Craniosynostosis Treatment Using Distraction Devices Background: The authors report on surgical treatment for 20 patients with craniosynostosis in Japan in collaboration with neurosurgery department since 2007. They could safely expand the skull using distraction devices. Methods: Total number of patients with craniosynostosis joint surgery was 20 (23 surgeries) at the time of this report. All patients were referred from the neurosurgery department. Neurosurgeons decided the patient selection and the surgical indications, and performed osteotomy, intraoperative measurement of intracranial pressure, and perioperative management. The plastic and reconstructive surgeons set in bone models and simulate bone cutting line preoperatively, and performed skin incisions with flap, set bone distractors or bone absorption plate fitted with flap closure during surgery. Postoperative systemic management was undertaken in the neurosurgery intensive care unit. In the plastic and reconstructive surgery department, postoperative wound care and bone lengthening, and removal of the bone distractors were done. Results: All patients showed good bone forms, and there were no patients of serious complications such as meningitis. Conclusion: With these roles shared, safe surgery and perioperative management could be performed. Use of the craniosynostosis distraction devices is safe and excellent way, and the authors will continue to explore that direction further. Address correspondence and reprint requests to Jiro Katahira, MD, PhD, 2-1-10 Nishiogu, Arakawa-Ku, Tokyo 116-8567, Japan; E-mail: katahira.jiro@twmu.ac.jp Received 31 July, 2018 Accepted 26 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.

Soft Tissue Damage in Patients With Hemifacial Microsomia Objective: The aim of this study was to evaluate the extent of the damage to soft tissues on the affected side in patients with hemifacial microsomia (HFM). Materials and methods: Nine patients with HFM were included in this study and underwent computed tomography (CT) examination in the craniofacial area. The axial and coronal CT images were used for evaluating the damage to related soft tissues. Results: The results showed that the masseter muscle, temporal muscle, pterygoid muscles, and parotid gland were damaged on the affected side in all 9 patients with HFM. However, the extent of the damage to the pterygoid muscles was less than that to the masseter muscle, temporal muscle, and parotid gland. Conclusions: These findings indirectly support the crucial role of hemorrhage in the development of HFM, and the extent of damage to soft tissues may depend on the distance and barrier effect of the mandible between the hemorrhage and the affected tissues. Address correspondence and reprint requests to Mingyan Hu, Dongying People's Hospital. No.317, Nanyi Road, Dongcheng District, Dongying 257091, Shandong, China; E-mail: 13792976827@163.com Received 26 August, 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.

Surgical Outcomes of Endoscopic Medial Orbital Wall Decompression Study Design: Retrospective chart review. Purpose: The aim of this study was to evaluate the surgical outcomes and complications after endoscopic medial orbital wall decompression. Method: From November 2016 to July 2017, we retrospectively reviewed 40 eyes of 20 patients who had undergone orbital decompression because of thyroid ophthalmopathy and other causes of proptosis. The eyes were classified into 2 groups: orbits which received only endoscopic medial wall decompression, and orbits which received both endoscopic medial wall decompression and transconjunctival inferior wall decompression. Statistical analysis was performed for all data generated. The preoperative and 3-month postoperative follow-up examinations for all patients were assessed by Hertel ophthalmometry, interpalpebral fissure, marginal reflex distance 1, Goldmann applanation tonometry, diplopia test, and Grave ophthalmopathy specific quality of life survey. Results: Endoscopic medial wall decompression was performed in 17 of the total 40 eyes, and endoscopic medial wall decompression and transconjunctival inferior wall decompression was performed in the remaining 23 eyes. Proptosis improved from 20.4 ± 1.16 mm preoperatively to 16.8 ± 1.02 mm postoperatively in the endoscopic medial wall approach group, and from 20.8 ± 1.75 mm preoperatively to 14.8 ± 1.79 mm postoperatively in the endoscopic medial wall and transconjunctival inferior wall approach group. Postoperative complications occurred in 2 patients who displayed periphery diplopia, in the endoscopic medial wall and transconjunctival inferior wall approach group. A survey to assess the level of cosmetic satisfaction was significantly improved in both groups after surgery. Conclusion: Endoscopic medial wall decompression is an approach that achieves sufficient orbital decompression while minimizing complications. Corresponding author: Sung Mo Kang, Department of Ophthalmology, Inha University Hospital, 7–206, Shinheung-Dong, Jung-Gu, Incheon 400-711, Korea; E-mail: ksm0724@inha.ac.kr 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.

Tissue Engineering and Regenerative Medicine in Craniofacial Reconstruction and Facial Aesthetics The craniofacial region is anatomically complex and is of critical functional and cosmetic importance, making reconstruction challenging. The limitations of current surgical options highlight the importance of developing new strategies to restore the form, function, and esthetics of missing or damaged soft tissue and skeletal tissue in the face and cranium. Regenerative medicine (RM) is an expanding field which combines the principles of tissue engineering (TE) and self-healing in the regeneration of cells, tissues, and organs, to restore their impaired function. RM offers many advantages over current treatments as tissue can be engineered for specific defects, using an unlimited supply of bioengineered resources, and does not require immunosuppression. In the craniofacial region, TE and RM are being increasingly used in preclinical and clinical studies to reconstruct bone, cartilage, soft tissue, nerves, and blood vessels. This review outlines the current progress that has been made toward the engineering of these tissues for craniofacial reconstruction and facial esthetics. Address correspondence and reprint requests to Hermann Peter Lorenz, MD, FACS, Professor and Chief, Pediatric and Craniofacial Surgery, Department of Surgery, Division of Plastic and Reconstructive Surgery, Hagey Laboratory for Pediatric Regenerative Medicine, Stanford University School of Medicine, 257 Campus Drive, Stanford, CA 94305–5148; E-mail: plorenz@stanford.edu Received 4 April, 2018 Accepted 6 June, 2019 This work was supported by the NIH grant R01 GM116892. The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Analysis of Dental Arch in Children With Oral Cleft Before and After the Primary Surgeries This study aimed to evaluate longitudinally the alteration of the dental arch dimensions of children with different oral cleft types, before and after the primary surgeries. Three-dimensional images of the maxillary dental casts of children with unilateral complete cleft lip (G1), unilateral complete cleft lip and palate (G2), and cleft palate (G3). The children were evaluated at pre-cheiloplasty (T1), pre-palatoplasty (T2), and 1 year after palatoplasty (T3). The measurements obtained: intercanine (C-C’) and intertuberosity (T-T’) distances, anterior (I-CC’) and total (I-TT’) arch lengths. To analyze the intraexaminer error, paired t-test was applied and Dahlbergh formula. The intragroups comparisons were applied: paired t-test, ANOVA followed by Tukey, Wilcoxon test, and Kruskal–Wallis test followed by Dunn test. The intergroup comparisons were performed by independent t-test and Mann–Whitney test. In G1, the C-C’, T-T’, and the I-TT’ distances revealed a significant increase of the maxilla. In G2, the C-C’ distance statistically decreased from T1 to T3, T-T’ distance showed statistical increase from T1 to T3. The I-TT’ length increased with statistically significant differences between T1 and T3, T2 and T3. In G3, the C-C’, T-T’, and I-TT’ distance increased was statistically significant. The longitudinal evaluation of the changes occurred in the dental arches with different oral cleft types showed that cheiloplasty and palatoplasty caused the most alterations in the development of the maxillary dimensions of children with complete cleft lip and palate. Address correspondence and reprint requests to Thais Marchini Oliveira, Bauru School of Dentistry, University of São Paulo, Alameda Dr. Octávio Pinheiro Brisolla, 9-75, Bauru, São Paulo 17012-901, Brazil; E-mail: marchini@usp.br Received 2 February, 2019 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.

National Analysis of Patients With External Ear Melanoma in the United States Background: External ear melanoma (EEM) is a rare condition with controversies in the literature. We analyzed patients with EEM in the United States compared to other head and neck melanomas (OHNMs). Methods: The National Cancer Database (NCDB) was used to select patients with head and neck melanoma from January 1, 2004 to December 31, 2015. Mann–Whitney and χ2 tests were used to estimate statistical significance, and multivariate logistic regression to identify independent associations adjusted for confounders. Results: A total of 137,233 patients met the study criteria. Among them, 16,991 (12.4%) had EEM and 120,242 (87.6%) had OHNM. For patients with EEM, the mean (standard deviation) age was 66.26 (15.798) years. Most of the patients with EEM were men (85.5%), insured by Medicare (52.4%), and treated in Academic/Research Programs (47.7%) or Comprehensive Community Cancer Programs (32.3%). Most of the EEM tumors had invasive behavior (68.0%) were Stages 0 (30.3%) or I (40.3%), and were without ulceration (76.9%). Mean time to receive any treatment was 14.1 days for EEM compared with 14.6 days for OHNM (P < 0.001). We noticed a greater proportion of EEM in men (14.8%; adjusted odds ratio [aOR] 2.72 [2.605–2.852]; P < 0.001) compared to women (6.22%; reference). EEM was an independent factor for tumor Stage I (14.47%; aOR 1.61 [1.101–1.224], P < 0.001) and invasive behavior (13.86%; aOR 1.268 [1.15–1.389]; P < 0.001) compared to OHNM. Conclusion: EEM was associated with higher odds of invasive behavior compared to OHNM. Furthermore, men were found to have a higher likelihood to develop EEM compared to women. Address correspondence and reprint requests to Antonio J. Forte, MD, PhD, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224; E-mail: ajvforte@yahoo.com.br Received 22 March, 2019 Accepted 13 May, 2019 Financial Disclosure Statement: This study was supported in part by the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. 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.

Stem Cells: Importance of Elucidating a Stem Cell Laboratory Stem cells, which were initially elucidated in the 1960s, are characterized by their ability to continuously renew themselves to differentiate into multiple cellular types. For this reason, they remain the subject of intensive research, for their potential to treat certain diseases. In craniofacial surgery, tissue engineering using stem cells can be employed in various techniques. These include 3D printing, which has the potential to regenerate dental, oral, and craniofacial structures, once lost to congenital anomalies, trauma and other diseases like cancer. With the growing battery of information about stem cells and their potential translation from research to clinical practice, it is important to outline what is the basic layout of a stem cell research facility. Address correspondence and reprint requests to Seth R. Thaller, MD, Division of Plastic, Aesthetic and Reconstructive Surgery, DeWitt-Daughtry Family Department of Surgery, Miami, FL 33136; E-mail: sthaller@med.miami.edu Received 1 May, 2019 Accepted 15 May, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

The Role of Bacterial Etiology in the Tear Duct Infections Secondary to Congenital Nasolacrimal Duct Obstructions Purpose: To define the microbiological features of dacryocystitis in childhood. Methods: Patients with dacryocystitis secondary to CNLDO between 2017 and 2019 in Izmir, Turkey were included in the study. Inclusion criteria of the study were: mucopurulent secretion, being under 4 years old and not having received prior antibiotic treatment. Samples from secretion were cultivated in sheep blood agar, eosin methylene blue, and chocolate agar. Reproduction was checked intermittently. Clinically significant growths were reported. Results: Seventy patients with dacryocystitis secondary to CNLDO were included in the study. Sixty percent of patients were female (n = 42) and 40% (n = 28) percent of patients were male. The average age of participants was 2.09 ± 0.68 (1–3) years old. Positive bacterial proliferation results were noted in 20 patients (28.6%). Eighty percent (n = 16) of culture-positive bacterias were gram-negative bacterias and 20% (4) were gram-positive bacterias. Twenty percent of culture-positive bacterias were aerobic and 80% were facultative bacterias. The most common bacteria seen in culture specimen was Haemophilus 40% [Haemophilus haemolyticus (20%) and Haemophilus influenzae (20%)]. Conclusions: Gram-negative organisms especially Haemophilus were most prevalent. These findings could be helpful for antibiotic selection. Address correspondence and reprint requests to Sinan Bekmez, MD, Izmir S.B.U. Dr. Behcet Uz Child Diseases and Surgery Research and Training Hospital, Izmir 35220, Turkey; E-mail: sinanbekmez@gmail.com Received 24 April, 2019 Accepted 6 June, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Multiplicity of Heads in Indian Mythology No abstract available

The Effects of Intraoperative Tarsorrhaphy on Conjunctival Chemosis During Orbital Fracture Repair Surgery Purpose: We employed intraoperative tarsorrhaphy depending on the degree of edema to treat moderate conjunctival chemosis during orbital fracture repair surgery. Methods: This is a retrospective case review of 1367 patients (1384 eyes) who underwent orbital fracture repair surgery by a transconjunctival approach. All cases of moderate conjunctival chemosis during surgery were included and were divided into 2 groups. In one group, intraoperative tarsorrhaphy was performed immediately the chemosis reached a moderate degree and the conjunctiva was incarcerated by the lower eyelid margin; once severe chemosis developed, stitches were added to cover all of the prolapsed conjunctiva with a palpebral margin. In the second group, moderate chemosis was treated with bandage pressure without stitches even after appearance of severe chemosis. The time course of conjunctival edema was recorded. Results: The incidence of moderate conjunctival chemosis in orbital reconstruction surgery by the transconjunctival approach was 9.4%. The average time for resolution of moderate chemosis in the tarsorrhaphy group (3.5 ± 1.4 days) was obviously shorter than in the bandage group (6.2 ± 1.9 days). The incidence of severe chemosis in the intraoperative tarsorrhaphy group (14.1%) was significantly lower than in the bandage group (31.8%). Overall, the total duration of severe chemosis in the tarsorrhaphy group was obviously shorter than that of the bandage group. Conclusion: Intraoperative tarsorrhaphy was a highly effective method of treating moderate chemosis and preventing severe conjunctival chemosis during orbital fracture repair surgery. Address correspondence and reprint requests to Zhengkang Li, MD and Yuan Deng, PhD, MD, Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, P.R. China; E-mail: lizhengkang58@hotmail.com; ophden@163.com Received 11 May, 2019 Accepted 6 June, 2019 YW and FY contributed equally to this work. This work was supported by the Chenguang Plan of the Shanghai Education Development Foundation (16CG16) and the Science and Technology Commission of Shanghai (17DZ2260100). The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.