Canalicular Incisional Approach for Recanalization of Punctum: A Modified Surgical Treatment for Acquired Complete Upper and Lower Punctum Occlusions as an Alternative to Bypass Methods Purpose: To define the success of surgical technique used in the treatment of epiphora that is caused by bi-canalicular acquired complete punctum occlusion. Materials and Methods: The study is a retrospective consecutive case series, who underwent canalicular incisional approach for recanalization (CIAFOR) for acquired bi-canalicular punctum occlusions. The authors have used this technique in the cases not possible to perform a punctum dilatation and not possible to determine the punctum location exactly due to severe fibrosis. Functional and anatomical success was evaluated by the absence of epiphora and with lavage at post-operative 6th months. Results: Seven eyes of 5 patients (3 males and 2 females) were included in the study. The ages of the patients were 70, 65, 45, 64, and 70 years, respectively. Current follow-up periods vary between 6 and 23 months. Although functional and anatomical success achieved in all eyes, complication such as accessory punctum observed. Conclusions: CIAFOR seems to be a successful and simple surgical technique to treat acquired total punctum occlusion. Address correspondence and reprint requests to Soner Demirel, MD, Inonu University, Faculty of Medicine, Department of Ophthalmology, Malatya, Turkey; E-mail: sonerdem2000@yahoo.com Received 27 June, 2019 Accepted 17 July, 2019 The preliminary results of our study were presented at the 52nd Turkish Ophthalmology Society Congress, October 13–18, 2018, Antalya, Turkey. The authors have no conflicts of interest to disclose. 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.

Plain Computed Tomography With Spectral Imaging Findings of Early Cerebral Ischemia Purpose: To investigate the findings of plain spectral computed tomography (CT) with multiparameter of early cerebral ischemia. Patients and Methods: Thirty-three patients with suspected early cerebral ischemia who received a one-stop CT examination (plain scan with spectral CT imaging mode, CTP and CTA) of the brain were enrolled in this study. No clear lesion was observed in any patient on the plain CT. However, the CTA displayed evidence of vascular stenosis and the CTP displayed a corresponding low perfusion area consistent with early cerebral ischemia. Regions of interest were placed in the abnormal perfusion regions and the contralateral symmetric regions on plain CT. Then, the CT value of the monochromatic images (70 kV), the slope of the spectral HU curve, blood (iodine), iodine (water), and water (iodine) concentrations were measured. A paired t-test was performed for data comparison. The receiver operating characteristic curve was used to evaluate diagnostic performance. Results: The CT values of the ischemic regions at 70 keV, the spectral HU curve, water, and blood values of the ischemic measurements were slightly lower than those of the contralateral symmetric regions (P < .05). Monochromatic images at 70 keV had the highest area under the curve value, and the sensitivity and specificity were 90.0% and 63.0%, respectively. Conclusion: The difference of monochromatic CT values, spectral HU curve, and basic material concentrations between the early cerebral ischemia region and the contralateral symmetric region on spectral CT imaging may provide a reference with the diagnosis of early cerebral ischemia. Address correspondence and reprint requests to Zhou Junlin, PhD, Department of Radiology, The Second Hospital of Lanzhou University, Lanzhou 730000, China; E-mail: ldeyzjl601@163.com Received 31 March, 2019 Accepted 12 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.

Review of “Surgery, Complications, and Quality of Life: A Longitudinal Cohort Study Exploring the Role of Psychosocial Factors” by Archer S et al in: Ann Surg: 270:95-101, 2019 No abstract available

Upper Fornix Approach to the Superonasal Intraconal Space: An Experience Including a Pediatric Patient In this study, we present 2 patients, including 1 pediatric patient, with orbital tumors in the deep superonasal intraconal space, which were approached with upper fornix technique combined with a superior lateral cantholysis. The first patient was a 1-year-old girl who had presented with left upper eyelid retraction since the age of 2 months. Imaging studies revealed an orbital mass in the left postero-superonasal intraconal space. The second patient was a 71-year-old man who complained of decreased vision after cataract surgery in the left eye. Imaging studies revealed an orbital mass in the left superonasal intraconal space surrounding the optic nerve in the posterior orbit. In both the patients, incisional biopsy of the orbital mass with upper fornix approach was performed under general anesthesia. The diagnoses of congenital upper eyelid retraction caused by fibrosis in patient #1 and extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue in patient #2 were made, after pathological examinations. No significant intra- or postoperative complications occurred during a follow-up period of 10 months and 2 months, respectively. Address correspondence and reprint requests to Yasuhiro Takahashi, MD, PhD, Department of Oculoplastic, Orbital & Lacrimal Surgery, Aichi Medical University Hospital, 1-1 Yazako-Karimata, Nagakute, Aichi 480-1195, Japan; E-mail: yasuhiro_tak@yahoo.co.jp Received 29 July, 2019 Accepted 17 August, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Metastatic Prostate Adenocarcinoma of the Mandible Diagnosed With Oral Manifestations Metastasis from the prostate gland to the mandible is rarely encountered and commonly present with non-specific features like unexplained pain, swelling, and numb chin syndrome. Here we present a case with metastatic prostate adenocarcinoma detected secondary to oral manifestations. Patients present with unexplained facial pain and numbness should alert clinicians to the presence of malignant disease, and appropriate hematological, radiological and or histological investigations should be performed. Thereby, clinicians can prevent the overlook of the first signs of metastasis, accelerate the early diagnosis and positively orientate the prognosis of the disease, especially in a patient without known malignancy. Address correspondence and reprint requests to Mustafa Ay, DDS, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ordu University, Ordu, Turkey; E-mail: mustafaayy55@gmail.com Received 10 July, 2019 Accepted 19 August, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Propranolol for Surgeons in the Treatment of Infantile Hemangiomas Introduction: Beta-blocker (Propanolol or Timolol maleate) treatment of infantile hemangiomas (IH) is a safe and effective treatment in the outpatient setting. The authors report a single surgeon's initial experience with setting up an outpatient service of beta-blocker treatment for head and neck IH at a tertiary children's hospital. Methods: A prospective study of children with head and neck IHs commenced in January 2015 with the end point being December 2018. Each child started either oral propranolol (2 mg/kg/day) or topical Timolol 0.5%. Results: Thirty-eight patients commenced a beta-blocker during the study duration. The mean age at time of starting therapy was 9 months (range 3 weeks to 116 months). Four patients were older than 12 months at commencement. The mean duration of treatment was 9 months. The response to treatment was excellent or complete in 29% (n = 11), good in 50% (n = 18) and mild in 10% (n = 4). The non response rate was 10% (n = 4). No major adverse effects occurred but 29% (n = 11) experienced minor side effects. Conclusion: Low dose propranolol and topical Timolol is been safe and easy to use for surgeons who may not be regular prescribers or unfamiliar with treating children with IHs with beta-blocker therapy. In patient monitoring is unnecessary and parents can be taught easily to recognise side effects. Treating children from the start builds a trusting relationship with the family before the child requesting cosmetic revision of the fibro-fatty remnant. Address correspondence and reprint requests to Mark Sheldon Lloyd, MPhil, FRCS (Plast), Birmingham Children's Hospital, 01213339999, United Kingdom; E-mail: marklloyd1@nhs.net Received 25 June, 2019 Accepted 15 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.

Clinical Experience in Emergency Management of Severe Facial Trauma Background: Published reports describing management of complex facial lacerations in the emergency department are limited, and there is little guidance on the treatment of massive soft tissue avulsions of the head and face or severely contaminated head and face lacerations. Here, the authors report on the wealth of clinical experience they have gained in treating major head and facial injuries through an emergency trauma repair platform that was established in the department of orthopedic surgery at their hospital. Methods: Six patients with massive soft tissue avulsions of the head and face caused by trauma were treated in our department between September 2017 and December 2018. Avulsion injuries occurred to the eyelids, ears, face, and part of the scalp. Defects extended from the skin to the surface of the bone. Emergency surgical repair involved reasonable debridement of the wound surface, accurate and meticulous suture, and use of local skin flaps. Results: No patients experienced postoperative complications, such as necrosis, infection, or scar hyperplasia. Our postoperative satisfaction survey showed that 3 patients were very satisfied and 1 patient was relatively satisfied with their outcomes. Several patients (2/6) still had some degree of deformity in the soft tissue around the eyes, which required further surgery Conclusion: Satisfactory functional and aesthetic outcomes can be achieved through reasonable debridement of the wound surface, accurate and meticulous suture, and use of local skin flaps in patients with massive soft tissue avulsions of the head and face caused by trauma. Address correspondence and reprint requests to Ying Shao, PhD, Department of Plastic and Reconstructive Surgery, The First Hospital of Jilin University, Changchun, Jilin, China; E-mail: leleshao@163.com Received 26 June, 2019 Accepted 7 August, 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.

Nasal Septum Actinomycosis Mimicking Mucocele Actinomycosis commonly occurs in the cervicofacial region, but rarely in the paranasal sinus. The authors report an unusual case of nasal septum actinomycosis that was mistaken for a mucocele. The patient was treated accordingly using antibiotic therapy after endoscopic sinus surgery was performed. It is noteworthy that actinomycosis of the nasal septum could appear as a mucocele without central calcification or bony destruction in imaging studies. 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 58128, South Korea; E-mail: limsc@jnu.ac.kr Received 14 August, 2019 Accepted 10 September, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Navigation-Assisted Treatment of Giant Cysts in the Pterygopalatine Fossa With Endoscopy Method A couple of cysts lying in the pterygopalatine fossa are rare. The authors report a case of a 28-year-old woman who was admitted to the authors’ hospital with a 1-month history of headache and numbness on the left head. Three-dimensional computed tomography revealed a large soft mass in the pterygopalatine fossa. Magnetic resonance imaging showed that there were a couple of cysts in the pterygopalatine fossa. One cyst measured 41 × 38 × 34 mm and the other 23 × 19 × 19 mm. A transpterygoid transnasal endoscopic approach and resection of the lesion was performed. The authors opened the cyst with coblation and the lesion showed a lot of transparent thick yellow liquid. The authors located the posterior wall the other cyst with ENT image navigation. The puncture was conducted and a lot of yellow liquid flowed out of the lesion. The patient recovered rapidly. The headache and numbness were alleviated and disappeared after 1 month. The patient currently has no evidence of recurrence at 1 year postoperatively. The coblation and ENT image navigation make the surgeon more easily to achieve risk-free surgery under endoscopy. Address correspondence and reprint requests to Weiliang Bai, MD, Department of Otolaryngology, Shengjing Hospital, China Medical University, Shenyang 110004, China; E-mail: bweiliangcmu@163.com Received 20 August, 2019 Accepted 7 September, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Chicken or the Egg: A Case Report of Endoscopic-Assisted Treatment of Concomitant Sagittal Craniosynostosis With Calcified Cephalohematoma Nonsyndromic craniosynostosis results in premature fusion of cranial sutures and is rarely found in the context of other craniofacial abnormalities. Here the authors present the case of a 3-month-old male infant with a rare presentation of sagittal craniosynostosis and concomitant calcified cephalohematoma repaired by endoscopic-assisted sagittal strip craniectomy with good cosmetic and functional outcomes. The authors discuss the advantages of endoscopic repair of craniosynostosis when found in the presence of a cephalohematoma and the need for further research to investigate a possible causal relationship between these 2 pathologies. Address correspondence and reprint requests to Renata S. Maricevich, MD, Baylor College of Medicine, Houston, TX; E-mail: renata.maricevich@bcm.edu Received 22 May, 2019 Accepted 18 August, 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.