Craniofacial Surgery

Clinical Characteristics and Microsurgery Treatment of Anterior Cranial Fossa Dural Arteriovenous Fistula Anterior cranial fossa dural arteriovenous fistulas (DAVFs) represent 6% of all intracranial DAVFs and have a high risk of intracranial hemorrhage. To analyze the clinical characteristics and microsurgery treatment of anterior cranial fossa DAVFs, a retrospective review of 21 patients with anterior cranial fossa DAVFs undergoing microsurgery was performed, including 8 bleeding patients and 13 non-bleeding patients. The Glasgow coma scale (GCS) scores were used to evaluate the conscious states of 8 bleeding patients before and after operation. All patients had no obvious complications and the clinical symptoms were improved after operation. No abnormal fistulas and drainage veins were detected by digital subtraction angiography postoperatively. The GCS scores of 8 bleeding patients showed that the conscious states became better than pre-operation. Of the 21 patients, 9 patients were followed up without recurrence. Taken together, microsurgery is an effective method for the treatment of anterior cranial fossa DAVFs and it is very important for the improvement of bleeding patients' conscious states. Address correspondence and reprint requests to Handong Wang, PhD, Department of Neurosurgery, Jinling Hospital, 305 East Zhongshan Road, Nanjing 210002, Jiangsu Province, P.R. China; E-mail: njhdwang@hotmail.com Received 11 September, 2018 Accepted 30 April, 2019 This work was supported by Grants from the National Natural Science Foundation of China (No. 81672503 and 81702484). The authors declare that they have no conflict of interests. 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.

Role of Autologous Fat Injection in Neglected Patients With Anterior Plagiocephaly Anterior plagiocephaly is a type of non-syndromic craniosynostosis requiring surgery. In this study, the authors have presented 15 neglected patients with anterior plagiocephaly. Two of patients had moderate plagiocephaly whereas others had mild plagiocephaly. A total of 38 procedures (fat injections) were performed on these patients. Following procedures, 2 of patients were under corrected, 2 of who were over corrected, and others were adequate corrected. One of the patients developed fat necrosis. None of them showed persistent over correction. Authors believe that autologous fat transplantation is a safe and effective method, in patients with anterior plagiocephaly who have not been operated, to improve patients' appearance and, subsequently, their self-esteem as well as their social function. Address correspondence and reprint requests to Abdoljalil Kalantar-Hormozi, MD, Department of Plastic and Craniofacial Surgery, Medical College of Shahid Beheshti University of Medical Science (SBMU), 15 Khordad Hospital, Azodi Street, Karim Khan Blvd, Tehran, Iran; E-mail: kalantarj@yahoo.com Received 18 January, 2019 Accepted 25 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Comparison of Patient Satisfaction Between Composite and Dorsum Augmentation-Only Nasal Reconstructions With Diced Cartilage Graft Wrapped in Fascia The comparison of patient satisfaction with the use of diced cartilage graft wrapped in fascia (DCF) graft in composite versus dorsum augmentation-only reconstructions (DAOR), technical hints and complications in our series, affecting the end-result and the patient satisfaction (PS) has been presented. Between 2013 and 2018 the DC-F graft is used in 32 rhinoplasty cases. Nine of patients have had composite reconstruction (CR). The DAOR has been needed for 23 of patients. The follow-up period has been 2 months to 3 years. The authors have obtained satisfactory results in 24 cases but some untoward progress in 8 cases. A questionnaire was prepared and asked all patients for the assessment of the satisfaction from appearance, breathing, self-esteem, and positive psychological effect. The learning curve for rhinoplasty should be calculated for, hump reduction, crooked nose, augmentation rhinoplasty, and so on. separately which is also relevant for the use of a DC-F graft. Placing the DC-F over a straight platform, choosing the accurate graft and fascia material wisely, proper tailoring of DC-F, sliding it under the skin-superficial musculoaponeurotic system properly etc. determine the quality of the end result and the degree of PS. Operating on the DAOR are relatively more comfortable compared to CRs but responses to our questionnaire denote higher degrees of satisfaction in CR cases. Utilization of the DC-F graft in secondary rhinoplasties for dorsum augmentation provides satisfactory results. The degree of PS with the DC-F reconstruction seems to have an adverse correlation with the extent of deformities that you start with. Address correspondence and reprint requests to Aret Çerçi Özkan, MD, Incirli Caddesi Bayrak Apt. No 89/7 Bakirköy, Istanbul, PK. 34147 Türkiye, Turkey; E-mail: aretmd@hotmail.com Received 1 February, 2019 Accepted 22 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Transcranioplasty Ultrasound Through a Sonolucent Cranial Implant Made of Polymethyl Methacrylate: Phantom Study Comparing Ultrasound, Computed Tomography, and Magnetic Resonance Imaging Background: Current methods of transcranial diagnostic ultrasound imaging are limited by the skull's acoustic properties. Craniotomy, craniectomy, and cranioplasty procedures present opportunities to circumvent these limitations by substituting autologous bone with synthetic cranial implants composed of sonolucent biomaterials. Objective: This study examined the potential to image the brain using transcranioplasty ultrasound (TCU) through a sonolucent cranial implant. Materials and Methods: A validated adult brain phantom was imaged using computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound without an implant. Next, for experimental comparison, TCU was performed through a sonolucent implant composed of clear polymethyl methacrylate. Results: All imaging modalities successfully revealed elements of the brain phantom, including the bilateral ventricular system, the falx cerebri, and a deep hyperdense mass representing a brain tumor or hematoma. In addition, ultrasound images were captured which closely resembled axial images obtained with both CT and MRI. Conclusion: The results obtained in this first-ever, preclinical, phantom study suggest TCU is now a viable immediate and long-term diagnostic imaging modality deserving of further clinical investigation. Address correspondence and reprint requests to Chad Gordon, DO, FACS, Division of Neuroplastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, JHOC, 8th Floor, 601N. Caroline St., Baltimore, MD 21287; E-mail: cgordon@jhmi.edu Received 11 February, 2019 Accepted 24 April, 2019 There was no external funding used for this study. CG is a consultant for Stryker and Longeviti Neuro Solutions. JH and CG are stockholders of Longeviti Neuro Solutions. None of the other authors have any conflicts to report. © 2019 by Mutaz B. Habal, MD.

The Use of a Three-dimensional Printed Model for Surgical Excision of a Vascular Lesion in the Head and Neck Facial vascular lesions are considered a great therapeutic challenge due to the considerable variability of clinical presentations. Surgical removal requires precise planning and advanced visualization to understand the three-dimensional anatomical relationships better. The aim of the study was to evaluate the feasibility of three-dimensional printed models, based on computed tomography angiography (CTA), in planning and guiding surgical excision of vascular lesions. A patient with a suspected vascular malformation in the face was recruited for participation in this feasibility study. Two personalized three-dimensional models were printed based off 2 separate CTA examinations. These constructs were used in preoperative planning and navigating surgical excision. The three-dimensional constructs identified the vicinity of the lesion and highlighted significant anatomical structures including the infraorbital nerve and vessels supplying the area of vascular anomaly. On postoperative follow-up the patient reported no recurrence of swelling and no sensory deficits. A personalized three-dimensional printed model of a facial vascular lesion was developed based on CTA images and used in preoperative planning and navigating surgical excision. It was most useful in establishing dangerous areas during the dissection process, including critical anatomical structures such as the infraorbital nerve. Combining conventional imaging techniques with three-dimensional printing may lead to improved diagnosis of vascular malformations and should be considered a useful adjunct to surgical management. Address correspondence and reprint requests to Marek A. Paul, MD, PhD, T. Marciniak Specialized Hospital, Fieldorfa 2, Wroclaw, Poland; E-mail: marek.adam.paul@gmail.com Received 11 February, 2019 Accepted 3 March, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Prediction of Number of Casts and Need of Tenotomy Using Pirani Score in the Management of Clubfoot Background: Clubfoot also called as congenital tailpipes equinovarus is a complex ankle and foot deformity characterized by forefoot adduction and supination, midfoot cavus and hindfoot varus and equinus. It is estimated that more than 100,000 babies are born each year worldwide with clubfoot, and 80% are seen in developing nations. Different scoring systems are used for grading the severity of deformity or monitoring the natural history of clubfoot. The Pirani scoring system is now routinely used in most clubfoot clinics, including Cure Ethiopia, Children's Hospital. Methods: A facility based retrospective study was conducted on 278 idiopathic club feet successfully treated by the Ponseti method and scored by Pirani system between September 2013/14 to September 2017/2018. Age at presentation, number of casts required, need for percutaneous Achilles tenotomy, casting effects were recorded. Results: A total of 287 clinical folders of children were retrieved (424 feet). The mean (±SD) number of casts required for correction of the deformity was 5.54 ± 1.63. The number of cast required for correction is significantly, and positively correlated with initial severity of Pirani score (r = 0.62 for right foot; r = 0.675 for left foot). There is a significant difference on the overall initial Pirani score between tenotomy and non- tenotomy group (P value < 0.001). Conclusion: The study revealed that severity of initial Pirani score can be used to estimate the number of Ponseti cast required for correction of clubfoot deformity and the need for tenotomy. Besides, the number of Ponseti cast required may not be affected by age of a child at the commencement of treatment. Address correspondence and reprint requests to Yared Asmare, MSc in Human Anatomy, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia; E-mail: kyared091107@gmail.com Received 27 February, 2019 Accepted 20 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 Fistula Development Following Palatoplasty Purpose: The aim of this study is to assess the influence of some risks factors on the fistula development after palatoplasty to improve the outcome of the patients Patients and Methods: A total of 48 patients (the males were 22, The females were 26) were included in this study. All the patients were examined weekly for the first month postoperatively to assess any breakdown in the wound by inspection and by asking the parents for any nasal regurgitation during fluids feeding. Results: The incidence of palatal fistula development after primary palatoplasty in this study was 12.5% (6\48). Occurrence of fistula was unrelated to the gender (P >0.5), but it was directly related to the age of patients (r = 0.98) and to the size of the cleft (r = 1). Fistula had occurred most likely in cases of Baradach 2 flap palatoplasty (83.3%) this was occurred especially when it was used for isolated cleft palate, but it was not associated with the type of the cleft (P >0.4). The surgeons experience and the use of prophylactic antibiotic were associated with the development of the fistula (P = 0.01 for both). Conclusion: knowledge of the expected risk factors for fistula after different protocols of palatoplasty can improve the experience of the surgeon and improve the outcome on the patients. Address correspondence and reprint requests to Osamah Mohammed Aldaghir, PhD, Lecturer, College of dentistry, University of Almuthanna, Iraq; E-mail: ousamahabdullameer@gmail.com Received 12 March, 2019 Accepted 18 April, 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 Utility of Endoscope-Assisted Rigid Bronchoscopy in Pediatric Airway Foreign Body Removals Introduction: Aspiration of foreign bodies is an emergency condition in children and may result in death, especially in children under 3 years of age. Therefore, diagnosis and treatment must be made rapidly. Objective: This study sought to summarize our experience with endoscope-assisted rigid bronchoscopy (RB) in the diagnosis and treatment of pediatric tracheobronchial foreign body emergencies to reduce complications and mortality. Methods: This was a retrospective cross-sectional study. The medical records of 337 children diagnosed with clinically suspected airway foreign body aspiration in the pediatric emergency department were analyzed retrospectively. The patients were divided into 2 groups with endoscopy used during RB in group 1 whereas group 2 was RB only. The surgeons who performed the bronchoscopies completed a survey on the advantages/disadvantages of these 2 procedures. Results: All of the patients had a positive history of suspected foreign body aspiration and foreign bodies were identified in 77.1% of the patients during RB. There were 161 (47.8%) patients in group 1 and 176 (52.2%) patients in group 2. In group 2, 5 patients showed transient hypoxia, and 6 patients had an episode of transient bleeding during the operations. These numbers were 3 and 3, respectively, in group 1. One patient in group 2 suffered cardiac arrest and died during surgery. The authors did not see any long-term complications after these operations and the authors did not find any statistically significant differences between the groups for complication rates. Conclusion: The RB is the gold standard procedure for removal of pediatric airway foreign bodies. The survey used in this study and our extensive experience have shown that the distal bronchi and foreign bodies can be visualized more effectively when using a rigid endoscope during RB, especially in children under the age of 3 years. In order to improve the safety of the surgical procedure, the authors propose that endoscope-assisted RB should be used in emergencies concerning foreign bodies in the airways of children. Address correspondence and reprint requests to Suleyman Ozdemir, MD, Cukurova University School of Medicine, Department of Otorhinolaryngology Head & Neck Surgery, 01380, Adana/Turkey; E-mail: drsozdemir@gmail.com Received 16 March, 2019 Accepted 30 April, 2019 The authors report no conflicts of interest. Suleyman Ozdemir: ORCID ID: https://orcid.org/0000-0002-0125-1536 Ozgur Surmelioglu: ORCID ID: https://orcid.org/0000-0001-5041-2802 Ozgur Tarkan: ORCID ID: https://orcid.org/0000-0002-0689-6632 Ulku Tuncer: ORCID ID: https://orcid.org/0000-0002-0689-1751 Mete Kiroglu: ORCID ID: https://orcid.org/0000-0001-5711-9182 Muhammed Dagkiran: ORCID ID: https://orcid.org/0000-0002-1923-3731 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.

Facial Feminization for the Transgender Patient This article provides an overview of the key concepts and techniques of facial feminization surgery. The author reviews 20 years of experience with thousands of patients. Address correspondence and reprint requests to Jeffrey H. Spiegel, MD, FACS, The Spiegel Center, Newton, MA, 335 Boylston Street, Newton, MA 02459; E-mail: DrSpiegel@DrSpiegel.com Received 18 April, 2019 Accepted 18 April, 2019 The author reports no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

The Familial Rhino Tooth: Two Mesiodentes The authors herein report on 2 cases of patients who had supernumerary teeth. The 2 cases outline how 1 was managed sub-optimally and other managed efficiently. The patients were direct relatives with a very similar clinical problem. This case report explores the genetic relevance of mesiodentes. This case report aims to outline the importance in examination, diagnosis and surgical removal of supernumerary teeth. It also describes several lessons that all members of the dental and wider surgical team can learn from, with regards to supernumerary teeth and more specifically mesiodentes. Address correspondence and reprint requests to Ariyan Sadeghzadeh-Araghi, BDS, North Manchester General Hospital, United Kingdom; E-mail: ariyanaraghi@live.co.uk Received 02 April, 2019 Accepted 23 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com