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.

Anthropometric Analysis of Secondary Cleft Lip Rhinoplasty Using Costal Cartilage Graft Despite the improvement of primary repair of nasal deformities during the management of cleft lip in infancy, this does not exclude the need for revision rhinoplasty in adulthood for complete patients’ rehabilitation. The purpose of this study was to evaluate the aesthetic outcome of secondary rhinoplasty using costal cartilage grafts in patients with unilateral cleft lip nasal deformity. Twenty patients who were operated at earlier ages for correction of cleft lip and had a residual unilateral cleft lip nasal deformity were included in this study. Costal cartilage rib grafts were harvested; carved and used for maxillary augmentation, columellar strut graft, and lateral crural strut graft. Five anthropometric measurements (nostril height, width and gap area, columellar axis deviation angle and nasal base inclination angle) were used for evaluation of aesthetic results. The ratio of nostril width, height and gap area between the cleft side and the non-cleft side showed significant improvement (P <0.05). The columellar axis deviation showed significant improvement towards the midline (P = 0.004), and the alar base inclination showed improvement towards the horizontal line (P = 0.0045). In conclusion, the aesthetic outcomes of secondary cleft lip rhinoplasty using the costal cartilage are satisfactory. The costal cartilage has the required strength, is easily carved and maintains shape for considerable time. Address correspondence and reprint requests to Wael M. Talaat, PhD, Oral and Maxillofacial Surgery, College of Dental Medicine, University of Sharjah, University Dental Hospital Sharjah, Office F125, P.O. Box: 27272, UAE; E-mail: wtaha@sharjah.ac.ae Received 15 February, 2019 Accepted 24 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.

Intracranial Volume Post Cranial Expansion Surgery Using Three-Dimensional Computed Tomography Scan Imaging in Children With Craniosynostosis Background: Craniosynostosis is a congenital defect that causes ≥1 suture to fuse prematurely. Cranial expansion surgery which consists of cranial vault reshaping with or without fronto-orbital advancement (FOA) is done to correct the skull to a more normal shape of the head as well as to increase the intracranial volume (ICV). Therefore, it is important to evaluate the changes of ICV after the surgery and the effect of surgery both clinically and radiologically. Objective: The aim of this study is to evaluate the ICV in primary craniosynostosis patients after the cranial vault reshaping with or without FOA and to compare between syndromic and nonsyndromic synostosis group, to determine factors that associated with significant changes in the ICV postoperative, and to evaluate the resolution of copper beaten sign and improvement in neurodevelopmental delay after the surgery. Methods: This is a prospective observational study of all primary craniosynostosis patients who underwent operation cranial vault reshaping with or without FOA in Hospital Kuala Lumpur from January 2017 until Jun 2018. The ICV preoperative and postoperative was measured using the 3D computed tomography (CT) imaging and analyzed. The demographic data, clinical and radiological findings were identified and analyzed. Results: A total of 14 cases (6 males and 8 females) with 28 3D CT scans were identified. The mean age of patients was 23 months. Seven patients were having syndromic synostosis (4 Crouzon syndromes and 3 Apert syndromes) and 7 nonsyndromic synostosis. The mean preoperative ICV was 880 mL (range, 641–1234 mL), whereas the mean postoperative ICV was 1081 mL (range, 811–1385 mL). The difference was 201 mL which was statistically significant (P < 0.001). In comparison, the mean volume increment for syndromic synostosis and nonsyndromic synostosis was 282 mL and 120 mL, respectively. The difference was statistically significant (P < 0.004). Three months post-operation, the copper beaten sign was still present in the CT scan which was statistically not significant in this study (P > 1.0). However, there was 100% (n = 13) improvement of this copper beaten sign. However, the neurodevelopmental delay showed no improvement which was statistically not significant (P > 1.0). Conclusion: Surgery in craniosynostosis patient increases the ICV besides it improves the shape of the head. From this study, the syndromic synostosis had better increment of ICV compared to nonsyndromic synostosis. Address correspondence and reprint requests to Shukriyah Sulong, MBBS, Department of Neurosurgery, Hospital Kuala Lumpur, 50586 Jalan Pahang Wilayah Persekutuan Kuala Lumpur, Malaysia; E-mail: shukriyah86@yahoo.com Received 22 February, 2019 Accepted 24 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.

Diagnosis and Treatment of Scalp Arteriovenous Malformations With Intracranial Extension Scalp arteriovenous malformations (AVMs) are rare entities that may present as large, tortuous vascular lesions with resultant craniofacial deformity. Radiologic findings include feeding arteries and veins associated with dilated tortuous vessels. Intracranial extension is rare. A 5-year-old African American male presented with an occipital mass presumed to be a dermoid cyst on referral. Further workup revealed the presence of a scalp AVM that demonstrated extension into the left sigmoid sinus. Radiologic and intraoperative images are presented. Literature search revealed only 4 patients with scalp AVM extending intracranially into the sagittal sinus, 2 of which were managed with coagulation and division of the feeding vessels and the other 2 underwent preoperative embolization. Our patient is the 1st to be reported to have sigmoid sinus extension. Scalp AVMs with intracranial extension are rare, and require further preoperative workup. Following ultrasound evaluation, computed tomography angiography, magnetic resonance angiography, magnetic resonance imaging, or cerebral angiography can be considered. Treatment entails resection, but preoperative embolization is increasingly used, mirroring patients without intracranial extension. Further studies are needed to evaluate the efficacy and risk profile of these treatments. Address correspondence and reprint requests to Oluwaseun A. Adetayo, MD, Division of Plastic Surgery, The Bernard & Millie Duker Children's Hospital at Albany Medical Center, 50 New Scotland Avenue, MC-190, Albany, NY 12208; E-mail: adetayo@amc.edu Received 18 March, 2019 Accepted 8 June, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

An Analysis of Association Between Nasal Bone Morphology and Sinonasal Anatomical Variations The goal of this study was to investigate the association between various sinonasal anatomical variations and the morphological features of lateral nasal bone, using paranasal computerized tomography (PNCT) sections. Two hundred and fifty patients who underwent a PNCT scan because of a prediagnosis of nasal septum deviation or sinusitis were included in the study. For each patient, presence of the following anatomical variations was determined on CT sections: length and thickness of nasal bone, thickness of intermediate nasal bone, pneumatized middle turbinate, paradox middle turbinate, Agger nasi cell, Haller cell, Onodi cell, supraorbital cell, pneumatized uncinate process, and nasal septal deviation. The effect of each anatomical variation on the length and thickness of the lateral nasal bone was investigated. The patients with bilateral pneumatized middle turbinate and the patients with bilateral Agger nasi cell had a thinner lateral nasal bone both on the right and the left sides compared to those without. The patients with bilateral Onodi cell and Agger nasi cell had a longer lateral nasal bone both on the right and the left sides compared to those without. The nasal bone thickness was significantly thicker on the deviation side than the contralateral nasal bone. The nasal bone length was significantly longer on the side of the septum deviation. In this study, we found that sex, presence of Agger nasi and Onodi cells, pneumatization of middle turbinate, and direction of nasal septal deviation influenced the morphology of the nasal bone. For successful nasal surgery, careful examination of preoperative anatomical variations is very important. Address correspondence and reprint requests to Deniz Baklaci, 931st Avenue 945th Street, Ilker Cankaya, Ankara, 06100, Turkey; E-mail: doktorent@gmail.com Received 25 April, 2019 Accepted 13 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.

Radiographic Assessment of Nasopalatine Canal Using Cone Beam Computed Tomography Purpose: To assess the morphology of nasopalatine canal and to determine the variation of this canal in correlations to age and gender in Iraqi sample using cone beam computed tomography (CBCT). Materials and methods: A total of 200 requested CBCT images for nasopalatine canal evaluation before dental implantology at the anterior maxillary region. The morphology of canals was classified into 3 groups in coronal cross-sections. The effects of age and gender were also measured. Results: The study comprised 100 males and 100 females with mean age of 30.64 ± 9.46 years. Most of the cases showed Y-shape configuration type III 43.5% followed by type I single canal 35.5%, and type II with 2 parallel canals 21%, Conclusion: Due to the wide variation in the morphology of nasopalatine canals, it is highly recommended to perform CBCT evaluation to the anterior maxilla before dental implantology in order to prevent any damage to the neurovascular bundle. Address correspondence and reprint requests to Zainab M. Al-Bahrani, BSc, University of Baghdad, College of Dentistry, Department of Oral Diagnosis. Baghdad-Iraq; E-mail: zainab_albahrany77@yahoo.com Received 29 April, 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.