Craniofacial Surgery

Comparison of 3 Different Techniques on the Movement of the Implants After Evisceration Purpose: To compare the results of 3 evisceration techniques involving placement of an acrylic implant within the scleral shell without posterior sclerotomy (Group 1), posterior sclerotomy with placement of a porous implant within the intraconal space (Group 2) and posterior sclerotomy with placement of a acrylic implant within the intraconal space (Group 3) with respect to ocular mobility, implant complications and patient satisfaction. Methods: Single-center, retrospective, interventional case series. A chart review of 72 patients undergoing evisceration between February 2013 and January 2018 was carried out. Thirty-five patients met the inclusion criteria having a normal or near normal size eye and at least 6 months follow-up. The horizontal movements of the implant and the artificial eye was measured by using a ruler. Data analyses were conducted using the Mann-Whitney U test for 2 independent samples. Results: Neither infection nor prolapse of the implant had occurred in any of the patients. The mean implant sizes were 18 mm in Group 1, 20 mm in Group 2 and 20 mm in Group 3. Statistically, a significant difference was assessed between Group 1 and Group 2 in both nasal and temporal movement of the socket; nasal and temporal movement of the prosthesis. Statistically, a significant difference was assessed between Group 1 and Group 3 in both nasal and temporal movement of the socket; nasal and temporal movement of the prosthesis. However, there was no statistically significant difference between Group 2 and Group 3 in neither nasal and temporal movement of the socket nor nasal and temporal movement of the artificial eye. Conclusion: Group 1 showed the significantly better movement of both prosthesis and socket in adduction and abduction than Group 2 and 3. The likely explanation of for this may be that preserving the scleral shell integrity allows more efficient transmission of muscle contraction to the socket and prosthesis. Address correspondence and reprint requests to Dr Selam Yekta Sendul, MD, Sisli Hamidiye Etfal Training and Research Hospital, Department of Ophthalmology, Istanbul., Etfal Street 34280 Sisli, Istanbul, Turkey; E-mail: sysendul@hotmail.com Received 21 February, 2019 Accepted 20 March, 2019 Written consent was obtained from the patients shown in the figures. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. All authors declare that they have no competing interests. © 2019 by Mutaz B. Habal, MD.

A Rotational Flap Combined With a Mucosal Advancement Flap for the Lip Reconstruction The lips play an important role in both esthetics and oral functions, so it should be reconstructed in the light of both. The authors present a patient with the upper lateral lip defect after widely excising the basal cell carcinoma. The lip reconstruction was completed with a rotational flap combined with a mucosal advancement flap. By using 2 flaps simultaneously, the defect was covered with sufficient adjacent tissue without severe deformity and tension. At 2-month follow-up, the patient retained good aesthetic results as the scar was on the natural lines of the face. There was no noticeable deformity on the vermilion contour and oral commissure. Oral competence was also good. Address correspondence and reprint requests to Hyungon Choi, MD, PhD, Department of Plastic Surgery, Konkuk University School of Medicine, 120-1 Neungdong-ro, Gwangjin-gu, Seoul 143-729, Korea; E-mail: sweetestfairy@hanmail.net Received 7 March, 2019 Accepted 16 April, 2019 © 2019 by Mutaz B. Habal, MD.

The Natural History of Treated and Untreated Zygomatic Arch Fractures The authors present the case of a 32-year-old patient treated for a left, isolated zygomatic fracture following assault. The injury was reduced without fixation via the Keene approach. The same patient presented to the emergency room 16 months later with a right-sided fracture similar to the previous contralateral injury. This fracture was left untreated. Repeated assaults over a 4-year period provide us with a natural history of both injuries, allowing for comparison between the 2 approaches. The authors found that reduction of the arch without fixation led to an outcome without palpable or visible deformity and no impaired mastication. Additionally, considering etiology of injury, such as alcohol or drug use, treatment may provide an important point of intervention to prevent recurrence. Address correspondence and reprint requests to Alexander Homer, Brown University, 69 Brown Street, Mail #3000, Providence, RI 02912; E-mail: alexander_homer1@brown.edu Received 30 January, 2019 Accepted 25 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Strategy of Mandibular Central Arch Reconstruction After Firearm Injury Gunshot wounds can cause extensive destruction of soft tissue and bone, and the maxillofacial region is often affected. The reconstructive treatment is complex due to the difficulty to reestablish the central arch mandibular contour and volume. Moreover, the goal is to avoid postoperative infections and obtain bone graft neovascularization. Therefore, this report shows a clinical case of a patient presenting mandibular deformity with a mandibular central arch discontinuity caused by a firearm injury. The strategy to the reconstructive treatment as performed with a condensed and stabilized particulate autogenous bone graft was essential and effectiveness. After 1 year, it was obtained a satisfactory result to the patient. Address correspondence and reprint requests to Bruno Coelho Mendes, DDS, Jose Bonifacio, 1193, Araçatuba, São Paulo 16015-050, Brazil; E-mail: brunocoelho.mnds@gmail.com Received 10 February, 2019 Accepted 24 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

An Extremely Rare Cause of Headache; Osteoma of the Middle Concha Bullosa Osteomas are benign, slow-growing tumors originating from bone tissue. Osteomas of the paranasal region, which are usually asymptomatic, are detected incidentally on tomographies taken for other medical needs. Paranasal sinus osteomas frequently localized in the frontal and ethmoid sinuses are among the infrequent reasons for headaches. In this case report, the authors submit the first case of an osteoma that was localized inside the middle concha bullosa and causing headache. It was successfully excised via an endoscopic endonasal approach without any complications. Address correspondence and reprint requests to Secaattin Gulsen, MD, Department of Otorhinolaryngology, Private HATEM Hospital, Allaben District, Kemal Köker avenue No:41 Şahinbey, Gaziantep, Turkey. Zip code: 27000; E-mail: drsecaattingulsen@gmail.com Received 3 March, 2019 Accepted 22 April, 2019 The authors report no conflicts of interest © 2019 by Mutaz B. Habal, MD.

Anterior Segmental Osteotomy Using Customized Spider-Plates Based on Computer-aided Surgery System Anterior segmental osteotomy (ASO) is considered the treatment modality of choice in patients with the bimaxillary dentoalveolar protrusion. However, this meticulous surgical technique accompanies a number of possible disadvantages. The considerable time required before, during, and after the operation, limited movement of the segment, damage of the mental nerve, loss of tooth vitality, loss of a tooth or teeth, or indeed total loss of the anterior segments are those that affect the result of the surgery. Recently, the authors have devised a computer-aided surgical simulation programme and fabricated the customized osteotomy guides and the spider-shaped plates based on the programme. They were then applied to a 28-year-old patient with the complaint of a bimaxillary dentoalveolar protrusion. This approach helped to overcome several problems related to ASO reported earlier. Address correspondence and reprint requests to Byoung-Eun Yang, DDS, PhD, Department of Oral and Maxillofacial Surgery, Hallym University College of Medicine Sacred Heart Hospital, 11, Gwanpyeong-ro 170beon-gil, Dongan-gu, Anyang-si, Gyeonggi-do 14066, South Korea; E-mail: face@hallym.or.kr, omsyang@gmail.com Received 25 March, 2019 Accepted 19 April, 2019 The authors received no financial support for the research, authorship, and publication of this article. Informed consent from the patient was obtained after detailed information of the necessary treatment, especially concerning the planned new technique. Furthermore, informed consent was also obtained for publication of the procedure and follow up treatment. The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Complication After PDO Threads Lift Thread-lifting is as a minimally invasive procedure with limited scarring, rapid recovery, and fewer complications compared with the standard incisional surgery for facial rejuvenation. Using absorbable thread-like polydioxanone is a relatively simple procedure that is also performed by nonmedical professionals in Korea. Although several acute or delayed complications after using nonabsorbable thread types were also reported, it is uncommon to find cellulitis caused by a delayed complication after thread-lifting. A 41-year-old woman presented to our clinic with inflamed multiple palpable masses. She underwent 3 courses of acupoint embedding therapy at a Korean oriental medical clinic. She was treated with combination antibiotic therapy; however, the inflammation did not subside. Consequently, excisional biopsy was performed under local anesthesia. During the procedure, threads were detected and removed. Dimpling, thread exposure, alopecia, under-correction, asymmetry, and parotid gland injury also can occur as early complications of the procedure. Fortunately, these reactions are predominantly mild to moderate in intensity, and can be corrected by a relatively simple procedure. Chronic inflammatory reactions in the thread-lifting area, as identified in the authors' case, are an infrequent complication. It is recommended to consult with experts in the field for the implementation of this procedure. In addition, experts also need to notify the above side effects and solutions in advance to ensure safe and satisfactory procedures for their patients. Address correspondence and reprint requests to Hwan Jun Choi, MD, PhD, Department of Plastic and Reconstructive Surgery College of Medicine, Soonchunhyang University, Bongmyeong-dong, Dongnam-gu, Cheonan 330-721, Republic of Korea; E-mail: medi619@hanmail.net Received 21 January, 2019 Accepted 19 March, 2019 This study was supported by the Soonchunhyang University Research Fund. The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Adding Depth to Cephalometric Analysis: Comparing Two- and Three-Dimensional Angular Cephalometric Measurements Introduction: Lateral cephalometric radiographs (LCR) have been the standard tool used for cephalometric analysis in craniofacial surgery. Over the past decade, a three-dimensional (3D) revolution in cephalometric analysis and surgical planning has been underway. To date, research has not validated whether cephalometric measurements taken from two-dimensional (2D) and 3D data sources are equivalent and interchangeable. The authors sought to compare angular cephalometric measurements taken with 2D and 3D modalities. Methods: Sixty-two head CT scans (36 females, 26 males) with an average age of 63 ± 20 years were studied. Twelve cephalometric angular measurements were taken from 3D reconstructed skulls using the software package Mimics 19.0 (Materialize; Leuven, Belgium). These same facial angles were measured from 2D lateral cephalograms reconstructed from the original CT scans using Dolphin 11.9. Measurements taken with both techniques were compared for agreement using a paired t test. Intra-class correlation coefficient assessment was used to determine inter-rater reliability. Statistical significance was set at P < 0.05. Results: Five of the 12 angular measurements (SNA, SNB, MP-FH, U1-SN, and U1-L1) demonstrated statistically significant differences (P < 0.05) between the 2D and 3D analyses. All of these differences were less than the standard deviations for the respective measure. Conclusion: The differences between angular cephalometric values obtained from 2D LCRs and 3D CT reconstructions are small. This supports the practices of using 2D and 3D cephalometric data interchangeably in most applications. Clinicians must be selective in which measures they employ to maximize accuracy and care must be taken when measuring dental inclination with lateral cephalograms. Address correspondence and reprint requests to S. Alex Rottgers, MD, Assistant Professor of Plastic Reconstructive Surgery, Johns Hopkins All Children's Hospital, Division of Plastic and Reconstructive Surgery, 601 Fifth Street South, Suite 306, St. Petersburg, FL 33701; E-mail: srottge1@jhmi.edu Received 28 November, 2018 Accepted 12 March, 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.

Risk Factors for Adult Postintubation Tracheal Stenosis Background: To identify risk factors for developing adult postintubation tracheal stenosis (TS) and determine if there were patient characteristics that could serve as prognostic indicators of clinical outcomes in this patient population. Methods: A total of 55 patients with postintubation TS admitted to our institution between February 2009 and March 2017 (TS group) and randomly selected 86 patients admitted to the intensive care unit and intubated over the same period in whom TS was ruled out (control group) were compared. Causal factors of intubation were noted. Patient-, treatment-, and procedure/cuff site-related risk factors of TS were compared. Results: Both groups did not differ from each other by means of age and gender (P = 0.640, and P = 0.724, respectively). Compared to controls, patients with TS had a significantly higher BMI (32.8 ± 7.64 kg/m2 versus 25.9 ± 6.68 kg/m2; p = 0.002) and were more likely to have diabetes (28.4% vs 9.82%; p = 0.0011). Patients who were previously intubated for more than 48 hours (P = 0.016) and patients treated with irradiation (P = 0.028) were significantly more likely to develop TS than control patients. Conclusion: Patients with TS had a significantly higher BMI, and were more likely to have diabetes compared to controls. Patients who were previously intubated for more than 48 hours and patients treated with irradiation were more likely to develop TS than control patients. Address correspondence and reprint requests to Murat Songu, MD, Department of Otorhinolaryngology, Izmir Katip Celebi University, Ataturk Training and Research Hospital, Izmir, Turkey; E-mail: songumurat@yahoo.com Received 16 January, 2019 Accepted 27 February, 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.

Transnasal Endoscopic Retrieval of a Metallic Intraorbital Intraconal Foreign Body Facilitated by an Intraoperative Magnetic Stick Here, we report the case of an intraorbital intraconal foreign body that was successfully retrieved by a transnasal endoscopic approach facilitated intraoperatively by a magnetic stick. A 36-year-old man was admitted to our unit with a left-sided intraorbital intraconal metallic foreign body. Following 2 failed attempts via a transconjunctiva approach, we finally recovered the foreign body using transnasal endoscopic surgery. During this procedure, a magnetic stick was used to help us locate and successfully remove the foreign body, grapeshot measuring approximately 0.5 cm in diameter. Visual acuity in the injured eye increased from 0.01 preoperatively to 0.04 6 days after surgical intervention. There were no complications. We therefore propose that in selected patients, the endoscopic transnasal approach is an effective, safe and minimally invasive approach for the removal of intraorbital intraconal foreign bodies. The intraoperative use of a magnet can facilitate the successful location and removal of magnetic metallic foreign bodies. Address correspondence and reprint requests to Jianfeng Liu, MD, Department of Otolaryngology, China-Japan Friendship Hospital, Yinghuadong Street, Chaoyang District, Beijing, China 100029; e-mail: mmconfucius@163.com Received 19 February, 2019 Accepted 31 March, 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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