although the majority of children were rated as falling within the average range, the difference in the mean between the sagittal and the normative group was significant in 5 of the 6 behavioral domains. Further research is required to examine whether these findings are stable over time and to look at the mechanism which might be driving these changes. It is anticipated that future CC-UK analysis will elucidate this more clearly. Address correspondence and reprint requests to Dr Helen Care, D.Clin.Psych, Oxford Craniofacial Unit, LG1 West Wing, Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington Oxford, OX3 9DU, UK; E-mail: helen.care@ouh.nhs.uk Received 10 December, 2018 Accepted 27 March, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Clinical Trial of Manual Reduction of Temporomandibular Joint Dislocation After Inhalation of Nitrous Oxide Objective: The aim of this study was to evaluate the efficiency of inhaled nitrous oxide (N2O) for manual reduction of acute nontraumatic temporomandibular joint (TMJ) dislocation in the supine position technique. Methods: This clinical trial included a total of 51 patients presenting with acute nontraumatic TMJ dislocation. The patients were grouped randomly. The supine position technique was applied in both N2O group (experimental group) and control group (without N2O). The visual analogue scale scores (VAS scores) of the pain perception and the operation time were recorded. Results: All patients with dislocated mandible were successfully managed. The VAS scores of pain perception were significantly reduced in N2O group. It was 1.63 compared to 4.00 in control group. The average operation time was also significantly reduced in N2O group (see Table 2, Supplemental Digital Content 2, available at: http://links.lww.com/SCS/A716). It was 129.92 seconds compared to 170.04 seconds in control group. Conclusion: Inhalation of N2O helps to reduce the pain perception and the operation time of manual reduction of acute nontraumatic TMJ dislocation using the supine position technique. It is beneficial to both patients and doctors. Address correspondence and reprint requests to Kun Lv, DDS, Ph.D, Faculty, associated chief physician, School and Hospital of Stomatology, Wuhan University, 237 Luoyu Road, Wuhan 430079, Hubei, People's Republic of China; E-mail: lvkun@whu.edu.cn Received 16 December, 2018 Accepted 8 May, 2019 ML and ML contributed equally to this article. 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). The authors report no conflicts of interest © 2019 by Mutaz B. Habal, MD.

A Modified Technique of Transposition of Temporalis Muscle in Selected Cases of Longstanding Facial Paralysis The authors present a modified technique of temporalis muscle transposition technique in cases of longstanding facial paralysis. Slips of the temporalis fascia were passed through the tunnels to reach the contralateral para-median plane. The procedure provides 2 point of fixation to the transferred muscle. Local flaps were used for temporal hollow obliteration and for temporalis muscle elongation. This case series included 11 patients. The modified technique was performed for all patients to reanimate the lower face while gold weight impanation in the upper eye lid was used for re-animation of the eye in 9 patients. By the end of follow up, the procedure was considered successful in 9 patients. Eight patients expressed their satisfaction and 7 patients were happy with the regained facial movement. The modified temporalis muscle transfer technique might be a valuable option in cases of longstanding facial paralysis. The lips would be camouflaged, non-stretched and would move with the whole mid-face. Address correspondence and reprint requests to Sherif M. Askar, MD, (2) Othman Bin Affan st, Zagazig City, Sharkia Governorate, Egypt; E-mail: askr_sh@yahoo.com; askr_sh2000@yahoo.com Received 17 January, 2019 Accepted 23 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.