Postoperative Management of Zygomatic Arch Fractures: In-House Rapid Prototyping System for the Manufacture of Protective Facial Shields Zygomatic fractures account for 10% to 15% of all facial fractures. The surgical management of isolated zygomatic arch fractures usually requires open reduction treatment without fixation through an intraoral access. Therefore, the main problem in the non-fixed treatment of zygomatic arch fractures is related to the difficulty in obtaining a stable reduction for a period long enough to guarantee the physiological bone healing process. We propose an innovative “in-house” rapid prototyping (RP) protocol for the 3D-zygoma mask manufacture of a patient-specific protective device to apply after zygomatic arch fracture reduction. Our study includes 16 consecutive patients who underwent surgical open reduction for an isolated zygoma fracture without fixation between January 2017 and February 2018. The patients received regular postoperative checks at weeks 1 and 2. Before the device was removed, a multiple choice questionnaire was administered to measure the degree of wearability of the mask. The estimated cost of the production is around €5 per case and the construction time is around 90 minutes. Based on the encouraging results, obtained in our experience, we hope that other studies can be conducted to confirm our procedure and improve its functionality in the field of facial trauma. Address correspondence and reprint requests to Vincenzo Abbate, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Maxillofacial Surgery, School of Medicine, University of Naples “Federico II,” Via Sergio Pansini 5, Naples 80131, Italy; E-mail: vincenzo.abbate@unina.it Received 8 October, 2019 Accepted 11 October, 2019 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.

Primary Lash Ptosis Introduction: Lash ptosis is often an overlooked sign that may coexist with congenital and acquired blepharoptosis. This is a report of case series of patients presented in an oculoplastic clinic with visual field loss associated with lash ptosis. On examination, the primary pathology was attributed to lash ptosis dehiscence. Methods: All patients underwent anterior lamellar repositioning and were followed for an average of 15 (10–24) months. Results: All patients had resolution of visual field loss and heaviness of eyelids. Conclusions: Lash ptosis is associated with abnormalities such as floppy eyelid syndrome. However it may be a primary condition, with no background eyelid pathology and no external explanation for the eyelash ptosis. The condition might result from anatomical changes in the orbicularis oculi, Riolan's muscle, and tarsal plate. Patients in this series complained of upper lid visual field restriction. Anterior lamellar repositioning resulted in complete resolution of complaints. Additional studies are needed to learn about the pathophysiology of this entity. Address correspondence and reprint requests to Arie Y. Nemet, MD, Department of Ophthalmology, Meir Medical Center, Kfar Sava, Israel; E-mail: nemet.arik@gmail.com Received 2 May, 2019 Accepted 17 August, 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.

Management of Pediatric Mandibular Fractures Using Resorbable Plates Introduction: Despite there being several clinical studies reporting promising outcomes of resorbable plates for fixation of pediatric mandible fractures, the literature is devoid of large studies or comprehensive reviews assessing safety rates, complications and long-term outcomes. The purpose of the current review is to obtain a global consensus, shed light on efficacy and complications, and provide the reader with evidence-based data to help guide clinical management. Methods: A systematic review of clinical studies assessing outcomes for resorbable plates in pediatric mandibular fractures was carried out. The main outcomes included infection, hardware failure, hardware exposure, malocclusion, reoperation and nonunion. Overall rates were pooled and stratified by fracture and implant type. Results: Ten studies were included yielding 232 patients with 269 fractures. The mean age at surgery was 8.24 years with a mean follow up of 1.03 years. The overall complication rate was 5.2% (n = 12). Complications included infection (n = 4, 1.7%), hardware exposure (n = 3, 1.29%), wound dehiscence (n = 2, .86%) and intra-oral fistula formation (n = 2, .86%). One patient (0.43%) had malocclusion and none (0%) had hardware failure, nonunion or revision surgery. Patients with multiple fractures (≥ 2) had higher complication rates compared to isolated fractures (12.5% versus 1.7%). Conclusion: The use of resorbable plates for pediatric mandibular fractures is a viable option with similar rates of post-operative complications and outcomes compared to standard metallic counterparts. In the absence of large studies or systematic reviews, this study provides craniofacial surgeons with an evidence-based reference to guide decision making and improve informed consent. Address correspondence and reprint requests to Peter Davison, MD, FRCSC, Division of Plastic and Reconstructive Surgery, McGill University Health Centre, 1650 Avenue Cedar, Montreal, QC, Canada H3G 1A4; E-mail: peter.davison@muhc.mcgill.ca Received 29 May, 2019 Accepted 20 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.

Necrotic Loxoscelism of the Scalp A 15 month old boy was referred to our department after he and his mother moved to our country. He had been bitten by a brown recluse spider (Loxosceles reclusa) at the age of 7 months, in Brazil. Initially, he presented to the emergency department of his local hospital with rash in the scalp, near the bite. After a few days, he developed systemic disease with multiorgan failure and was admitted on intensive care unit, where he has been treated for 2 months. During this hospital stay he developed skin necrosis of the scalp, right preauricular, mandibular, and neck regions. He also developed right foot ischemia, which resulted in amputation. At the discharge time, he was under topical treatment with silver sulfadiazine, which was maintained until our observation, 8 months after being bitten. The child was successfully treated, and is now stable and awaiting lower limb prosthetic replacement. Loxoscelism (bites by spiders of the genus Loxosceles) is the only proven arachnological cause of dermonecrosis. The brown recluse spider, Loxosceles reclusa, is the best known and can cause necrotic dermatologic injury throw an enzyme, sphingomyelinase D, that has been shown to be cytotoxic to endothelial and red blood cells. Although the majority of persons bitten by a brown recluse spider probably will not seek medical attention, some patients may develop systemic loxoscelism, especially children. Address correspondence and reprint requests to Ricardo Horta, MD, PhD, Rua Heróis de França, 850, P2, 3° Direito, 4450-156, Matosinhos Sul- Porto, Portugal; E-mail: ricardojmhorta@gmail.com Received 11 July, 2019 Accepted 6 August, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Absorbable Plating of Nasoorbitoethmoid Fractures for Adults No abstract available

Long-Term Outcomes for Adult Patients With Cleft Lip and Palate The purpose of this study was to evaluate a single center's experience with adult patients who had cleft lip, cleft palate, or both. The authors aimed to identify common long-term needs in this patient population and evaluated the relationship of team-based care in meeting those needs. To do so, the authors retrospectively reviewed chart records from a single private practice and tertiary referral cleft center for all patients who were ≥15 years of age and who had a history of clefts of the lip or palate, or both, from January 1, 2013, to June 30, 2014. The authors compared the concerns of the patients who received cleft-team–based care by a single, multidisciplinary cleft team; multiple multidisciplinary cleft teams; or no formal cleft team. The authors analyzed data for 142 patients. The most common patient concerns were lip aesthetics (64%), nose aesthetics (61%), septal deviations (47%), nasal obstruction (44%), malocclusion (32%), oronasal fistulas (29%), and speech (21%). Oronasal fistulas were more commonly reported in the group of patients who had care by multiple teams (42.9%; P < .001). Malocclusion was more commonly reported in the group of patients who had care by multiple teams (50%; P = .001). The authors found that adult patients who have undergone rehabilitation for cleft lip and palate appear to have a common set of long-term needs. Multidisciplinary cleft-team–based care appears to be the most effective way to address these needs. Address correspondence and reprint requests to Stephen P. Beals, MD, Barrow Children's Cleft and Craniofacial Center, 500 W Thomas Rd, Suite 960, Phoenix, AZ 85013; E-mail: jill.hailpern@bealsmd.com Received 12 November, 2018 Accepted 27 July, 2019 Presented at the American Cleft Palate-Craniofacial Association 72nd Annual Meeting and Symposium, Palm Springs, CA, April 20 to 25, 2015, and the American Society of Plastic Surgeons Meeting, Boston, MA, October 16 to 20, 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.

Qualitative Assessment of Columella Scar Quality After Extended Mohler Unilateral Cleft Lip Repair Background: The Extended Mohler cleft lip repair restores upper lip form using a columellar flap to fill the defect created by the downward rotation of Cupid's bow. The resulting columella incision is mentioned as a potential drawback. This study seeks to evaluate the morbidity of the resulting scar. Materials and methods: This retrospective study enrolled 50 unilateral cleft lip patients treated using the Extended Mohler repair. 5 reviewers examined post-operative images. Three validated scar assessment scales were utilized: Manchester Scar Scale (MSS), Modified Scar-Rating Scale (MSRS), and Stony Brook Scar Evaluation Scale (SBSES). A scar score for the lip and columellar portion of each patient was determined. Results: Three different scar scales demonstrated significantly better scar quality for the columellar portion of the scar compared to the lip portion. The average score for the lip and columella using the MSS was 7.0 ± 1.4 and 5.7 ± 1.1 (P <0.001). The average score for the lip and columella using the MSRS was 5.5 ± 1.4 and 4.3 ± 0.9 (P <0.001). The average score for the lip and columella using the SBSES was 3.5 ± 1.1 and 3.9 ± 0.7 (P = 0.014). The intraclass correlation coefficient for lip scar assessments was 0.901 (MSS), 0.91 (MSRS), and 0.873 (Stony Brook Evaluation Scale [SBES]). The intraclass correlation coefficient for columellar scar assessment was 0.786 (MSS), 0.761 (MSRS), and 0.726 (SBES). Conclusion: The Extended Mohler unilateral cleft lip columellar scar is of superior quality compared to the lip portion. This analysis ameliorates one of the major concerns regarding the Extended Mohler cleft lip repair. Address correspondence and reprint requests to Roberto L. Flores, MD, Joseph G. McCarthy Associate Professor of Reconstructive Plastic Surgery, Hansjorg Wyss Department of Plastic Surgery, NYU Langone Health, 222 East 41st Street, New York, NY 10017; E-mail: Roberto.Flores@nyulangone.org Received 10 December, 2018 Accepted 30 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.

Coordination of the Fetal Medicine Institute and the Cleft and Craniofacial Center: Application to Early Management of Infants With Cleft Lip and Palate Background/Purpose: The primary objective of this study is to describe the authors’ experience at the Children's National Health System with the coordination of the Fetal Medicine Institute and the Cleft and Craniofacial Center. This collaboration highlights the accuracy and completeness of prenatal diagnosis of cleft abnormalities with expedient postnatal management. Methods: With Institutional Review Board approval, the authors retrospectively reviewed 74 patients referred for potential orofacial cleft and 44 met the inclusion criteria. Follow-up fetal ultrasonography is typically performed and three-dimensional imaging was performed when feasible. If questionable anomalies or facial findings are present on these studies, the authors proceed with fetal magnetic resonance imaging. A thorough consultation is held with the cleft team, resulting in a comprehensive plan of care. Postnatal examination confirmed the correct prenatal diagnosis in nearly all patients. Results: Sensitivity and specificity for isolated unilateral cleft lip were 89% and 100%, respectively; for unilateral cleft lip and palate, sensitivity and specificity were 82% and 90%, respectively; for bilateral cleft lip and palate, sensitivity and specificity were 97% and 90%, respectively. Initial postnatal evaluation by the cleft surgeon occurred at an average age of 21 days after birth. All patients who were candidates for presurgical orthodontia were treated at an appropriate young age (mean: 66.5 days). Conclusions: Coordinated prenatal evaluation of patients with cleft lip/palate by multidisciplinary centers plays an important role in the care of these complex patients. The results of the authors’ study demonstrated high sensitivity and specificity for the prenatal diagnosis of cleft lip/palate, leading to timely postnatal evaluation and treatment. Address correspondence and reprint requests to Albert K. Oh, MD, Division of Plastic and Reconstructive Surgery, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010; E-mail: AOh@childrensnational.org Received 12 March, 2019 Accepted 13 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.

Combined Use of Specially-Designed Digital Surgical Guides and Pre-Formed Reconstruction Plate to Treat Bilateral Mandibular Fracture This paper describes the application of a modified digital surgical guide, an occlusal template and a pre-formed reconstruction titanium plate in the open reduction and internal fixation of a bilateral mandibular fracture. Bilateral mandibular fracture is a commonly encountered simple type of fracture. However, even for an experience surgeon, achieving precise treatment remains a challenge due to the movable temporomandibular joint, unstable fractured segments, the difficulty in forming a reconstruction plate, and the lack of an effective stabilizing and locating device. In this case, the surgeon used a specially-designed modified guide together with a reconstruction plate and an occlusal template to treat a bilateral mandible fracture, effectively improving the accuracy and the medical outcome of the operation, saving operation time and reducing postoperative complications. Address correspondence and reprint requests to Jie Long, PhD, Sichuan University West China College of Stomatology, China; E-mail: dr.jielong@hotmail.com Received 19 July, 2019 Accepted 17 August, 2019 YH, ZX, XZ, and XL contributed equally to this work. This study was supported by grants from the National Nature Science Foundation of China (Nos. 31570950, 10502037, and 31070833) and the Science and Technology Foundation of Sichuan Province (Nos. 2017SZ0032, 2010GZ0225, 2011GZ0335, and 2009SZ0139). The authors have no conflicts of interest to disclose. © 2019 by Mutaz B. Habal, MD.

Preoperative Planning and Simulation in Patients With Cleft Palate Using Intraoral Three-Dimensional Scanning and Printing Background: In cleft palate, surgery is necessary for recovering important functions of the normal palate, such as speech and feeding. Herein, a three-dimensional (3D) scanning program with an intraoral scanner was used to evaluate the palate status of patients with cleft palate before palatoplasty. Further, a 3D cleft palate printed model of the patients’ palate using 3D printing technology was produced. Methods: Three patients with cleft palate were included (1 male and 2 female patients with a mean age of 13 months). Extended scanning from the maxillary arch to the soft palate was conducted, without any direct contact of the scanner with the tissues of the palatal area. The maxillary arch dimensions and cleft size of the scanned data were measured using a 3D analysis software. After all 3D analyses, the scanned data were printed to a 3D cleft model, which was used as a training and simulation model. Results: The overall contour and size of the cleft were observed on the scanned 3D images. There was a large inter-individual range in the cleft dimensions among the subjects. Double-opposing Z-plasty was then simulated on the printed 3D cleft palate model completely. Conclusions: The present study concentrated on the possibility of an intraoral scanner as a novel diagnostic tool for recording data of patients with cleft palate; 3D cleft palate models created using 3D printers can be used as training models for surgical trainees. Address correspondence and reprint requests to Ho Seong Shin, MD, PhD, Department of Plastic and Reconstructive Surgery, Soonchunhyang University Bucheon Hospital, 170, Jomaru-ro, Wonmi-gu, Bucheon-si, Gyeonggi-do 14584, South Korea; E-mail: shinerim@hanmail.net Received 25 April, 2019 Accepted 17 August, 2019 The authors have no conflict of interest to declare. 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.