Mattress Suture Technique for Caudal Septum Dislocations in Open and Endonasal Septoplasty: Which Approach is Better? Objectives: Various techniques have been described to correct caudal septum dislocations but the issue has not been resolved conclusively. This study aimed to describe a suture technique that can be used to correct and stabilize the caudal septum on the maxillary spine and also to evaluate the effects on patientsymptoms. Methods: Fifty-two patients with caudal septal dislocation were included in this study. Nineteen of the patients underwent open septoplasty and 33 patients underwent endonasal septoplasty. The caudal cartilage septums were fixed to the maxillary spine with horizontal mattress suturing in all patients. The patient followed up between 3 and 24th month. The modified “NOSE” survey was used to assess surgical outcome in all patients. The degree of septal correction was also classified. Results: Complete correction was achieved in the postoperative period in 96% of the patients. The status was near complete correction in 2 (3.8%) of the patients. But in these 2 patients, degree of caudal septal dislocation was corrected from severe to moderate after surgery and the fixation suture side is correct and stable. Postoperative modified NOSE survey scores were lower than the preoperative scores in all open and endonasal septoplasty groups (P <0.05). NOSE 2 (nasal blockage or obstruction) and NOSE 4 (trouble sleeping) scores were higher in patients with higher follow-up duration in open septoplasty group. Conclusion: Suturing technique is quite suitable for caudal septum dislocations and can easily be used in open and endonasal septoplasty. This suture reduces postoperative NOSE scores and the patients are satisfied with the results of the surgery. The septal stability may decrease in open septoplasty group with the longer post-operative duration. However, wide exposure can be ensured with an open septorhinoplasty approach. We concluded that it will be better to use endonasal septoplasty in appropriate cases and suture with nonabsorbable sutures. Address correspondence and reprint requests to Nuray Bayar Muluk, MD, Birlik Mahallesi, Zirvekent 2. Etap Sitesi, C-3 blok, No: 6-3/43, 06610 Çankaya/Ankara, Turkey; E-mail: nuray.bayar@yahoo.com; nurayb@hotmail.com Received 26 June, 2019 Accepted 14 August, 2019 The study was approved by the Ethics Committee of Bursa Yüksek Ihtisas Training and Research Hospital, on March 16.2016, number 2011-KAEK-25 2016/05-01. 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.

A Small Dose of Butorphanol Prevents Sufentanil-induced Cough During General Anesthesia Induction Purpose: This study aimed to evaluate the suppressive effects of a small dose of butorphanol on sufentanil-induced cough during general anesthesia induction. Methods: 120 patients who were scheduled for elective maxillofacial surgery of American Society of Anesthesiologists I∼II, aged 18∼65 years were randomly divided into 3 groups (n = 40). Patients received butorphanol 0.1 mg (group I), 1 mg (group II) or an equal volume of 0.9% normal saline (group III) 5 seconds right before sufentanil bolus (0.5ug/kg). Sufentanil was diluted into 5ug/mL and administrated within 5 seconds. The incidence and reflex degree of cough in all groups were evaluated within 2 minutes after the injection of sufentanil during anesthesia induction. Mean arterial pressure (MAP) and heart rate (HR) were recorded at T0 (before the injection of butorphanol or normal saline), T1 (before the injection of sufentanil) and T2 (2 minutes after sufentanil injection). Results: The HR and MAP values were no significant difference among the 3 groups at the same observation point. In group II, the HR decreased significantly at T2 compared with T0 and T1 (P <0.05, T2 VS T0, T1). None of the patients in group I and group II had cough, and 33 patients in group III developed cough, of which 12.5% were mild, 40% were moderate, and 30% were severe. Conclusions: The results of present study suggest that a small dose of butorphanol 0.1 mg can prevent sufentanil-induced cough and ensure a relatively stable hemodynamic state during general anesthesia induction. Address correspondence and reprint requests to Tiejun Zhang, MD, Department of Anesthesiology and The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) and Key Laboratory for Oral Biomedicine, Ministry of Education, School and Hospital of Stomatology, Wuhan University, Luoyu Street 237, Wuhan, 430079, China; E-mail: ztj@whu.edu.cn Received 28 June, 2019 Accepted 14 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.

Cavernous Lymphangioma in the Maxillary Sinus Lymphangioma in the maxillary sinus is rare. Herein, the authors report an unusual case of cavernous lymphangioma, in the maxillary sinus, with imaging examinations. Clinicians should be aware of the possibility of lymphangioma in the maxillary sinus, and be capable of distinguishing it, from other benign cystic lesions. 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, 160 Ilsimri, Hwasun, Jeonnam 519-809, South Korea; E-mail: limsc@chonnam.ac.kr Received 9 July, 2019 Accepted 15 August, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Krishnan's Comprehensive Classification for Distraction Osteogenesis of Maxilla and Mandible Distraction osteogenesis technique has gained popularity and has been established as a successful procedure in the management of cranio-maxillofacial deformities for more than 2 decades. Varieties of distractor designs were evolved for the procedures in the maxilla and mandible. Various distraction parameters are clinically important as planned in each case. Inspite of distraction osteogenesis as a well-accepted procedure, currently there is no single classification available for the distraction procedure in maxilla and mandible taking into consideration all the relevant parameters. A simple and user-friendly classification was designed with coding all the relevant parameters. A retrospective data collection from distracted case records were used to validate the classification. A survey from maxillofacial surgeons in a regional meeting was also carried out. The validation and the survey showed that the new classification is comprehensive, simple, easy to use and beneficial for communication, data storage, research, coding, and billing purposes. Address correspondence and reprint requests to Dr Pandurangan Harikrishnan, MDS, FDSRCS (England), Craniofacial Orthodontist and Oral-Maxillofacial Surgeon, Teeth “N” Jaws Center, 23 & 25, Lake Area 1st Cross Street, Nungambakkam, Chennai 600034, Tamil Nadu, India; E-mail: teethnjaws@rediffmail.com Received 25 January, 2019 Accepted 14 August, 2019 The author reports 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.

Histologic Evaluation of Healing Lip Defects Treated With Injected Onabotulinum Toxin A and Topical Mitomycin C Objective: Using an experimental rat model, the efficacy of injected Onabotulinum Toxin A (BoNT-A) versus topical Mitomycin C in surgical wound healing of rat lip defects was evaluated. Methods and Materials: Sixty-seven male Wister rats received a triangular cut (7 × 7 × 4 mm) on their upper lip. Then they were divided randomly into 4 equal groups: group A (topical Mitomycin C plus injected BoNT-A); group B (topical Mitomycin C); group C or control group (saline solution) and group D (injected (BoNT-A). After 3 months, the animals were euthanized and scars were evaluated using hematoxylin and eosin and Masson's trichrome. For qualitative analysis, inflammatory cell density, new capillary formation, fibroblast proliferation, and collagen deposition were reported using relative ranks from 0 to 3 (absence, mild, moderate, marked). Data were analyzed by post hoc and Kruskal–Wallis tests. The significance level was P < 0.05. Result: Mean collagen deposition values and fibroblast proliferation in the 4 groups showed statistically significant differences with each other (P value < 0.001). A significant difference between group A and controls existed for fibroblast proliferation (median 1 versus 2, P value < 0.001); also, collagen deposition (median 1 versus 2, P value < 0.001). A significant difference existed between the control and group D (median 2 versus 1, P value = 0.004); also, group A and B (median 1 versus 2, P value = 0.002) for collagen deposition. However, no significant differences existed between the 4 groups regarding inflammatory cells and angiogenesis (P value > 0.05). Conclusion: Local injection of BoNT-A plus Mitomycin C followed by BoNT-A alone provided less collagen formation and fibroblastic proliferation in the healing lip defect in a rat model. Address correspondence and reprint requests to Parastoo Namdar, DDS, MS, Department of Orthodontics, School of Dentistry, Khazar Square, Sari, Iran; E-mail: dds.pnamdar@gmail.com Received 20 February, 2019 Accepted 13 August, 2019 AJ, PN, and MK have equally contributed to this study. The authors have no conflicts of interests to disclose. This study was supported financially by Vice Chancellor for Research of Mashhad University of Medical Sciences (grant number:961648), and was approved by the Ethics Committee of the Mashhad University of Medical Sciences, Mashhad, Iran. 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.

Lower Face Reconstruction Using the Visor Flap We present an alternative method instead of classical methods for lower face reconstruction in this study involving clinical experiences. We aimed to achieve more esthetic and functional results using visor flap. This flap has been used for the reconstruction of lower lip and submental region in two patients. Satisfactory functional and cosmetic outcomes were obtained in patients. Flaps and donor sides healed with no complications. The hair follicles on the flap continued to grow in new locations. The visor flap is a useful alternative method for lower face reconstruction. This technique offers perfect color and texture matching and hair growth. Address correspondence and reprint requests to Orhan Gazi Dinç, MD, Department of Plastic Reconstructive and Aesthetic Surgery, Faculty of Medicine, Inonu University, 44280, Battalgazi, Malatya, Turkey; E-mail: orhan_gazi_dinc@hotmail.com Received 26 March, 2019 Accepted 17 August, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Identification and Recent Approaches for Evaluation, Operative Counseling, and Management in Patients With Freeman-Burian Syndrome: Principles for Global Treatment For many, the experience of a complex craniofacial malformation condition, such as Freeman-Burian syndrome (FBS), formerly Freeman-Sheldon syndrome, is deeply distressing. There are few references in the literature addressing initial evaluation and operative counseling for FBS, and guidance is absent. Two major outcomes of FBS are explored, namely diagnostic accuracy and therapeutic result, to identify factors influencing optimal clinical care in (1) diagnosis, (2) evaluation, (3) general and craniofacial operative counseling, and (4) craniofacial management. PubMed searches have yielded 15 results describing craniofacial surgery in FBS and 29 manuscripts describing psychosocial aspects of surgery and patient and family counseling and education in other non-intellectually impairing craniofacial malformation conditions. Research in this area of scholarship is plagued by problems, especially considerable knowledge gaps and an absence of study data for operative outcomes. As a result, the literature remains unsettled, though our experience presents a much more clear picture of the clinical reality for this challenging patient population. While many challenges and limitations to treatment are present, much can be done to afford these patients a good and productive quality of life through operative intervention and longitudinal psychosocial support. Address correspondence and reprint requests to Mikaela I. Poling, BA, 8501 Arlington Blvd, Suite 420, Fairfax, VA 22031, USA; E-mail: poling_mi@fsrgroup.org Received 3 June, 2019 Accepted 14 August, 2019 An early draft was presented by Dr Poling to the Pediatric Residents’ Noon Conference, Robert C Byrd Health Sciences Center, West Virginia University School of Medicine, Morgantown, WV, on December 13, 2006. This study was unfunded by, and completed for, Freeman-Sheldon Research Group, Inc. The authors have no conflicts of interests to disclose. © 2019 by Mutaz B. Habal, MD.

Large Anterior Oronasal Fistula Repair Using Pedicled Buccal Fat Pad and Fibroepithelial Tissue Oronasal fistula (ONF) is the most common complication after palatoplasty in patients with cleft lip and palate (CLP). When left untreated, it may negatively affect the quality of life, leading to development of other comorbidities. This study reports for the first time, the use of a portion of a hyperplasic tissue associated with pedicled buccal fat pad flap to repair a large anterior ONF in a 60-year-old man. The hyperplasic tissue may have developed due to the combination of a loose fitting upper denture and long-term use of dihydropyridine calcium channel blocker (amlodipine besylate). There is controversy in the literature about use of pedicled buccal fat pad flap in the anterior region. However, in this study, we report successful repair of a large anterior ONF using a portion of a fibroepithelial hyperplasic tissue associated with pedicled buccal fat pad flap. Address correspondence and reprint requests to Rafaela Scariot, School of Health Sciences, Department of Oral and Maxillofacial Surgery, Positivo University, 5300 Professor Pedro Viriato Parigot de Souza St. Campo Comprido, Curitiba – Paraná, 81280330, Brazil; E-mail: rafaela_scariot@yahoo.com.br Received 4 June, 2019 Accepted 14 August, 2019 This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001. The authors have no conflicts of interests to disclose. © 2019 by Mutaz B. Habal, MD.

Identifying Differences Between a Straight Face and a Posed Smile Using the Homologous Modeling Technique and the Principal Component Analysis Recently, a homologous modeling method was developed to simulate 3D human body forms, which can visualize principal component analysis (PCA) results and facilitate its detailed comparison with results of previous method. Herein, we aimed to construct a homologous model of the face to identify differences between a straight face and a posed smile. Thirty-eight volunteers (19 males and 19 females, 38 straight faces and 38 posed smiles) with no medical history associated with a posed smile were enrolled. Three-dimensional images were constructed using the Homologous Body Modeling software and the HBM-Rugle; 9 landmarks were identified on the 3D-model surfaces. The template model automatically fitted into an individually scanned point cloud of the face by minimizing external and internal energy functions. Faces were analyzed using PCA; differences between straight faces and posed smiles were analyzed using paired t tests. Contribution of the most important principal component was 23.8%; 8 principal components explained >75% of the total variance. A significant difference between a straight face and a posed smile was observed in the second and the fourth principal components. The second principal component images revealed differences between a straight face and a posed smile and changes around the chin area with regard to length, shape, and anteroposterior position. Such changes were inclusive of individual differences. However, the fourth principal component image only revealed differences between a straight face and a posed smile; observed differences included simultaneous shortening of upper and lower eyelid length, evaluation of the nasal ala ase, swelling of the cheek area, and elevation of the mouth angle. Although these results were clinically apparent, we believe that this article is the first to statistically verify the same. Consequently, the homologous model technique and PCA are useful for evaluation of the facial soft-tissue changes. Address correspondence and reprint requests to Hiroyuki Nakano, DDS, PhD, Department of Oral Surgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki city, Osaka 569-8686, Japan; E-mail: ora099@osaka-med.ac.jp. Received 11 June, 2019 Accepted 14 August, 2019 This work was financially supported by JSPS KAKENHI, grant number 18H03001. 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.

Myelomeningocele: Medical Considerations and Stomatologic Aspects in the Dental Treatment The aim was to analyze systemic and oral aspects of patients with myelomeningocele (MMC), relevant for their dental treatment. Dental treatment of these individuals requires the dentist's extensive knowledge and careful information to determine the dental treatment plan. Thirty participants aged 3 to 16 years were divided into 2 groups: study group (15 MMC individuals) and control group (15 healthy subjects). All patients were evaluated for: systemic conditions, use of medications, sequela of the underlying pathology, oral hygiene, diseases, convulsion, cerebrospinal fluid (CSF), allergy, behavior, learning, and mouth physical examination to assess the oral conditions. The study group presented: higher percentage using drugs (P < 0.05), 40% had convulsions (P < 0.05), 86.67% using CSF shunt, 53.33% presented latex allergies (P < 0.05), 53.33% were classified as anxious and with cognitive deficit (P < 0.05), showed more gingivitis (P < 0.05). The MMC individuals, in the majority, have shown cognitive impairment and anxious behavior, use of controlled drugs, convulsion, CSF shunt use, and latex allergy. The presence of periodontal tissue damage was higher in patients with MMC. Address correspondence and reprint requests to Cristhiane Olívia Ferreira do Amaral, DDS, Ms, PhD, Department of Special Care Dentistry, University of West Sao Paulo, Rua Jose Bongiovani,700, Presidente Prudente, SP 19050-920, Brazil; E-mail: crisamaral@unoeste.br Received 13 June, 2019 Accepted 14 August, 2019 This study was approved by the Research Ethics Committee (REC) under number: 930.528. 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.