Application of a Lateral Pedicled Cranial Bone Flap for the Treatment of Secondary Zygomaticomaxillary Defects This study aimed to evaluate the effect of laterally-based pedicled cranial bone flap (LBPCBF) for the repair of secondary zygomaticomaxillary defects. Between December 2014 and December 2016, 6 patients with unilateral zygomaticomaxillary defects were selected; of these, 5 had trauma, and 1 was exposed to titanium mesh in the infraorbital area due to radiotherapy following total maxillectomy for right maxillary squamous cell carcinoma. Preoperatively, 3 patients suffered from an intraoral vestibular groove fistula, 2 suffered from an extraoral fistula, and 1 from local exposure of titanium mesh. Surgical treatment was implemented in all 6 patients, of which, the 5 trauma patients underwent debridement, reduction, and fixation of periorbital fracture, followed by repair of the defects in the infraorbital margin, anterior wall of maxillary sinus, and zygomatic body with LBPCBF, and then, reconstruction of the orbital floor with titanium mesh. The other patient with exposed titanium mesh underwent repair of defects in the infraorbital margin and anterior wall of the maxillary sinus with LBPCBF after titanium mesh trimming. Postoperative review at 6 months revealed disappearance of intraoral fistula, wound healing, and improvement of facial deformity in all 6 patients, of which 2 patients demonstrated postoperative ectropion. The application of LBPCBF can simultaneously repair bone defects in the infraorbital margin, anterior wall of maxillary sinus, and zygomatic body, as well as, supplement the soft tissue, thereby indicating a satisfactory treatment effect. Address correspondence and reprint requests to Yang He, 22 Zhongguancun South Avenue, Haidian District, Beijing 100081, China; E-mail: fridaydust1983@163.com Received 4 July, 2018 Accepted 12 May, 2019 Authors WH and XG contributed equally to this work. This study was supported by Beijing Natural Science Foundation (17L20291) and Medical Scientific Research Foundation of Guangdong Province, China (B2018136). 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.

Alcohol Intoxication-related Soft Tissue Injuries in Patients With Orbital Wall Fractures Background: To date, involvement of alcohol intoxication (AI) in the occurrence of traumatic bone injuries has been well described in the literature. Still, however, there is a paucity of data regarding its involvement with soft tissue injuries in the oral and maxillofacial region. Considering that it is one of the significant predisposing factors that are involved in facial bone fractures in assault victims, we have speculated that they are also vulnerable to soft tissue injuries. We therefore examined the incidence, type and, pattern of soft tissue injuries in patients with trauma owing to the AI in a single-institution setting. Materials and Methods: A total of 488 patients underwent reconstructive surgery for orbital wall fracture at our medical institution between 2012 and 2017. Of these, 162 eligible patients were enrolled in the present study; they were divided into 2 groups (the AI group and the control group) based on a history of the AI. Then, we compared baseline and clinical characteristics, including the incidence, type, and pattern of soft tissue injury, between the 2 groups. Results: In our series, assault was the most common cause of traumatic injuries. We found that the patients with AI were at increased risks of preoperatively developing subconjunctival hemorrhage and diplopia and postoperatively developing infraorbital nerve (ION) hypesthesia. Conclusions: In conclusion, our results indicate that the AI is closely associated with the preoperative risks of subconjunctival hemorrhage and diplopia and the postoperative risks of ION hypesthesia. But further large-scale, multicenter studies are warranted to establish our results. Address correspondence and reprint requests to Dong In Jo, MD, PhD, Department of Plastic and Reconstructive Surgery, Konkuk University Chungju Hospital, Konkuk University School of Medicine, 82 Gugwon-daero, Chungju 27376, Korea; E-mail: cozarmd@kku.ac.kr Received 7 October, 2018 Accepted 8 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.

Using a Modified Postauricular Hemicoronal Incision to Manage Unilateral Zygomaticomaxillary Complex Fracture Background: The surgical approach of the zygomaticomaxillary complex fracture is usually performed with preauricular coronal incision assisted with intraoral maxillary sulcus incision. There will be preauricular scars postoperatively. Methods: The authors introduce a postauricular hemicoronal incision to avoid the formation of scars in front of the ear. Results and Discussion: The postauricular hemicoronal incision can avoid vascular damage caused by careless operation in the preauricular approach. It eliminates the possibility of dissection or ligation of the superficial arteries and veins when preauricular approach was used. It results in no scar in front of ear, while reducing suture time and complexity. Address correspondence and reprint requests to Kun Lv, DDS, PhD, Faculty, Associated Chief Physician, School and Hospital of Stomatology, Wuhan University, 237 Luoyu Road, Wuhan 430079, Hubei, China; E-mail: lvkun@whu.edu.cn Received 4 January, 2019 Accepted 11 June, 2019 This study was permitted by the School and Hospital of Stomatology, Wuhan University IRB. We have read the Helsinki Declaration and have followed the guidelines in this investigation. Informed written consents from the patient involved in this study were obtained. The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

A Comparison of the Aesthetics Outcomes and Respiratory Side Effects of the Use of Spreader Flap and Spreader Graft Techniques in Open Rhinoplasty Background: Considering the fact that both spreader flap and spreader graft techniques cause respiratory complications and yield different aesthetics results in patients undergoing open rhinoplasty, this study was aimed at comparing these 2 techniques in terms of aesthetics and respiratory side effects. Methods: The study was conducted on patients undergoing open rhinoplasty in Ardabil, Iran, during 2016 to 2017. During the Study, a questionnaire containing 7 items related to respiratory complications and 7 items related to aesthetics side effects was completed for each of the patients. After that, the patients were photographed from 6 standard views by the researchers and then the aesthetics side effects were assessed. Finally, the obtained data were all fed into SPSS Software Version 16 and the needed statistical analyses were conducted. Results: One hundred thirty patients were investigated in this study the majority of whom were female. Rhinoplasty in 69 of them was done with spreader graft technique and in 61 of them with spreader flap technique. The analysis of the side effects in these 2 groups of patients indicated that the use of spreader graft technique increases the incidence of nasal hump while the use of spreader flap technique results in an increase in the incidence of obstructive sleep apnea. As regards the other respiratory and aesthetics side effects, the 2 techniques did not yield significantly different results. Conclusion: The findings of the present research indicated that there is no significant difference between the use of spreader graft and spreader flap techniques. Therefore, considering the clinical conditions of patients, either of the 2 techniques can be used effectively in rhinoplasties. Address correspondence and reprint requests to Narges Jafari Zare, MD, Department of Community and Preventive Medicine, Ardabil University of Medical Sciences, Ardabil, 5618953141, Iran; E-mail: jafarizarenarges.narges@gmail.com Received 13 January, 2019 Accepted 9 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.

The Use of Dehydrated Human Amniotic/Chorionic Membrane Skin Substitute in the Treatment of Pediatric Facial Burn Background: Facial burns have lasting physical and psychological effects on pediatric patients. Proper management to minimize morbidities challenges reconstructive surgeons. New technologies allowed the development of skin substitutes such as amniotic and chorionic membranes, yet the use of these skin dressings and their impact on burn outcomes have not been sufficiently studied to guide practices. The objective of this study is to report on the outcomes of dehydrated amniotic membrane as a biologic skin dressing in pediatric facial burn injury compared to cadaveric allografts. Methods: Retrospective review of data collected from our institutional burn registry from 2012 to 2016. The study population included patients younger than 16 years with facial burns. Patients between 2012 and 2014 received cadaveric allografts, whereas during 2015 to 2016 patients received dehydrated human amniotic/chorionic membrane as standard treatment. Demographic characteristics and outcome measures were compared between the 2 groups. Results: Included 30 patients with a mean age of 3.7 years and with an average total body surface area burn of 6.8% (2%–27%). Mean injury severity scores did not significantly differ between both groups, 1.8 in amniotic group versus 2.3 in cadaveric skin group (P > 0.05). There were 4 complications (3 hypertrophic scars and 1 wound infection) in the cadaveric allografts group versus no complications in the amniotic membrane group (P < 0.05). Conclusion: Dehydrated amniotic/chorionic membrane wound dressings are a safe alternative to cadaveric allografts in treating pediatric partial thickness facial burns. Address correspondence and reprint requests to Salomon Puyana, MD, MS, 11750 SW 40th Ave, Miami, FL 33133; E-mail: salomon.puyanabarcha@hcahealthcare.com Received 28 January, 2019 Accepted 13 May, 2019 The authors report no conflicts of interest. Disclaimer: This research was supported by Kendall Regional Medical Center, an HCA affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA or any of its affiliated entities. 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.

Clivus Intraosseous Meningioma Mimicking Chordoma A 78-year-old woman with progressive worsening vertigo and new onset of diplopia. Neurological examination revealed bilateral abducens nerve paralysis and gait disturbance with truncal ataxia. Neuroimaging revealed a mass lesion within the clivus with brain stem compression. The patient was operated with provisional diagnosis of clivus chordoma by neuro-navigation-guided extended endoscopic endonasal approach. Subtotal resection of the tumor was achieved with no intra- or postoperative complications. Histopathologic examination revealed intraosseous meningioma (WHO grade I). To the authors’ best knowledge this is the first case reporting clivus site of intraosseous meningioma. Address correspondence and reprint requests to Bashar Abuzayed, MD, Consultant Neurosurgeon, The Specialty Hospital, P.O. Box: 930186, Amman, Jordan; E-mail: sylvius@live.com Received 21 April, 2019 Accepted 10 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.

Effect of a Mandibular Advancement Device on the Upper Airway in a Patient With Obstructive Sleep Apnea The authors present a case of a 33-year-old male patient with obstructive sleep apnea syndrome who was treated with a mandibular advancement device with excellent results. The aim of this study is to underline the importance of new instruments that allow evaluating the upper airway with greater precision, such as cone beam tomography. Given the diagnosis and treatment, the upper airway was assessed using cone beam tomography; an increase in UA volume of 22% was observed (initial volume 22,962 mm3), along with a 28% increase in area (initial area 971 mm2). The evaluation of the UA using teleradiography also showed an increase in the points evaluated, with the midpoint of the soft palate presenting the greatest increase. Address correspondence and reprint requests to Francesco Gazia, MD, Universita degli Studi di Messina, Messina, ME, Italy 98123; E-mail: ssgazia@gmail.com Received 25 April, 2019 Accepted 6 June, 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.

Surgical Techniques and Prevention of Complications in the Treatment of Basal Ganglia Hemorrhage Through the Distal Transsylvian Approach Objective: Basal ganglia hemorrhage can damage the internal capsule and lead to high rates of disability and mortality. The distal transsylvian approach is a validated approach in the treatment of basal ganglia hemorrhage. However, this approach is difficult and prone to complications. The present study was performed to investigate the surgical techniques and prevention of complications of basal ganglia hemorrhage through the distal transsylvian approach. Patients and Methods: From January 2015 to January 2018, the authors treated 40 cases of basal ganglia hemorrhage using the distal transsylvian approach. The surgical video recordings and the patients’ clinical data were retrospectively analyzed. The authors discussed the surgical techniques and prevention of complications through the distal transsylvian approach. Results: Thirty-eight cases of basal ganglia hemorrhage were successfully treated through the distal transsylvian approach. The other 2 cases were converted to the transcortical transtemporal approach. In the early cases, complications occurred in 3 stages: sylvian fissure dissection, insula lobectomy, and hematoma removal. In the subsequent cases, the authors implemented appropriate surgical techniques to prevent complications. Conclusion: Basal ganglia hemorrhage can be treated through the distal transsylvian approach, but not in all patients. The distal transsylvian approach is highly technical and more problematic than the transcortical transtemporal approach. Mastering certain operative skills can reduce the surgical complications. Address correspondence and reprint requests to Liangwen Zhang, Department of Neurosurgery, Qilu Hospital, Shandong University, No. 107 Wenhua Xi Road, Jinan, Shandong, China; E-mail: zhangliangwen123@126.com Received 28 April, 2019 Accepted 5 June, 2019 This work was supported by the Science and Technology Plan of Binzhou Medical University (No. BY2018KJ08). 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.

Semi-Automated Three-Dimensional Condylar Reconstruction The objective was to validate a semi-automated segmentation method for 3-dimensional (3D) reconstruction of the mandibular condyle from cone beam computed tomography (CBCT) data and illustrate its application in volumetric analysis of the condyle. Ten CBCT datasets were used to validate the proposed semi-automatic method for 3D rendering of mandibular condyles. First, a standardized orientation protocol of the skull was applied. After defining the volume of interest, a grey-scale cut-off value was selected to allow an automatic reconstruction of the condyle's surface. Subsequently, condylar contour was optimized manually. The whole process was repeated twice by 2 independent investigators. Volumetric measurements of the condyle were used as a measure of conformity between both investigators. The reproducibility of condylar volume reconstruction was excellent for intra-examiner measurements (CV = 3.65%, intraclass correlation coefficient = 0.97) and good for inter-examiner measurements (CV = 7.15%, ICC = 0.89). The overall mean time required for the segmentation process was 6.31 + 2.78 minutes. The proposed protocol provides an accurate and reproducible tool for 3D reconstruction of the mandibular condyle using CBCT data. Its implementation will enable adequate follow-up of morphological changes in bone tissue with a Hounsfield unit-based imaging segmentation method. Address correspondence and reprint requests to Irene Méndez-Manjón, MSc, PhD, Institute of Maxillofacial Surgery, Teknon Medical Center. Vilana 12, D-185, 08022 Barcelona, Spain; E-mail: manjon.irene@uic.es Received 29 April, 2019 Accepted 18 May, 2019 This study was approved by the Ethics Committees of Teknon Medical Centre and Universitat Internacional de Catalunya. 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.

Effects of Maxillary Skeletal Expansion on Upper Airway Airflow: A Computational Fluid Dynamics Analysis The effect of maxillary skeletal expansion (MSE) on upper airway in adolescent patients is not clear. The purpose of this study was to determine the upper airway airflow with MSE treatment using computational fluid dynamics analysis. Three-dimensional upper airway finite element models fabricated from cone beam computed tomography images were obtained before and after treatment in an adolescent patient with maxillary constriction. Turbulent analyses were applied. The nasal cavity (NC) was divided into 6 planes along the y-axis and the pharynx was divided into 7 planes in the z-axis. Changes in cross-sectional area, airflow velocity, pressure, and total resistance at maximum expiration and maximum inspiration were determined at each plane after MSE treatment. The greatest increase in area occurred in the oropharynx which was around 40.65%. The average increase in area was 7.42% in the NC and 22.04% in the pharynx. The middle part of pharynx showed the greatest increase of 212.81 mm2 and 217.99 mm2 or 36.58% and 40.66%, respectively. During both inspiration and expiration, airflow pressure decreased in both the NC and pharynx, which ranged from −11.34% to −23.68%. In the NC, the average velocity decrease was -0.18 m/s at maximum expiration (ME) and −0.13 m/s at maximum inspiration (MI). In the pharynx, the average velocity decrease was -0.07 m/s for both ME and MI. These results suggest that treatment of maxillary constriction using MSE appliance may show positive effects in improvement of upper airway cross-sectional areas and reduction of upper airway resistance and velocity. Address correspondence and reprint requests to Hong He, DDS, MS, PhD, Department of Orthodontics, Hubei-MOST KLOS & KLOBM, School & Hospital of Stomatology, Wuhan University, Luoyu Road 237, Hongshan District, Wuhan 430079, China; E-mail: drhehong@whu.edu.cn Received 1 May, 2019 Accepted 23 May, 2019 Effects of maxillary skeletal expansion on upper airway airflow: a computational fluid dynamics analysis TZ and XZ contributed equally to this work Availability of data and materials: The data supporting the conclusions of this article are included within the article. This work was supported by the National Key Clinical Specialties Construction Program of China (No. [2013]544). The funding source had no involvement in the study design, collection, analysis, and interpretation of data, preparation of the manuscript, or in the decision to publish. TZ and XZ reviewed the related literatures, reconstructed the FME model, made the CFD analysis, and wrote manuscript. PN and FH assisted in design of the study and article revision. WY and XC assisted in the boundary condition definition, CFD analysis, and article revision. HH carried out the study and reviewed the manuscript for publication. All authors read and approved the final manuscript. 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.