Craniofacial Surgery

Is There an Increasing Interest in Facial Feminization Surgery? A Search Trends Analysis Facial feminization surgery (FFS) has increased in prevalence and recent studies show that transgender women are just as likely to want facial feminization surgery compared to genital affirmation surgery. While previous research has demonstrated an increase in individuals seeking gender affirmation surgery, little is known on the prevalence of facial feminization surgery. Categorizing the number of facial feminization surgeries performed is difficult given lack of reimbursement rates and paucity of centers of excellence which publish data on their case numbers. Research has also shown a general increase in the information that patients seek on the internet with respect to gender affirmation surgery as procedures have become more prevalent. However, to date, there have been no studies looking at the overall interest in individuals seeking information on facial feminization surgery on the internet. Therefore, this study looks for the first time at an analysis of Google Trends data with respect to global interest in facial feminization surgery. Address correspondence and reprint requests to Michael J. Nuara, MD, Department of Facial Plastic Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, X10-ON, Seattle, WA 98101; E-mail: Michael.nuara@virginiamason.org Received 23 September, 2019 Accepted 11 November, 2019 There is no conflict of interest for the authors. © 2020 by Mutaz B. Habal, MD.

Value of Presurgical Virtual Planning for the Treatment of Plagiocephaly No abstract available

Congenital Four Eyelid Ectropion Associated With Clefting Anomaly An infant with congenital 4 eyelid ectropion associated with cleft lip and palate developed exposure keratopathy. He underwent skin grafting of the upper eyelids and lateral canthal reconstruction. Ectropion and signs of exposure keratopathy improved. Congenital eyelid ectropion is a rare disorder. Surgical repair can successfully correct the condition. Address correspondence and reprint requests to Abbas Bagheri, MD, Labbafinejad Medical Center, Boostan 9 St. Pasdaran Ave., Tehran 16666, Iran; E-mail: abbasbagheri@yahoo.com Received 13 October, 2019 Accepted 18 November, 2019 The authors report no conflicts of interest. © 2020 by Mutaz B. Habal, MD.

Improvement of Periorbital Appearance in Apert Syndrome After Subcranial Le Fort III With Bipartition and Distraction Aim and Scope: Children with Apert syndrome have a characteristic inversion of the orientation of the palpebral fissures, an increase of the inter-orbital distance, telecanthus, and exorbitism. Here, Le Fort III osteotomy with subcranial bipartition and distraction osteogenesis was evaluated as a tool to improve the position of the palpebral fissures in Apert syndrome. Material and Methods: All patients with Apert syndrome who underwent Le Fort 3 osteotomy with subcranial bipartition and distraction osteogenesis using an external device, with canthopexy, between 2009 and 2014, with available preoperative and postoperative frontal photographs, were included into the study. Palpebral fissure inclination was measured. Ratios of the intercanthal distance (ICD) to the outer-canthal distance (OCD) and the interpupillary distance to the OCD were computed. Preoperative and postoperative values were compared using the Wilcoxon signed-ranks test. Results: The authors included 15 patients with Apert syndrome. The mean age at surgery was 10 ± 3.4 years and the average follow-up was 7.3 ± 2.9 years. We found normalization of the negative inclination of the palpebral fissures (right eye: 10.7 ± 2.4 degrees preoperatively versus 7.0 ± 3.1 degrees postoperatively, P < 0.001; left eye: 12.4 ± 3.9 degrees preoperatively versus 8.7 ± 4.1 degrees postoperatively, P = 0.01) and a significant reduction of the inter-pupillary distance: OCD ratio (0.717 ± 0.027 preoperatively versus 0.699 ± 0.030 postoperatively, P = 0.03). These modifications were stable on the long term. There was no significant change of the inter-canthal distance:OCD ratio. Conclusions: Le Fort III facial advancement with subcranial bipartition and distraction improves the position and orientation of the orbital region in children with Apert syndrome Address correspondence and reprint requests to Eric Arnaud, MD, 34 avenue d’Eylau, 75116 Paris, France; E-mail: drericarnaud@hotmail.com Received 17 July, 2019 Accepted 18 November, 2019 The authors report no conflicts of interest. © 2020 by Mutaz B. Habal, MD.

Quantifying the Severity of Metopic Craniosynostosis: A Pilot Study Application of Machine Learning in Craniofacial Surgery The standard for diagnosing metopic craniosynostosis (CS) utilizes computed tomography (CT) imaging and physical exam, but there is no standardized method for determining disease severity. Previous studies using interfrontal angles have evaluated differences in specific skull landmarks; however, these measurements are difficult to readily ascertain in clinical practice and fail to assess the complete skull contour. This pilot project employs machine learning algorithms to combine statistical shape information with expert ratings to generate a novel objective method of measuring the severity of metopic CS. Expert ratings of normal and metopic skull CT images were collected. Skull-shape analysis was conducted using ShapeWorks software. Machine-learning was used to combine the expert ratings with our shape analysis model to predict the severity of metopic CS using CT images. Our model was then compared to the gold standard using interfrontal angles. Seventeen metopic skull CT images of patients 5 to 15 months old were assigned a severity by 18 craniofacial surgeons, and 65 nonaffected controls were included with a 0 severity. Our model accurately correlated the level of skull deformity with severity (P < 0.10) and predicted the severity of metopic CS more often than models using interfrontal angles (χ2 = 5.46, P = 0.019). This is the first study that combines shape information with expert ratings to generate an objective measure of severity for metopic CS. This method may help clinicians easily quantify the severity and perform robust longitudinal assessments of the condition. Address correspondence and reprint requests to Jesse A. Goldstein, MD, One Children's Hospital Drive, 4401 Penn Avenue Floor 3 Pittsburgh, PA 15224; E-mail: Jesse.goldstein@chp.edu Received 28 August, 2019 Accepted 30 October, 2019 Presented at the Robert H. Ivy Society 2018 Plastic Surgery meeting and the Ohio Valley Society of Plastic Surgeons 2018 Meeting. Accepted to the 18th Congress of International Society of Craniofacial Surgery for presentation September 16–19th, 2019 in Paris, France. 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). © 2020 by Mutaz B. Habal, MD.

Prediction of Lower Eyelid Malpositioning After Surgical Correction of Orbital Fracture Using the Subciliary Approach Through the Canthal Area and Orbital Vector Analysis A subciliary incision has been widely used not only for blepharoplasty but also for facial fracture surgery. However, lower eyelid malpositioning is one of the most common complications after fracture surgery. A limited number of studies have been conducted on the relationships among evaluation of the canthal area, orbital vector analysis, and lower eyelid malpositioning following the subciliary approach for surgical repair of fractures. The primary goal of this study was to identify and analyze the possible risk factors, including incidence of lower eyelid malpositioning and orbital vector after surgical correction of the orbital fracture. A total of 241 cases of orbital fracture surgery was retrospectively reviewed. Data related to the patient and surgery were collected. Orbital vector and angle that reflects the vector, distance between soft tissue and bone in the lateral canthal area were measured for orbital vector analysis. The relationship between the prevalence of the malpositioning of the lower eyelid and each factor was statistically analyzed. The distance between the soft tissue and bone at the lateral canthal area was statistically significant (P = 0.031). The distance between the soft tissue and bone at lateral canthal area illustrates the lateral side or periorbital anatomical morphology. It could be inferred that patients with a negative orbital vector were relatively more vulnerable to scar formation or lower eyelid malpositioning caused by iatrogenic factors. Therefore, it could be analyzed as a risk factor to predict the malpositioning of the lower eyelid postoperatively. Address correspondence and reprint requests to Ji Seon Cheon, MD, PhD, Department of Plastic and Reconstructive Surgery, Chosun University Hospital, 365, Pilmun-daero, Dong-gu, Gwangju 61453, Republic of Korea; E-mail: ps9107@naver.com Received 13 September, 2019 Accepted 11 November, 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). © 2020 by Mutaz B. Habal, MD.

Distraction Therapy to Correct Trismus Following Noma Trismus is a frequent complication of healed Noma infection and is caused by soft tissue and muscle contraction. Free-flap surgery is recommended to replace the missing oral mucosa and soft tissue. However, significant complications can occur if this surgery is performed in places like Africa, where conditions are usually less than optimal. In 2007, the authors started to treat patients with trismus in Niamey, Niger by distracting the soft tissue and muscle constriction between the jaws with a bone distractor continuously for 1 month with the aim of achieving a mouth opening of 3 cm. The distraction was limited to 1 mm/d. performed under local anesthesia with some sedation. Minor complications such as infection in the pin holes were easily managed. In 2009, 2 patients with trismus after Noma with a follow-up of 2 years were reported. Till date, the authors have successfully performed trismus release in more than 69 patients in Niamey and Guinea Bissau. The present study analyses the results of distraction therapy in 40 patients with follow-ups until 60 months. At the end of distraction, the mean interincisal distance was 2.7 ± 0.5 cm. Mouth opening 6 months after distraction had not reverted. However, 3 to 5 years after treatment, some signs of relapse were detected, with an average mouth opening of 1.5 ± 1.9 cm. Physiotherapy was unfortunately not feasible. The presented results strongly support the efficacy of distraction therapy to correct trismus in Noma patients. Address correspondence and reprint requests to Jürgen Holle, MD, Pfarrwiesengasse 23 B/236, A-1190 Vienna, Austria; E-mail: juergen@holle.at Received 10 April, 2019 Accepted 13 September, 2019 This study was carried out in cooperation with the German Hilfsaktion Noma Foundation. 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). This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 © 2020 by Mutaz B. Habal, MD.

Vocal Cord Paralysis as a Complication of Endotracheal Intubation Endotracheal intubation is a commonly used method for securing airway. It is considered to be safe but it can still lead to some complications of the airway. Recurrent nerve paralysis due to endotracheal intubation is a rare complication. Pathophysiology is explained as neuropraxia of RLN's compression between the tube and the lamina of the thyroid cartilage or between arytenoid and cricoid cartilages due to tube cuff pressure or tube itself. In literature, unilateral vocal cord paralysis (VCP) due to intubation is more common than bilateral paralysis. In the presented case report, a young patient stayed intubated for only 3 days in intensive care unit who experienced bilateral VCP 2 days after extubation. He had total recovery 5 days after emergency tracheotomy suggesting neuropraxia of the nerve. Neuropraxia of RLN resulting in bilateral VCP due to inappropriate size or excess cuff pressure of the intubation tube may be the underlying reasons. The clinicians must be aware of complications of intubation and should apply appropriate treatment method as soon as possible. Appropriate size and cuff pressure should be chosen for endotracheal intubation. Address correspondence and reprint requests to Melis Demirag Evman, MD, Lutfi Kirdar Training and Research Hospital, Semsi Denizer Cad. Cevizli Mevkii, Kartal, Istanbul, Turkey; E-mail: melisdemirag@hotmail.com Received 19 June, 2019 Accepted 6 August, 2019 The authors report no conflicts of interest. © 2020 by Mutaz B. Habal, MD.

Three-Dimensional Assessment of Pharyngeal Volume on Computed Tomography Scans: Applications to Anesthesiology and Endoscopy Pharyngeal volume is important in anesthesiology for correctly assessing intubation procedures. However, most of studies are based on patients in upright position and do not assess possible relationships between pharyngeal volume and cranial size. This study aims at measuring pharyngeal volume in CT-scans and to assess possible statistically significant differences according to sex. Eighty healthy subjects (40 males and 40 females) aged between 21 and 86 years were retrospectively chosen from a hospital database of maxillofacial CT-scans; 3D segmentation was performed separately for naso-, oro- and laryngopharyngeal portion through ITK-SNAP software, and their volume was calculated. Three cranial measurements were obtained: distance between anterior and posterior nasal spine, upper facial height (nasion-prosthion) and biorbital breadth (ectoconchion-ectoconchion distance). The effect of sex on volume for each pharyngeal portion was assessed through one-way ANCOVA test using each of the 3 cranial measurements as covariate (P < 0.05). On average, the volume of nasopharynx, oropharynx and laryngopharynx was 7.2 ± 2.7 cm3, 7.5 ± 4.2 cm3, 3.5 ± 2.2 cm3 respectively in males, and 6.4 ± 2.9 cm3, 5.2 ± 2.1 cm3, 3.0 ± 1.8 cm3 in females. Statistically significant differences according to sex were found only for oropharyngeal volume, independently from cranial measurements (P < 0.05). This study provides data concerning volume of pharyngeal air space in supine subjects: these reference standards can be useful for anaesthesiologic procedures. Address correspondence and reprint requests to Daniele Gibelli, MD, PhD, Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milano, Italy; E-mail: daniele.gibelli@unimi.it Received 24 August, 2019 Accepted 7 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). © 2020 by Mutaz B. Habal, MD.

Review of “An Empirical National Assessment of the Learning Environment and Factors Associated With Program Culture” by Ellis RJ et al in Ann Surg 270: 585–592, 2019 No abstract available