Measuring the Position of the Mandibular Foramen in Relation to the Dentoalveolar Plane in Pierre Robin Patients: Establishing Safety of the Horizontal Osteotomy Background: Mandibular distraction with horizontal osteotomy of the ramus and vertical distraction vector has successfully treated airway obstruction in young Pierre Robin patients. Placing the osteotomy just above the dentoalveolar plane can minimize damage to the inferior alveolar nerve. This study maps the position of the mandibular foramen relative to the height of the dentoalveolar plane to demonstrate the safety of this technique in Pierre Robin neonates. Methods: Retrospective review of 3D CT scans of Pierre Robin patients was performed with inclusion criteria: ≤1 year of age, bilateral micrognathia requiring surgical intervention for airway (ie, tracheostomy versus mandibular distraction), no prior mandible surgery, and pre-operative 3D CT study. Demographic information collected included: age at CT scan, age at surgery, and genetic diagnosis. Using the 3D study of each patient's right mandible, a line at the level of the mandibular dentoalveolar plane was drawn across the lingual surface of the ramus and the distance to the mandibular foramen at a length perpendicular to the dentoalveolar plane line was then measured. Results: Fifteen patients were included in the study (at least 9 Pierre Robin). Average age at time of CT scan was 71.4 days old. The mandibular foramen was below the level of the dentoalveolar plane in all cases at an average distance of 4.7 mm. Average ramus height 46.2±13.4 Conclusions: The dentoalveolar plane was consistently above the mandibular foramen in all patients. Thus, the horizontal corticotomy at a level just above the mandibular dentoalveolar plane spares the inferior alveolar nerve in neonatal Pierre Robin patients undergoing vertical vector mandibular distraction. Address correspondence and reprint requests to Arlen D. Denny, MD, FACS, Center for Craniofacial Disorders, P.O. Box 1997, MS C340, Milwaukee, WI 53201-1997; E-mail: adenny@chw.org Received 11 August, 2018 Accepted 5 September, 2019 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). Supplemental digital content is 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 Website (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Atlantoaxial Rotatory Subluxation: A Rare Complication of Craniofacial Surgery Introduction: Neck pain is common in the post-operative period after craniofacial procedures. If patients present with neck pain and torticollis, it could be a manifestation of atlantoaxial rotatory subluxlation (AARS), which describes a rare condition in which there is lateral displacement of C1 relative to C2. When this occurs in the post-operative patient, it is termed Grisel syndrome. In this case series, we report on 3 patients diagnosed with Grisel syndrome after a craniofacial procedure. Methods: A retrospective chart review of a single craniofacial surgeon at a pediatric hospital was conducted over the last 3 decades. Demographics, procedures performed, and management strategies of AARS were included for review. Results: Three patients were identified who were diagnosed with Grisel syndrome after a craniofacial procedure and required inpatient cervical traction. All patients presented with torticollis within 1 week of their operation. Conservative management was ineffective, and all 3 patients were admitted for inpatient cervical traction, for an average of 13 days followed by an average of 47 days of outpatient therapy. No patients showed any signs of recurrence after removal of outpatient traction device. Conclusion: Grisel syndrome is a rare, but serious complication of craniofacial procedures. Physicians caring for these patients must have a high degree of suspicion if a patient with a recent craniofacial procedure presents with torticollis. Delaying the initiation of therapy has been shown to lead to higher rates of recurrence and increases the likelihood that patients will require surgical intervention. Address correspondence and reprint requests to Robin Yang DDS, MD, Division of Plastic Surgery, The Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, PA, E-mail: yangr@email.chop.edu Received 12 July, 2019 Accepted 11 September, 2019 This study was reviewed and approved by the Institutional Review Board of the Children's Hospital of Philadelphia for an exemption of consent. Funding by the Department of Surgery of The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania. 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 Outcomes of Bony Batten Grafting Through Endonasal Septoplasty in the Correction of Caudal Septum Deviation Objective: The aim of the present study was to evaluate the efficiency and usefulness of bony batten grafts through endonasal septoplasty in the correction of caudal septum deviations. Method: In this case-controlled retrospective study, 65 patients who had bony batten graft procedure for the correction of caudal septum deviation using endonasal septoplasty with complete pre-operative and post-operative questionnaire information and complete post-operative follow-up data (an average follow-up period of 24.1 months) in our hospital in September 2013 and August 2018 period were evaluated. Nasal Obstruction Symptoms Evaluation (NOSE) scores of the patients before and after the operation were compared. Besides, severity of nasal symptoms (mouth dryness, hyposmia, rhinorrhea, epistaxis and snoring) before and after the operation was compared using visual analog scale (VAS). Complications which developed in post-operative period were also analyzed. Findings: Average age of the 65 patients (14 female and 51 male) was 27.6 ± 11.3. A straight septum was achieved in 57 patients (87.6%) in post-operative period while 8 patients (12.4%) had residual deviation. Average pre-operative NOSE score was 79.8 ± 22.3 while average post-operative NOSE score was 21.4 ± 4.6 and the difference was significant (P < 0.0001). Significant improvements were observed in VAS scores of all evaluated symptoms in post-operative period. Two patients developed septal hematoma in post-operative period. Conclusion: Bony batten graft procedure through endonasal septoplasty is an efficient and useful method with low complication rate for the correction of deviation of caudal septum. Address correspondence and reprint requests to Ceyhun Aksakal, MD, Tokat State Hospital Ear Nose Throat Department, Merkez, Tokat, TR 60100, Turkey; E-mail: ceyhunaksakal0@hotmail.com Received 31 July, 2019 Accepted 9 September, 2019 The author has 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.

Pediatric Mandible Reconstruction for Osteomyelitis During Largest Reported Mycobacterium Abscessus Outbreak In 2016, water lines at a children's dental clinic in Orange County, California were contaminated with Mycobacterium abscessus (MA), a non-tuberculosis rapidly-growing mycobacterium, leading to the largest MA outbreak ever reported. Mandatory reporting and active case finding directed by the Public Health Department was conducted in collaboration with community Pediatric Infectious Disease physicians for patients who underwent dental pulpotomies at the contaminated Dental Clinic from January 1 to September 6, 2016. Seventy-one cases (22 confirmed and 49 probable) were identified. One case that required extensive debridement and reconstruction of the mandible is presented in detail. CT maxillofacial demonstrated osteomyelitis extending from the right mandibular angle to the left ramus with multifocal periapical lucencies. CT chest and neck revealed numerous pulmonary nodules and bilateral cervical lymphadenopathy. Extraction of several involved teeth, bilateral selective neck dissection, and extensive mandibular debridement was performed, followed by mandibular stabilization with a custom pre-bent 2.0-mm locking plate. CT images 1-year post-operative showed clearance of infection and sufficient bony stability. Subsequent removal of hardware and bone grafting was performed and the patient is doing well. In the event of a future odontogenic mycobacterium outbreak, the experience at our institution can inform multidisciplinary treatment approaches. Prophylactic extraction of primary teeth that received pulpotomies with contaminated water should be performed. Early and thorough debridement of affected bone, including enucleation of secondary teeth, should be performed if necessary for early source control. Address correspondence and reprint requests to Dr. Raj M. Vyas, Department of Plastic Surgery, University of California Irvine, Department of Plastic Surgery, Orange, CA, 200 S. Manchester, Suite 650, Orange, CA 92868; E-mail: rajv1@uci.edu Received 19 August, 2019 Accepted 7 September, 2019 MAM and MDK contributed equally and are co-authors. The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Periorbital Injection of Hyaluronic Acid Gel in Patients With Deep Superior Sulcus Purpose: Hyaluronic acid gel (HAG) fillers provide a versatile and safe correction method for a sunken superior sulcus (SS) resulting from soft tissue volume loss occurring with aging, previous surgery, or enophthalmos related to trauma or phthisis bulbi. The purpose of this study was to report the long-term clinical outcomes of filler injection for soft-tissue augmentation in patients with a deep SS. Design: Retrospective, interventional case series Methods: The medical records of 27 patients (32 eyes) with deep superior sulci were reviewed. Twenty injections of hyaluronic acid fillers (Restylane; Q-med AB, Uppsala, Sweden) were performed in the retrobulbar (RB) area, and 15 injections were performed in the SS. Pre- and post-treatment photographs were taken. Main Outcomes Measures: Visual acuity for seeing eyes, intraocular pressure, exophthalmos measurement, marginal reflex distance 1, interpalpebral fissure, tarsal platform show, and SS hollowing depth grade Results: Enophthalmos corrections were 1.3 ± 0.8 mm (P < 0.001) and the SS hollowing grade decrease was 1.2 ± 0.9 (P < 0.01) after 1 month of RB injection. Enophthalmos corrections were 0.1 ± 0.4 mm (P = 0.317) and the SS sunkeness grade decrease was 1.7 ± 0.8 (P < 0.001) after 1 month of SS injection. The amount of filler to correct enophthalmos of 1 mm was 0.83 ± 0.53 mL using the RB injection. Using Kaplan-Meier survival analysis, the mean period of maintenance for deep SS correction was 9.1 months for RB injections and 8.5 months for SS injections. Conclusion: Retrobulbar (RB) hyaluronic acid gel (HAG) injections corrected enophthalmos and a deep SS, while SS injections corrected only a deep SS. These 2 techniques of RB and direct sulcus injection are safe and effective methods for the correction of a deep SS. Address correspondence and reprint requests to Helen Lew, MD, PhD, Department of Ophthalmology, Bundang CHA Hospital, CHA University, College of Medicine, #351 Yatap-dong, Bundang-gu, Seongnam 463-712, Republic of Korea; E-mail: eye@cha.ac.kr Received 20 December, 2018 Accepted 7 September, 2019 Presented at the meeting of American Academy of Ophthalmology; Las Vegas, NV, 2015. 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.

Demographic Factors of Nasal Bone Fractures and Social Reflection Introduction: The nose is the most protruding central part of the face, and nasal bone fractures are the most common of facial bone fractures, leading up to 39%. Despite its high frequency, not many studies handled the etiology of nasal bone fractures, leading to the necessity of a recent demographic study. Materials and Methods: A total of 1111 patients diagnosed with nasal bone fracture from 2013 to 2018 at our institute were evaluated. A retrospective review of the various demographic and etiologic characteristics was done. Results: Numerous factors associated with nasal bone fractures were analyzed. Male patients were 3.3 times greater than the number of female patients, and twenties were the most common age range. Violence was the overall most common cause of injury, while slip down was the most common cause for females. Upon monthly distribution, the highest incidence of nasal bone fractures occurred in September, followed by March and December. The authors further divided the patients by time zone of the fractures, and male patients were most commonly injured from midnight to 3 AM, while female patients were 6 PM to 9 PM. Conclusion: Our findings represent a recent urban data of various etiologic factors of nasal bone fracture. The concept of school violence has been widely used since 1990s, and our data reflects that violence of the youth is a serious issue of the society. The mechanism of injury differed among sexes and age groups, and such discrepancies will aid physicians to better understand facial bone fracture patients and educate them in the future. Address correspondence and reprint requests to Jong Won Hong, MD, PhD, Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea; E-mail: prs@yuhs.ac Received 11 April, 2019 Accepted 13 September, 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.

Anatomical and Clinical Implications in Neocondyle Stability After a Condylectomy A condylectomy of the mandibular condyle is considered to be the treatment of choice in most cases of condylar head hyperactivity. The aim of the procedure is to remove the growth center of the mandible which is responsible for the mandibular enlargement and asymmetry. This surgical procedure has an impact on the condyle shape and position, but the restoration of mandibular movement and a stable joint position (namely, the proper alignment of the newly shaped condylar head within the condyle fossa) should also be considered important surgical outcomes. In this article, the authors present their own experience in performing condylectomies with an arthroplasty procedure and a special forced suturing technique (FST) in terms of achieving early, accurate mandibular movement and maintaining a stable condyle position in early and late outcomes. Materials and Methods: A modified high condylectomy with arthroplasty and FST results had been studied in anatomical, radiological, and clinical model. Results: Early findings after FST are promising. A slight improvement in lateral jaw movement was noted after condylectomy with arthroplasty (P < 0.05) both in early and late follow-up. Incisal opening, mandibular protrusion, and lateral movement were sustained. A stable condyle position within the fossa was achieved in each case of condylectomy with arthroplasty (P < 0.05). Conclusions: The FST condylectomy and reattachment of the lateral pterygoid muscle in a new, wider position provided an improvement in lateral jaw movement as well as in incisal opening and mandibular protrusion in early follow-up examination compared to the presurgical values. It seems that the FST enabled a better new condylar head position in the glenoid fossa and improved early functional mandibular movement. Address correspondence and reprint requests to Kamil H. Nelke, DMD, PhD, Department of Dental Anatomy, Medical University in Wrocław, Wrocław, Poland; E-mail: kamil.nelke@gmail.com Received 14 April, 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.

Cephalosomatic Sharing in the Hindu Mythology No abstract available

Custom-Made Three-Dimensional Models for Craniosynostosis The use of computer-aided design and computer-aided manufacturing in oral and maxillofacial surgery is an ever-growing field. The availability of 3D models, cutting guides, and customised surgical instruments gives surgeons the opportunity to modify and improve their surgical procedures. Here, we discuss the use of computer-aided design-computer-aided manufacturing to improve the management of a case of nonsyndromic metopic synostosis through the construction of: A cutting guide for the cranium, custom-made orbital protectors, a 3D model of the predicted postoperative meninges to allow off the table bone recontouring, and a template frontal bar to allow more specific recontouring of the frontal bar. Address correspondence and reprint requests to Luke Bowen, BDS, DCT3 OMFS, St John's Hospital, Livingston, EH54 6PP, UK; E-mail: luke.bowen@nhs.net Received 15 June, 2019 Accepted 16 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.

Bilateral Versus Unilateral Cranialization in the Management of a Breached Frontal Sinus Background: Frontal sinus breach during craniotomy may occur inadvertently or intentionally. Management of a breached frontal sinus is controversial as numerous operative techniques have been described. Frontal sinus breach may result in life-threatening complications, require additional surgeries, and increase the risk for long-term infectious sequelae. A literature review found a paucity of neurosurgical reports examining breached frontal sinus management or specific analyses of unilateral versus bilateral frontal sinus cranialization. Objective: A frontal sinus cranialization technique employed for patients involving frontal sinus breach and analyze outcomes managed with bilateral versus unilateral cranialization was presented in this study. Methods: A retrospective review of outcomes was performed using our Institutional Review Board-approved surgical case database between September 2012 and September 2018. Results: Thirty-three frontal sinus cranializations following frontal sinus breach were identified. Average follow-up time was 25 months. A statistically significant difference in postoperative infections was observed in patients with a history of previous cranial surgery who underwent unilateral compared to bilateral frontal sinus cranialization. Conclusion: These results suggest surgeons performing craniotomy or consulted intraoperatively for suspected frontal sinus breach should have a high suspicion for breached frontal sinus and a low threshold for frontal sinus cranialization. Furthermore, when performing frontal sinus cranialization, surgeons should consider performing bilateral, instead of unilateral, cranialization in patients with a history of previous craniotomy as bilateral cranialization was shown to decrease the risk of postoperative infection. Address correspondence and reprint requests to Chad Gordon, DO, FACS, Director, Neuroplastic and Reconstructive Surgery, Associate Professor of Plastic Surgery and Neurosurgery, Johns Hopkins University School of Medicine, JHOC, 8th Floor, 601 N Caroline St, Baltimore, MD 21287; E-mail: cgordon@jhmi.edu Received 17 June, 2019 Accepted 26 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.