Endoscopy-Assisted Intraoral Removal of Elongated Styloid Process: Mini-Invasive Surgical Treatment of Eagle Syndrome The aim of this work is to illustrate a transoral mini-invasive approach to safely remove elongated styloid process in Eagle syndrome. A 34-year-old Asian male came to our center referring pharyngeal and cervical pain on the right side on swallowing and opening the mouth. Computed tomography showed elongation of the right styloid process. Surgical removal was performed through endoscopy-assisted intraoral approach using a pituitary curette to perform dissection and piezosurgery for the osteotomy. Surgical intervention was completed in 25 minutes. Postoperative period was uneventful except for transient (12 hours) right facial palsy that resolved spontaneously. Two months after surgery, patient referred resolution of symptoms. This technique is easy to perform and permits to obtain good result with reduction of surgical time and with low risk of complication. Address correspondence and reprint requests to Ingrid Raponi, MD, Viale del Policlinico 155, Rome 00161, Italy; E-mail: Ingrid.raponi@uniroma1.it Received 27 February, 2019 Accepted 12 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.

Minimally Invasive Technique to Reduce the Isolated Anterior Wall Fracture of the Frontal Sinus Conventional open reduction and internal fixation of frontal sinus anterior wall fractures are associated with risks of visible scarring and limited access to the nasofrontal duct. The goal of this study was to report the minimally invasive surgical techniques and their results in cases with frontal sinus anterior wall fractures. A retrospective study was performed on 20 consecutive cases of isolated anterior wall fractures of the frontal sinus between July, 2008 and February, 2017. Causes of injury, interval between the injury and operation, and operation time were reviewed. The fractures were reduced using the minimally invasive techniques of endoscopic endonasal reduction or reduction through a small trephination. Anatomical and aesthetic outcomes were evaluated, and postoperative complications were reviewed. The fractures were reduced with endoscopic endonasal techniques in 11 patients and through a small trephination with a minimal incision in the forehead in 9 patients. The fractures were successfully reduced in all cases. The mean follow-up period was 21.2 months, and no postoperative complications were observed. For isolated anterior wall fractures of the frontal sinus, minimally invasive techniques, such as endonasal endoscopic reduction or reduction through a small trephination, are safe and effective options. Address correspondence and reprint requests to Hahn Jin Jung, MD, Department of Otorhinolaryngology-Head and Neck Surgery, Chungbuk National University College of Medicine, Chungbuk National University Hospital, 776, 1Sunhwan-ro, Seowon-gu, Cheongju-si, Chungcheongbuk-do, 28644, Korea; E-mail: hahnjin2@naver.com Received 26 December, 2018 Accepted 17 July, 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.

The Effect of Bone Marrow Aspirate Concentrate Application on Distracted Bone Biomechanical Properties Background: This study was conducted to assess effect of bone marrow aspirate concentrate (BMAC) on enhancing biomechanical properties of distraction osteogenesis (DO). Methods: Twelve rami of goats had distraction and were divided into test group (DO bone supplemented with BMAC) and control group. Results: Assessment of bone-width showed nonsignificant (P = 0.9) increase in test group (mean = 5.3 mm, standard deviation = 1.9 mm) compared to control group (mean = 5.2 mm, standard deviation = 0.8 mm). Assessment of radiographic density showed nonsignificant (P = 0.5) increase in test group (mean = 163.4 Hounsfield Unit, standard deviation = 6.5 Hounsfield Unit) compared to control group (mean = 156.6 Hounsfield Unit, standard deviation = 21.8 Hounsfield Unit). Histomorphometry of mature-bone % showed significant (P = 0.02) increase in test group (mean = 30%, standard deviation = 9.8%) compared to control group (mean = 15.9%, standard deviation = 7.2%). Assessment of biomechanical testing (bone strength) by 3-point bending test showed nonsignificant (P = 0.7) increase in test group (mean = 511.6 Newton, standard deviation = 189.1 Newton) compared to control group (mean = 467.8 Newton, standard deviation = 201.1 Newton). Conclusion: The BMAC failed to improve both bone quantity and biomechanical bone strength of distracted bone. Address correspondence and reprint requests to Yasser Nabil El Hadidi, MOMS, RCSEd, Associate Lecturer of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ain Shams University, Cairo, Egypt; E-mail: yasserelhadidi@asfd.asu.edu.eg Received 19 May, 2019 Accepted 17 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.

Basal Cell Carcinoma Arising over a Venous Malformation of the Forehead Communicating with the Endocranial Veins Introduction: An increasing number of skin cancer arising over vascular anomaly has been reported in literature. In such cases, the oncologic radicality required to threat skin malignancies may be in contrast with the safety needed when dealing with vascular malformation. As a result, treatment of this association may be insidious and treacherous and imposes a sound knowledge and carefulness. Materials and Methods: The authors report on a case of a 77-years-old woman affected by a basal cell carcinoma (BCC) arising over a vascular malformation of forehead. Preoperative radiological imaging revealed an underlying venous malformation (VM) communicating with intracranial district. Patient underwent sclerotherapy of the VM with gelified ethanol in order to reduce potentially fatal bleeding during surgery and, on the other hand, any leakage of the sclerosant in the intracranial veins. Excision of the BCC was then performed without complications. Results: Neither intra-operative nor post-operative complications were observed. Current 3-years follow-up shows no recurrence of BCC whilst the residual VM is stable and clinically silent. Conclusions: Mechanisms leading to the onset of skin cancers over venous malformations are still unclear. However, association between these 2 conditions may be underestimated with possible catastrophic consequences. Thorough knowledge of vascular malformations and a multidisciplinary approach is of the uttermost importance when dealing with such clinical challenges. Address correspondence and reprint requests to Giacomo Colletti, MD, Piazza della Repubblica 21, 20124, Milan, Italy; E-mail: giacomo.colletti@gmail.com Received 21 May, 2019 Accepted 8 August, 2019 The authors have no conflict of interest to declare. The authors alone are responsible for the content and writing of this article. © 2019 by Mutaz B. Habal, MD.

Advancement Flap Using Excess Skin for Upper Eyelid Full-Thickness Defects Reconstruction of upper eyelid defects should aim for a moveable lid with perfect corneal protection and good aesthetic quality. Numerous procedures to reconstruct large upper eyelid defects have been reported, but these methods require 2-stage procedures. A new method for reconstructing full-thickness upper eyelid defects after tumor excision in a single stage was presented in this study. The preferred technique uses excess skin as an advancement flap together with an ear cartilage graft for the lining. Reconstruction was performed with an advancement flap using excess skin and ear cartilage for full-thickness defects after upper eyelid tumor excision. The rectangular flap was outlined on the excess skin of the upper eyelid. After tumor resection of the full-thickness defect, the ear cartilage was sutured to the remaining tarsus. The residual levator aponeurosis and posterior lamellar were connected to the transplanted ear cartilage. The outer layer was reconstructed with an advancement rectangular flap. The authors performed this technique for 4 patients, aged 62 to 88 years, for upper eyelid reconstruction. Good functional and aesthetic results were achieved for all patients. Our method involves a single-stage reconstruction, which is simpler and less invasive than other techniques. Address correspondence and reprint requests to Toshihiko Hayashi, MD, DDS, Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku, Sapporo, Hokkaido 060-8638, Japan; E-mail: toshi-116@nifty.com Received 1 June, 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.

Barriers to the Effective Management of Gynecomastia in Adolescents Background: The aim of this study was to explore the impacts of gynecomastia on adolescents, explore the surgical and psychological success of mastectomy, and evaluate the adequacy of insurance guidelines and coverage. Methods: American College of Surgeons National Surgical Quality Improvement Program (NSQIP) surgical database from 2010 to 2014 was evaluated for current procedural terminology codes 19300 and 19303, representing mastectomies for gynecomastia and complete mastectomies respectively to compare surgical site complications. Results: Of 1132 procedures for mastectomy for gynecomastia 1.5% of patients (n = 17) were associated with postoperative superficial surgical site complications. In the same timeframe, a total of 33,124 procedures for simple, complete mastectomy performed with a postoperative surgical complication rate of 2.2% (n = 721). Results of a Chi-squared goodness of fit χ2 (1, N = 34,997) = 2.10, P > 0.05 suggests no statistically significant difference between incidence of surgical site complications for a mastectomy for gynecomastia versus typical mastectomy. Discussion: High surgical success rate, coupled with significant improvements in psychosocial functioning suggests that mastectomy is a highly effective intervention for adolescents with gynecomastia. However, due to vague and inadequate coverage and evaluation criteria surgery is often not performed. This paper offers a framework for developing a quantitative system by which to evaluate surgical candidates by adopting well-established guidelines currently in use for reduction mammoplasties and suggests further analysis into a cost/benefit analysis for coverage of the procedure. Address correspondence and reprint requests to Yingyot Arora, BS, University of Miami, Miller School of Medicine, 1600 NW 10th Ave #1140, Miami, FL 33136; E-mail: y.arora@med.miami.edu Received 19 June, 2019 Accepted 18 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.

Comparison of Hamra's and Mendelson's Models of Midface Lift The aim of this study was to compare Hamra's and Mendelson's models of midface lift. The terms “Hamra ST” and “Mendelson BC” were used to search PubMed, yielding 35 and 48 papers, respectively. Of the 83 abstracts, 55 were excluded and 28 full papers discussing midface lift were reviewed. Among those 28 papers, 13 were excluded because they did not have sufficient content. Among the 15 full texts, 5 mined papers were added. Thereafter, 20 papers were analyzed. Hamra's description of his surgical technique changed twice. In 1990 (The Deep-Plane Rhytidectomy), he wrote that he performed Skoog-type subsuperficial muscular aponeurotic system (SMAS) dissection to the nasolabial fold. In 1992 (Composite Rhytidectomy), however, he cited a paper insisting that the SMAS does not exist in the cheek area. He wrote that his deep-plane rhytidectomy was not a sub-SMAS procedure, stating that he dissected the cheek fat that is attached to the zygomaticus major, then repositioned the skin. This was a substantially different explanation of the dissection plane. In 1997, he stated that instead of dividing the orbicularis oculi muscle from the zygomaticus major and minor, he elevated them together in a flap. Thus, his method returned to the sub-SMAS plane. Mendelson introduced the concepts of the prezygomatic space, orbicularis-retaining ligament, and zygomatic-retaining ligament, and proposed an anatomical model. If the authors explain Hamra's zygorbicular dissection using Mendelson's model, the dissection starts just beneath the roof of the prezygomatic space, traverses the floor, and then releases the zygomatic ligament (lower boundary of the space). The authors should consider the necessity and riskiness of this release. Address correspondence and reprint requests to Kun Hwang, MD, PhD, Department of Plastic Surgery, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon 22332, Korea; E-mail: jokerhg@inha.ac.kr Received 9 July, 2019 Accepted 12 July, 2019 This study was supported by a grant from Inha University Hospital. 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.

Veau III and Veau IV Cleft Palate: Do Peri-Operative Complications Differ? Objective: The Veau classification represents the most commonly used system for characterizing cleft palate severity. Conflicting evidence exists as to how increasing Veau classification affects outcomes. This study compared perioperative outcomes between Veau III and IV cleft palate repairs. Methods: The National Surgical Quality Improvement Program Pediatric (NSQIP-P) database was used to identify cleft palate repairs between 2012 and 2016 using CPT codes. Patients with alveolar bone grafts were excluded. Veau III (unilateral) and Veau IV (bilateral) cleft palate repairs were identified using International Classification of Disease code 9 and 10 (ICD-9 and -10 codes. Patient demographics, comorbidities, and adverse events were compared between the cohorts. Results: A total of 5026 patients underwent cleft palate repair between 2012 and 2016. Of the 2114 patients with identifiable Veau classification, 1302 had Veau III cleft palates and 812 had Veau IV cleft palates. The Veau IV cleft palate patient population was older (377.8 versus 354.1 days, P < 0.001) and had significantly more comorbidities including a higher incidence of chronic lung disease (P = 0.014), airway abnormalities (P = 0.001), developmental delay (P = 0.018), structural central nervous system deformities (P < 0.001), and nutritional support (P < 0.001). Veau IV cleft palate repairs also had longer operative times (153.2 versus 140.2 minutes, P < 0.001). Despite significant differences in comorbidities and perioperative factors, there were no differences in 30-day complications, readmissions, or reoperation rates between Veau III and IV cleft palate repairs. Conclusions: Patients undergoing Veau IV cleft palate repair have a significantly greater number of comorbidities than Veau III cleft palate repairs. Despite differences in patient populations, 30-day surgical outcomes are comparable between the cohorts. Address correspondence and reprint requests to Michael Alperovich, MD, MSc, Department of Surgery, Section of Plastic and Reconstructive Surgery, Yale School of Medicine, 330 Cedar Street, Boardman Building, 3rd Floor, New Haven, CT 06510; E-mail: michael.alperovich@yale.edu Received 26 January, 2019 Accepted 15 July, 2019 Author Roles: FC, BS: study design, data collection, statistical analysis, tables, manuscript preparation and revisions; EJM, BA: study design, data collection & analysis, manuscript preparation and revisions; KSG, MD: study design, tables, manuscript preparation and revisions; MA, MD, MSc: principle investigator, study design, tables, manuscript preparation and revisions. The authors report no conflicts of interest. NSQIP Disclosure: The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. 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 Relationship Between the Supratrochlear Nerve and Trochlea: Anatomical Study and Application to Migraine Headaches Supratrochlear nerve (STN) is a terminal branch of the frontal nerve arising from the ophthalmic nerve (V1). Compression of the STN by adjacent structures might result in migraine headaches. The aim of this study was to explore the relationship of the STN and trochlea for a better understanding of potential entrapment of the STN. Nineteen orbits from ten fresh-frozen cadaveric heads were dissected. The relationship of the STN and the trochlea was classified into three types: In type I, the STN passed lateral to the trochlea; In type II, the STN passed through the trochlea; In type III, the STN passed medial to the trochlea. Type I was found in 52.6% (10/19 sides), type II was found in 42.1% (8/19 sides), and type III was seen in 3.4% (1/19 sides). In type III, both the STN and infratrochlear nerve were identified as separate branches. The authors propose a new classification of the pathway of the STN based on its relationship with the trochlea. This study might shed light on headaches emanating from this region. Address correspondence and reprint requests to Joe Iwanaga, DDS, PhD, Seattle Science Foundation, 550 17th Ave, James Tower, Suite 600, Seattle, WA 98122; E-mail: joei@seattlesciencefoundation.org Received 4 April, 2019 Accepted 16 July, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Fabrication of Nasoalveolar Molding Devices for the Treatment of Cleft Lip and Palate, Using Stereolithography Additive Manufacturing Processes and Computer-Aided Design Manipulation Software Introduction: Nasoalveolar molding (NAM) is a presurgical orthopedic treatment modality that attempts to reorient misaligned bony and soft tissue structures in patients with clefting of the lip and palate. The NAM devices are implemented prior to surgical intervention in order to minimize the gap across the cleft and thereby reduce tension across the eventual repair. Currently, NAM devices are fabricated in a laboratory and then refined chairside by the provider. The present article describes the potential of three-dimensional (3D) printing and computer-aided design (CAD) software for the fabrication of NAM devices. Material and methods: A workflow was developed to demonstrate the use of 3D printing and CAD software to design NAM devices. This workflow encompasses scanning an impression into CAD software, performing a series of manipulations, and then printing the digital model. Results: To test the workflow, a cleft palate plaster model was scanned into CAD software. Through a series of linear and angular freeform manipulations of the body, the model was modified to display a cleft with a reduced alveolar gap. Sequential molding devices were produced which would gradually apply pressure to targeted areas of hard and soft tissue until the cleft is minimized. The resulting devices are printed using a stereolithography printer. Conclusions: The use of 3D printing and CAD software shows promise in improving the accuracy, speed, and cost-effectiveness of designing NAM devices. The accuracy and flexibility from digitally visualizing the manipulations made to an appliance before its creation can result in a more personalized device for the patient. Address correspondence and reprint requests to Sofia Ahsanuddin, BA, 50 E. 98th St. Apt. 3E-4 New York, NY 10029; E-mail: sofia.ahsanuddin@icahn.mssm.edu Received 20 June, 2019 Accepted 16 July, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.