| Adult Cranioplasty Objectives: After reading this article, the participant should be able to: Understand the etiology of cranial defects. Understand the anatomy of the cranium. Understand the importance of the preoperative workup in the cranial reconstruction decision-making process. Describe the options available for calvarial reconstruction including autologous and alloplastic materials. Describe the basic differences between available alloplastic materials. Understand the intraoperative and postoperative complications that may arise during cranioplasty. Summary: Cranial defects can arise from a variety of causes, yielding a diverse group of patients who require cranioplasty. The goals of calvarial reconstruction are to protect the underlying brain, to restore the aesthetic contour of the calvarium, and/or to treat postcraniectomy cerebrospinal fluid circulation abnormalities that may be symptomatic. Options for calvarial reconstruction include the autogenous bone flap that was removed for access, autologous bone grafting, and a variety of alloplastic materials such as titanium, hydroxyapatite, polymethylmethacrylate, polyether ether ketone, and high-density porous polyethylene. A detailed preoperative workup and discussion with the patient is important to choosing the appropriate reconstructive path. Address correspondence and reprint requests to Peter J. Taub, MD, Division of Plastic Surgery, 5 East 98th Street, 15th Floor, New York, NY 10029; E-mail: Peter.taub@mountsinai.org; Christina Marie Pasick, MD, Icahn School of Medicine at Mount Sinai, New York, NY; E-mail: christinapasick@gmail.com Received 26 January, 2019 Accepted 24 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD. |
| A Comparison of Surgical Outcomes of 2 Combination Surgeries for Involutional Entropion: Fixing 3 vs 2 Pathologic Components The purpose of this study was to compare the surgical outcomes of two combinational surgeries for involutional entropion: Inferior retractor tightening (IRT) + lateral tarsal strip (LTS) + skin muscle excision (SME) vs LTS + SME. The authors reviewed the records of 2 groups which were made up of 80 (85 eyelids) and 58 (63 eyelids) involutional entropion patients with 71.4 and 71.8 years on average respectively. The 2 groups were categorized into Group A and Group B by different surgical techniques. The former underwent IRT + LTS + SME surgery between April 2004 and February 2014, while the latter received LTS + SME surgery between March 2014 and February 2018. The authors evaluated the surgical outcomes of 2 combinational surgeries. In Group A, 84 out of 85 (98.8%) lids were successfully corrected and 1 (1.2%) lower eyelid suffered from recurrence during the follow-up period of 26.5 ± 4.6 months. Two canthal deformity cases occurred in this group. In Group B, 62 out of 63 (98.2%) lids were successfully treated and there was 1 (1.8%) case of recurrence during the follow-up period of 21.0 ± 10.0 months. No cases of complications were noted. IRT + LTS + SME procedure took 26.4 ± 2.4 minutes and LTS + SME procedure took 20.6 ± 3.9 minutes (P < 0.001). The LTS + SME technique exhibited a comparable success rate with the IRT + LTS + SME operation. LTS + SME appeared to be significantly faster and safer compared to the IRT + LTS + SME procedure. Address correspondence and reprint requests to Sehyun Baek, Department of Ophthalmology, Guro Hospital, Korea University College of Medicine, 148 Gurodong-ro, Guro-gu, Seoul 08308, Republic of Korea; E-mail: shbaek6534@korea.ac.kr Received 15 February, 2019 Accepted 22 April, 2019 The authors declare 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. |
| Development and Validation of Novel Three-Dimensional Craniofacial Landmarks on Cone-Beam Computed Tomography Scans As cone-beam computed tomography (CBCT) scans become increasingly common, it is vital to have reliable 3-dimensional (3D) landmarks for quantitative analysis of craniofacial skeletal morphology. While some studies have developed and used 3D landmarks, these landmark sets are generally small and derived primarily from previous 2-dimensional (2D) cephalometric landmarks. These derived landmarks lack information in parts of the skull such as the cranial base, which is an important feature for cranial growth and development. The authors see a real need for development and validation of 3D landmarks, particularly bilateral landmarks, across the skull for improved cephalometric analysis. The primary objective of this study is to develop and validate a set of 61 3D anatomical landmarks on the face, cranial base, mandible, and teeth for use in clinical and research studies involving CBCT imaging. Each landmark was placed 3 times by 3 separate trained observers on a set of 10 anonymized CBCT patient scans. Intra-rater and inter-rater estimates of consistency and agreement were calculated using the intraclass correlation coefficient. Measurement error was calculated per landmark and per X, Y, and Z landmark coordinate. The authors had high ICC estimates within rates, indicating high consistency, and high ICC estimates among raters, indicate good agreement across raters. Overall measurement error for each landmark and each X, Y, and Z coordinate was low. Our results confirm the accuracy of novel 3D landmarks including several on the cranial base that will serve researchers and clinicians for use in future studies involving 3D CBCT imaging and craniofacial development. Address correspondence and reprint requests to Janice S. Lee, Clinical Director NIDCR/NIH, 10 Center Dr. Room 5-2531, MSC 1470, Bethesda, MD 20892-1470; E-mail: janice.lee@nih.gov Received 18 December, 2018 Accepted 10 April, 2019 This research was supported by the Intramural Research Program of the NIH, NIDCR. 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. |
| The Utility of an Open-Access Surgical Simulator to Enhance Surgeon Training Background: Smile Train, an international children's charity committed to improving cleft care around the world, empowers local medical professionals in developing countries to provide quality comprehensive cleft care in their own communities. As part of their sustainable model, Smile Train developed a web-based, interactive virtual simulator to improve surgical training of cleft procedures for surgeons around the world, replicating the anatomical and technical steps involved in cleft surgery. This study evaluated the simulator as a tool for enhancing surgical training. Methods: A pre-test and questionnaire addressing cleft care, surgical knowledge, and confidence level was administered to surgeons-in-training at an academic institution. Participants completed 3 simulator modules followed by a post-test and questionnaire to measure changes in knowledge and confidence levels. Results: Sixteen surgeons-in-training participated in this study. The mean score on the knowledge examination increased after reviewing the modules for both junior residents (33.1%–64.4%) and senior residents (46.9%–70.8%). Reviewing the modules increased participants’ confidence in the knowledge of cleft anatomy, understanding of surgical procedures, and ability to follow along meaningfully while assisting in operations. Conclusions: The Smile Train Virtual Surgery Simulator increased knowledge and reported surgeon confidence in understanding and assisting in cleft lip surgery, signifying its usefulness as a training tool for surgeons-in-training. Virtual simulation is a valuable resource for improving understanding and competence of the craniofacial surgeon while serving as an educational resource to other members of the comprehensive cleft care team, patients, and families. Address correspondence and reprint requests to Kristina P. Marsack, M.S. PA-C, DFAAPA, Texas Children's Hospital, 6701 Fannin St., Suite 610.00, Houston, TX 77030; E-mail: kpmarsac@texaschildrens.org Received 15 January, 2019 Accepted 15 June, 2019 Presentation: Accepted for a QuickShot Presentation at the 14th Annual Academic Surgical Congress February 7, 2019 in Houston, TX. The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD. |
| Our Experience Managing Difficult Accidental Chainsaw Trauma Background: Chainsaw and circular-saw injuries represent a rare condition within the maxillofacial region. The purpose of this clinical report is to describe the injuries and the clinical and surgical management of these rare traumas. Methods: In this clinical report, 11 patients, presenting themselves to the emergency room in the hospital “Policlinico Le Scotte,” Siena, from March 2016 to September 2017 with severe chainsaw and circular-saw injuries, were included. All of the patients underwent general anesthesia and surgical treatment. This study describes 3 of the 11 patients with saw injuries. Results: No complications occurred during surgeries and a good primary closure of the wound margins were achieved in all patients. However, after surgery, the authors experienced some complications in 2 patients: the 1st one displayed chewing problems due to extensive local edema; the 2nd one developed a total loss of vision in his left eye, even though there was no damage inflected to the eye ball during the trauma or surgery. Conclusion: All the patients were followed during the 1st year after surgery. The authors evaluated the patients at 3 months, 6 months, and after 1 year, and none of them developed complications or alterations related to the trauma. However, 1 patient is still experiencing loss of vision and he is under constant specialized follow-up. Address correspondence and reprint requests to Niccolò Pini, Via prestini 15, 50053 Empoli, Italy; E-mail: nick.pini45@gmail.com Received 7 March, 2019 Accepted 6 June, 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. |
| Reconstruction of Large Anterior Palatal Fistulae Using Anteriorly Based Dorsal Tongue Flaps Background: An anterior palatal fistula in a bilateral cleft lip and palate is a challenging clinical dilemma. The authors evaluate the feasibility and outcomes of the reconstruction of large anterior palatal fistulae using anteriorly based dorsal tongue flaps. Methods: Eight patients with anterior palatal fistulae after repair of a bilateral cleft lip and palate using anteriorly based dorsal tongue flaps. The defect size varied from 1.0 × 1.0 cm to 1.5 × 2.0 cm, and the tongue flap size varied from 1.5 × 3.5 cm to 2.0 × 3.5 cm. Results: All patients underwent successful reconstruction of palatal defects using anteriorly based tongue flaps, and no case of spontaneous detachment of the tongue flap occurred. The patients with palatal fistulae were followed up for 10 to 30 months, and no recurrence was encountered. Conclusion: An anteriorly based dorsal tongue flap is a safe and feasible surgical technique for the closure of anterior palatal fistulae. Address correspondence and reprint requests to Wei-liang Chen, DDS, MD, Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan-jiang Road, Guangzhou, China; E-mail: drchen@vip.163.com Received 10 March, 2019 Accepted 31 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. |
| Sphenopalatine Foramen Computed Tomography Landmarks Objective: The aim of the study was to assess different radiologic bony landmarks for endoscopic localization of the sphenopalatine foramen (SPF). Methods: Paranasal computed tomography (CT) scans of adults without sinonasal pathology were included. On axial cuts, the anteroposterior distances from the SPF to maxillary line, anterior head of the middle turbinate, basal lamella of the middle turbinate, choanal arch, and posterior fontanel of the maxillary sinus ostium were measured. While on coronal cuts, the vertical distances from the SPF to the nasal floor was measured. The registered measurements were then studied and statistically analyzed. Results: In 70 patients (140 sides, 840 measurements), the mean distances from the SPF to nasal floor, choanal arch, maxillary line, anterior head of the middle turbinate, basal lamella, and posterior fontanel were 25.6 ± 2.4, 8.5 ± 1.38, 36.4 ± 2.6, 34.6 ± 4.26, 8.1 ± 1.27, and 13.7 ± 1.7 mm, respectively, without significant differences between right and left sides. Females showed significantly shorter mean distances between SPF and the nasal floor (P = 0.0011), choanal arch (P = 0.0459), and posterior fontanel (P < 0.0001) than males. While no significant differences were detected between both sexes as regard distances from SPF to maxillary line (P = 0.5579), anterior head of middle turbinate (P = 0.8581), and basal lamella (P = 0.0638). Conclusion: Preoperative CT can provide multiple easily detected, reliable, and simple bony landmarks that can help SPF endoscopic localization. Thus the authors recommend adding these measurements to the preoperative CT checklist for patients scheduled for sphenopalatine artery ligation and/or excision of vascular lesions. Address correspondence and reprint requests to Mohammad Waheed El-Anwar, MD, Otorhinolaryngology-Head and Neck Surgery Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt; E-mail: mwenteg@yahoo.com Received 16 March, 2019 Accepted 14 June, 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 Surgery May Improve Upper Airway Collapse in Patients With Obstructive Sleep Apnea: A Drug-Induced Sleep Endoscopy Study Objective: The aim of this study is to evaluate the effects of nasal surgery in the upper airway (UA) collapse using drug induced sleep endoscopy (DISE) in a group of patients with obstructive sleep apnea hypopnea syndrome (OSAHS). Methods: Prospective cohort of patients treated with nasal surgery between 2015 and 2016. All patients were diagnosed with mild to severe OSAHS. The inclusion criteria were age between 18 and 70 years, apnea–hypopnea index (AHI) higher than 15, and septal deviation. All patients had a DISE performed before surgery and 3 months after. The DISE findings were evaluated through the NOHL scale. Results: Thirty-four patients were included. Surgical success with subjective and objective improvement in nasal obstructions was achieved in all cases. The pattern of UA obstruction did change significantly following nasal surgery (P < 0.05). Before nasal surgery, 74% of the patients demonstrated multilevel obstruction. After nasal surgery, only 50% patients showed multilevel collapse (P < 0.05). Among patients with single-level collapse, the oropharynx was the most common location of obstruction. It became more frequent after nasal surgery was done (41% vs 21%, P < 0.05). Significant improvement was shown in hypopharyngeal collapse. Postoperative AHI decreased from a mean of 26.7 to 19 events/h, but this change was not significant. Conclusion: Nasal surgery may improve hypopharyngeal collapses observed during DISE in patients with OSAHS. Thus, an improvement in nasal obstruction may also modify the surgical plan based on UA functional findings in OSAHS patients. Address correspondence and reprint requests to Gabriela Bosco, Servicio de Otorrinolaringología, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, Camino del Molino no 2, Fuenlabrada. 28942. Madrid, Spain; E-mail: maria.bosco@salud.madrid.org Received 2 April, 2019 Accepted 13 June, 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. |
| Comprehensive Three-Dimensional Technology Strategies for Autologous Free Fat Graft in Parry-Romberg Syndrome Autologous free fat graft is a widely accepted method of facial contour restoration in Parry-Romberg syndrome (PRS); however, complex and unpredictable facial anatomy can render this surgery extremely challenging. The integration of 3-dimensional (3D) technology strategies as a method to enhance surgical aesthetic outcomes has been demonstrated. A retrospective chart review was performed for PRS with autologous, free fat graft between 2016 and 2017. Based on 3D volumetric facial analysis and presurgical simulation, a 3D printed fat graft guide was produced. Surgical outcomes were analyzed by volumetric measurements of the upper, middle, and lower face segments. A total of 9 patients were included in the study. Their upper and middle facial volumes before and after the procedures showed statistically significant volume augmentation (upper face, P = 0.004; middle face, P = 0.002) 6 months postoperatively (T1). Facial asymmetry was also statistically significantly corrected (middle face P = 0.012; lower face P = 0.025) at 1 year after the procedure (T2). The advantageous application of 3D comprehensive technology for aesthetic improvements in patients with PRS with autologous, free fat graft treatment has been demonstrated. Precise preoperative planning based on simulations and postoperative 3D volumetric analyses can help adequately predict fat graft strategies. Address correspondence and reprint requests to Jong Woo Choi, MD, PhD, MMM, Professor, Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul 05505, Republic of Korea; E-mail: pschoi@amc.seoul.kr Received 5 April, 2019 Accepted 15 June, 2019 This research was financially supported by the Ministry of SMEs and Startups (MSS), Korea, under the “Regional Specialized Industry Development Program” (R&D, P0002783) and supervised by the Korea Institute for Advancement of Technology (KIAT). 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. |
| Relationship Between Lacrimal Bone Thickness and Lacrimal Sac in Chronic Dacryocystitis Background: Chronic inflammation in the lacrimal sac may lead to thickening of the surrounding bony tissues. This study aimed to assess the thickness of lacrimal bone surrounding the lacrimal sac, and the thickness of maxilla, based on the presence of purulent secretion in the lacrimal sac in patients who underwent EDCR. Material and Methods: Lacrimal bone thickness and the maximum and midpoint maxillary bone thickness of 70 patients (mean age of 49.07 years) who underwent EDCR, were assessed along 3 planes (upper, middle, and lower) using CT of the paranasal sinus. The patients were divided into 2 groups: the 1 who had purulent secretion in the lacrimal sac during the intraoperative period (Group 1) and another who did not have purulent secretion (Group 2). Results: No significant difference was detected between the 2 groups in terms of maximum and midpoint maxillary bone thickness. The increase in the thickness of lacrimal bone in Group 1 was statistically significant in all the 3 planes as compared to that in Group 2. Cutoff values for the thickness of the upper, middle, and lower plane of lacrimal bone were detected to be 0.710 mm, 0.685 mm, and 0.675 mm, respectively. Conclusion: The presence of purulent secretion in the lacrimal sac, along with the detected increase in the thickness of the lacrimal bone, as assessed by CT, offers an insight on the lacrimal sac before the surgery. Address correspondence and reprint requests to Suphi Bulgurcu, MD, Sultan Abdülhamid Han Training and Research Hospital, Haydarpaşa, Istanbul 34500, Turkey; E-mail: suphibulg@yahoo.com Received 19 April, 2019 Accepted 13 June, 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. |
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