Morbidity in Patients With Separation of Cartilaginous Framework: Temporoparietal Fascia Flap and Treatment With Dermal Regeneration Template Background: The full creation of an ear requires 2 reconstruction stages. In the second stage of reconstruction, the cartilaginous framework placed at first stage is separated from the head creating an auriculocephalic sulcus. Then a piece of rib cartilage is placed in the sulcus to maintain this separation and is covered with tissue that allows the integration of a full-thickness skin graft. Methods: A descriptive study based on the pre and postoperative medical records and photographic archives of patients diagnosed with microtia who underwent separation of the cartilaginous framework from February 2010 to July 2015 in the Plastic and Reconstructive Surgery Department at Hospital General Dr. Manuel Gea González. Results: Fifty-four patients met the selection criteria. 85% (n = 46) The temporoparietal fascial flap was performed on 85% (n = 46), and 8 cases with random occipito-temporal fascial flap in association to a dermal regeneration template. The average time at the operating room was 177 minutes in patients with temporoparietal fascial flap versus 84.5 minutes in dermal regeneration template. The complication rate was 25.9% (n = 14), being similar rate with both techniques. Conclusions: Coverage with dermal regeneration template and random occipito-temporal fascia flap as an alternative use instead of temporoparietal fascial flaps, offers good postoperative results, lower operating times, and similar rate of complications, with the advantage of producing no visible scars and reserve the temporoparietal fascial flap for possible exposure of the cartilaginous framework. Address correspondence and reprint requests to Lucas Lesta-Compagnucci, MD, Plastic and Reconstructive Surgery, Hospital General “Dr. Manuel Gea González,” Calzada de Tlalpan 4800, Tlalpan Centro I, Tlalpan, Ciudad de México, Mexico; E-mail: lucaslesta@gmail.com Received 4 June, 2018 Accepted 14 July, 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.

Surgical Treatment of Mandible Fracture Using Unsintered Hydroxyapatite/Poly L-Lactide Composite Fixation System Recently, absorbable plates have been used for various types of facial fractures. However, in the case of mandibular fractures, a large amount of force is applied after fixation. Thus, a firm fixation is necessary. In particular, unfavorable fractures are more frequent in mandibular fractures. Therefore, plates should be strong enough to withstand forces at the time of surgery. The purpose of this study was to determine clinical efficacy and usefulness of unsintered hydroxyapatite (u-HA)/poly (L-lactide) (PLLA) composite system by clinical application and follow-up of fixation in patients with mandible fracture. A total of 13 patients with mandible fractures were assessed for compliance with the selection criteria. Fracture site was confirmed with radiographic findings including X-ray and facial computed tomography images. Subjects who fulfilled all criteria underwent operation using HA/PLLA composite fixation system (OSTEOTRANS; Takiron Co Ltd, Osaka, Japan). After reduction of fracture site through oral or skin incision, we placed OSTEOTRANS plates on fracture line and performed rigid fixation with OSTEOTRANS-MX screws. Follow-up was performed at 1 week, 1, 3, and 6 months after surgery. Occlusion and mouth opening were checked by physical examination and radiographic finding. We also confirmed bone approximation status, bony gap change, and bone union status. All patients finished every follow-up. They were satisfied with outcomes without complications such as malocclusion, foreign body sensation, or tenderness. This study confirms that OSTEOTRANS can be used appropriately for mandibular fractures. Address correspondence and reprint requests to Eun Soo Park, MD, PhD, Department of Plastic and Reconstructive Surgery, Soonchunhyang University, College of Medicine, Bucheon Hospital, Bucheon, Korea 170, Jomaru-ro, Wonmi-gu, Bucheon-si, Gyeonggi-do, Korea; E-mail: peunsoo@schcm.ac.kr Received 8 February, 2019 Accepted 17 August, 2019 This work was supported by the Soonchunhyang University 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.

Temporomandibular Joint Ankylosis Following Mandibular Distraction Osteogenesis: A Dreadful Complication Introduction: Mandibular distraction osteogenesis (MDO) is an effective treatment for severe micrognathia, as it helps to avoid tracheostomy but has some adverse effects on the temporomandibular joint (TMJ). TMJ ankylosis is a serious condition leading to feeding difficulties and growth impairment, and could result in worse consequences in cases with micrognathia who already have limited growth potential. Here, we aimed to report on cases with TMJ ankylosis—a rare but devastating complication of MDO. In total, we described 3 syndromic cases with TMJ ankylosis that developed after MDO and reviewed the associated literature. Material and Methods: We retrospectively enrolled 3 patients who presented with TMJ ankylosis following MDO at the Oral and Maxillofacial Surgery Department of the University Hospital of Lille, France. Results: All 3 patients had craniofacial syndrome with micrognathia. MDO was performed at least twice in each case, and the 3 patients developed subsequent TMJ ankylosis. They all presented with TMJ ankylosis and micrognathia in our Department. Discussion: MDO leads to a certain amount of stress on the TMJ, and in cases with congenital TMJ deformation, such stress could lead to TMJ ankylosis. To our knowledge, 12 cases of TMJ ankylosis after MDO have been described in studies involving 309 patients while it is not reported in other publications. They were all syndromic patients. Thus, TMJ health should be carefully monitored during and after MDO to avoid TMJ ankylosis, and alternative treatments such as costochondral grafts should be considered. Address correspondence and reprint requests to M. Schlund, Service de Chirurgie Maxillo-Faciale et Stomatologie, Hôpital Roger Salengro, Rue Emile Laine, 59037 Lille, France; E-mail: matthias.schlund@chru-lille.fr Received 9 March, 2019 Accepted 11 July, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

What Are We Missing From Asymmetric Relationship Between the Retinal Nerve Fiber Layer Thickness Profiles and Sphenoid Sinus Volume? Purpose/Aim of the Study: Detailed analysis of retinal structure such as the retinal nerve fiber layer can be performed by spectral-domain optical coherence tomography (OCT). There are no published studies concerning there is a relationship between retinal nerve fiber layer and human sphenoid sinus volumes. We investigated this relationship. Material and Methods: Spectral-domain OCT. The peripapillary retinal nerve fiber layer (RNFL) thickness and sphenoid sinus volume estimation of both sides of sex-matched patients were retrospectively analyzed. Results: The mean RNFL thicknesses at the left side (918,542) were significantly smaller than the right side (945,833) (P = 0.040). However, the mean left sinus volume (44573) is larger than the right side, (34,413) (P < 0.005). Left and right differences of both parameters are statistically significant (P < 0.06). Conclusion: There is a negative correlation between mean RNFL thicknesses and mean sinus volumes. To our knowledge, this article is the first report demonstrating the asymmetry relationship between RNFL and sphenoid sinus volumes. Address correspondence and reprint requests to Ayhan Kanat, MD, Department of Neurosurgery, Medical Faculty, RecepTayyip Erdogan University, 53100 MerkezRize, Turkey; E-mail: ayhankanat@yahoo.com Received 25 March, 2019 Accepted 11 July, 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.

Applied Deep Learning in Plastic Surgery: Classifying Rhinoplasty With a Mobile App Background: Advances in deep learning (DL) have been transformative in computer vision and natural language processing, as well as in healthcare. The authors present a novel application of DL to plastic surgery. Here, the authors describe and demonstrate the mobile deployment of a deep neural network that predicts rhinoplasty status, assess model accuracy compared to surgeons, and describe future directions for such applications in plastic surgery. Methods: A deep convolutional neural network (“RhinoNet”) was developed to classify rhinoplasty images using only pixels and rhinoplasty status labels (“before”/“after”) as inputs. RhinoNet was trained using a dataset of 22,686 before and after photos which were collected from publicly available sites. Network classification was compared to that of plastic surgery attendings and residents on 2269 previously-unseen test-set images. Results: RhinoNet correctly predicted rhinoplasty status in 85% of the test-set images. Sensitivity and specificity of model predictions were 0.840 (0.79–0.89) and 0.826 (0.77–0.88), respectively; the corresponding values for expert consensus predictions were 0.814 (0.76–0.87) and 0.867 (0.82–0.91). RhinoNet and humans performed with effectively equivalent accuracy in this classification task. Conclusion: The authors describe the development of DL applications to identify the presence of superficial surgical procedures solely from images and labels. DL is especially well suited for unstructured, high-fidelity visual and auditory data that does not lend itself to classical statistical analysis, and may be deployed as mobile applications for potentially unbridled use, so the authors expect DL to play a key role in many areas of plastic surgery. Address correspondence and reprint requests to Mona Ascha, University Hospitals Cleveland Medical Center, Division of Plastic Surgery, 11000 Euclid Avenue, Cleveland, OH 44113; E-mail: Mona.ascha@uhhospitals.org Received 21 April, 2019 Accepted 9 July, 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.

Evaluation of Direct Surgical Remodeling of Frontal Bossing in Patients With Sagittal Synostosis Background: The need for surgical correction of frontal bossing in patients with sagittal synostosis is currently debated. The authors retrospectively analyzed frontal bossing in patients with isolated, nonsyndromic sagittal synostosis who underwent calvarial remodeling with and without frontal craniotomy and compared with control subjects. Methods: The authors analyzed computed tomography (CT) scans of patients with sagittal synostosis <9 months of age (6.2 ± 1.6 months) who underwent modified-pi procedure either with frontal craniotomy (FC, n = 15) or without frontal craniotomy (NFC, n = 10). Only patients treated with both pre-operative and 1-year post-operative CT scans were included. Non-synostotic age-matched control scans were also analyzed. Cephalic index (CI), 3 previously validated measures of frontal bossing (bossing angle, horizontal bossing ratio, and vertical bossing ratio), and pre-nasion volume ratio were obtained. Additionally, three-dimensional photographs of 10 FC patients were evaluated for frontal bossing between 1 and 8 years post-operatively. Results: Pre-operatively, no significant differences were found between the 2 groups (.064

Pituitary Adenoma Deposit in the Nasolabial Region Following Sublabial Transsphenoidal Surgery in the Setting of Nelson Syndrome Pituitary adenomas are a group of tumors arising from the anterior pituitary gland, and with the exception of prolactin-secreting adenomas, transsphenoidal resection is the cornerstone of treatment. Although most adenomas are located within the pituitary fossa, ectopic adenomas have been reported, primarily occurring along the route of embryologic development. In this article, we present the case of an ectopic pituitary adenoma in the nasolabial fold that likely resulted from seeding during transsphenoidal resection via sublabial approach. Address correspondence and reprint requests to Aaron Wallace, BA, Pritzker School of Medicine, University of Chicago, Chicago, IL 60637; E-mail: aaron.wallace@uchospitals.edu Received 17 April, 2019 Accepted 12 July, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Isolated Lambdoid Craniosynostosis Introduction: Lambdoid craniosynostosis is an extremely rare anomaly in which there is premature fusion of one or both lambdoid sutures. The mainstay of treatment is surgical intervention, for which various procedures have been described, but there is a paucity of data on long-term outcomes. This study examines the long-term outcomes in the surgical management of this challenging condition, showing that accurate diagnosis and careful planning can lead to safe and consistent results. Materials and Methods: A retrospective chart review was performed looking at all cases of isolated lambdoid craniosynostosis treated with surgical intervention by the senior author from 1999 to 2016. Data collected included gender, age at diagnosis, age at surgery, length of follow up, method of diagnosis, side of affected suture, pre-operative and post-operative physical exam findings, surgical technique, complications, re-operation rate, and associated torticollis. Results: Twenty-five patients (N = 25) were included in the study. All patients underwent posterior calvarial remodeling with/without barrel stave osteotomies and full thickness calvarial bone grafts. Mean length of follow up after operative intervention was 43.8 months (+/− 23.2 months). All patients were judged to have significantly improved head contour which was near-normal at conversational distance during post-operative follow up by the senior author. Residual plagiocephaly was present in 24% of patients. There were no major complications in this series. Reoperation rate was 8%. Seventy-six percent of patients also presented with torticollis, of which 37% had refractory torticollis that required sternocleidomastoid (SCM) release by the senior author. Discussion: The authors present one of the largest series of operative cases of isolated lambdoid craniosynostosis to date. Our data show that with accurate diagnosis and careful planning, safe and consistent long-term results can be achieved with surgical intervention. A significant number of patients in our series also presented with concomitant torticollis. The authors recommend that all patients being evaluated for posterior plagiocephaly should also be evaluated for torticollis, because without recognition and intervention, patients may continue to have residual facial asymmetry and head shape abnormalities despite optimal surgical correction of the lambdoid synostosis. Address correspondence and reprint requests to Vedant Borad, MD, Division of Plastic and Reconstructive Surgery, University of Minnesota, 420 Delaware St. SE, MMC 195, Minneapolis, MN 55455; E-mail: borad002@umn.edu Received 27 April, 2019 Accepted 21 August, 2019 This work was supported by Gillette Children's Foundation and Gillette Foundation Craniofacial Research Scholarship. 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.

Does Meningioma Volume Correlate With Clinical Disease Manifestation Irrespective of Histopathologic Tumor Grade? Objectives: The aim of the study was to investigate the association between meningioma volume and the occurrence of clinic-radiologic signs of tumor aggressiveness. For volumetric approximation, the authors evaluated the method of semiautomatic image segmentation at hand of high-resolution MRI-image sequences. Methods: ITK-SNAP was utilized for semiautomatic image segmentation of 58 gadolinium-contrast enhanced T1-weighted thin-slice MRI datasets for volumetric analysis. Furthermore, multimodal imaging datasets (including T2, FLAIR, T1) were evaluated for radiological biomarkers of aggressiveness and growth potential. Thereby generated data was checked for association with retrospectively collected data points. Results: Location (P = 0.001), clinical disease manifestation (P = 0.033), peritumoral edema (P = 0.038), tumor intrinsic cystic degeneration (P = 0.007), three-dimensional complexity (P = 0.022), and the presence of meningioma mass effect (P = 0.001) were statistically associated with higher tumor volumes. There was no association between higher tumor volumes and histopathological tumor grade. Conclusion: The size of a meningioma does not seem to reliably predict tumor grade. Growth potential seems to be influenced by tumor location. Higher tumor volumes were significantly associated with the occurrence of clinical symptoms. Address correspondence and reprint requests to Dr Ali-Farid Safi, MD, DMD, Harvard Medical School, Francis Street 45, 02115 Boston, MA; E-mail: asafi@bwh.harvard.edu Received 9 May, 2019 Accepted 6 June, 2019 MK and A-FS contributed equally to this work. 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.

Modified Cartilage Sparing Tip Plasty Technique for Extra Projection: Hemitransdomal Suture With Submucosal Dissection: A New Approach to Nasal Tip Dynamics The nasal tip projection and rotation to be obtained with tip plasty play a key role in achieving successful results. Cartilage sparing techniques provide extra ease to reshape the cartilage in revision rhinoplasty. Freed dome cartilage eliminates the restricting forces of mucosa. The authors recommend to free the dome cartilage from mucosa during the tip plasty which ensures the desired dome shape and extra projection. A total of 218 patients who were operated between the dates of January 2017 and August 2018 were included in this study. About 3 mm parts of the marked domes toward medial and lateral crurae were dissected from the mucosa. New domes were created with bilateral hemitransdomal sutures. The outcome of the operation was asked to the patients verbally and answers were recorded. Of 218 patients who were included in the study, 182 were females and 36 were males. Patients had a mean age of 26.5 years. The length of follow-up was 11.8 months. About 205 patients had primary rhinoplasty while 12 patients had secondary rhinoplasty and 1 patient had revision rhinoplasty. Of the patients, 89.9% (196/218) were very satisfied with the result and 7.4% (16/218) were satisfied, whereas 2.7% (6/218) were dissatisfied. Only 5 patients who were dissatisfied with the result underwent revision rhinoplasty operation. The combination of the modified free dome suture with the mucosal dissection in dome area provides achieving the desired tip projection and symmetry. Address correspondence and reprint requests to Ömer Faruk Ünverdi, MD, Department of Plastic Reconstructive and Aesthetic Surgery, Istanbul Okan University School of Medicine, Içmeler Mahallesi, Aydinli Yolu Caddesi, Aydemir Sokak No: 2 34947, Tuzla/Istanbul, Turkey; E-mail: unverdiomer@gmail.com Received 13 May, 2019 Accepted 10 July, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.