An Aplasia Cutis Congenita: Suggestion of Management Algorithm Background: When a child is born with Aplasia cutis congenita (ACC), it is important for the surgeon to decide promptly whether to perform early surgical intervention, or proceed with conservative care. Several patients of ACC have been reported in which various treatments have attempted. However, the criteria of treatment remain controversial. In this study, the authors present an algorithm and the literature review to assist with objective decisions during ACC management. Methods: A total of 4 cases of infants born with ACC were referred to our department between January 2017 and April 2019. Conservative care was to be considered a first choice of management. Results: The ACC lesions were presented in the scalp vertex area in all 4 infants with the intact dura mater. There was no large vein exposure or sagittal sinus exposure in all infants. All 4 infants were managed with conservative care, which immediately resulted in complete healing of the defects without any complications. Conclusions: Rapid decision-making is required whether or not the patient requires emergency surgical coverage. Even extensive defects may be healed by conservative care alone, if the dura mater is intact and accompanying large vein or sagittal sinus exposure is not identified. Address correspondence and reprint requests to Suk-Ho Moon, MD, Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea; E-mail: nasuko@catholic.ac.kr Received 15 May, 2019 Accepted 25 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.

Is Three-Dimensional Virtual Planning in Cranial Reconstruction for Advanced Cutaneous Squamous Cell Carcinoma of the Skull a Feasible Option? Background: Cutaneous squamous cell carcinoma (cSCC) is a common type of malignant skin disorder. An uncommon feature is local bony invasion, as can rarely be seen in lesions on the scalp. The optimal treatment strategy in these rare cases is still under debate. Objective: The aim of this case report is to present a 1-stage three-dimensional planned surgical resection and reconstruction of a cSCC with bony invasion into the scalp and to discuss the alternative options and potential pitfalls. Materials and methods: A patient diagnosed with rT4N0M0 cSCC of the scalp underwent a cranial resection and reconstruction in 1 stage. With the use of computer-assisted design and computer-assisted manufacturing a patient-specific implant (PSI) of poly (ether ether ketone) was manufactured. After the PSI was inserted, it was covered with a latissimus dorsi muscle and a split-thickness skin graft. Results: Intraoperatively the resection template generated an accurate resection and accurate and fast placement of the PSI. The reconstruction had a clinical satisfactory esthetic result, but was hampered by the development of a small wound dehiscence was observed over the postoperative course. Conclusion: Three-dimensional planned resection and reconstruction for composite defects of the skull after resection of a cSCC of the scalp with bony invasion may lead to an accurate and predictable resection and accurate and fast placement of the PSI. However, patient specific characteristics should be considered to assess potential risks and benefits before opting for this one-stage treatment strategy. Address correspondence and reprint requests to Sophie E.C.M. van de Vijfeijken, MD, PhD, Department of Oral and Maxillofacial Surgery, Amsterdam UMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; E-mail: s.e.vandevijfeijken@amc.uva.nl Received 27 May, 2019 Accepted 11 July, 2019 This research is supported by the Dutch Technology Foundation STW (Project Nr. 14326; CranioSafe), which is part of the Netherlands Organization for Scientific Research (NWO), and which is partly funded by the Ministry of Economic Affairs. CranioSafe Group: Collaborators include: A.G. Becking, L. Dubois, L.H.E. Karssemakers, D.M.J. Milstein and S.E.C.M van de Vijfeijken, Department of Oral and Maxillofacial Surgery, Academic Medical Center, University of Amsterdam, the Netherlands; P.R.A.M. Depauw, Department of Neurosurgery, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands; F.W.A. Hoefnagels and W.P. Vandertop, Neurosurgical Center Amsterdam, Academic Medical Center, University of Amsterdam, the Netherlands; C.J. Kleverlaan and T.J.A.G. Münker, Department of Dental Material Sciences, Academic Centre for Dentistry Amsterdam, the Netherlands; T.J.J. Maal, 3D Laboratory of Oral and Maxillofacial Surgery, Academic Medical Center, University of Amsterdam, the Netherlands; E. Nout, Department of Oral and Maxillofacial Surgery, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands; M. Riool and S.A.J. Zaat, Department of Medical Microbiology, Academic Medical Center, Amsterdam Infection and Immunity Institute, University of Amsterdam, the Netherlands. The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Orthognathic Surgery Has a Significant Positive Effect on Perceived Personality Traits and Perceived Emotional Facial Expressions in Subjects With Primary Mandibular Deficiency This study tested the hypothesis that a layperson's social perceptions of a dentofacial deformity (DFD) patient with primary mandibular deficiency (PMD) are more positive after bimaxillary orthognathic surgery. A survey was implemented comparing layperson's social perceptions of emotional expressions and personality traits before and >6 months after orthognathic surgery when viewing standardized facial photographs. The study sample comprised 20 patients selected randomly from a larger primary mandibular deficiency database, treated by 1 surgeon after orthognathic surgery. The outcome variable was change in 6 perceived emotional expressions and 6 personality traits studied. Descriptive and bivariate statistics were computed (P < .05). Five hundred respondents (raters) completed the survey. The respondents were 52% male with 44% aging from 25 to 34. After bimaxillary and chin orthognathic surgery, primary mandibular deficiency patients were perceived to be significantly more dominant, trustworthy, friendly, intelligent, attractive, and less threatening (P < .05). They were also perceived as happier and less angry, surprised, sad, afraid, or disgusted than before surgery (P < .05). Laypeople consistently report improved social traits in primary mandibular deficiency patient's perceived emotional expressions and perceived personality traits after bimaxillary and chin orthognathic surgery. Address correspondence and reprint requests to Jeffrey C. Posnick, DMD, MD, 5530 Wisconsin Ave, Suite 1250 Chevy Chase, MD 20815; E-mail: jposnick@drposnick.com Received 5 November, 2019 Accepted 8 November, 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.

Identification of Stress Fields in a Customized Mandibular Reconstruction Based on a Photoelastic Model Tumors, trauma and infections are the main reasons for subjecting a patient to a bone reconstruction made with the use of bone grafts or prosthetic elements, using for example components such as osteosynthesis plates, meshes and screws for their stabilization. This study focuses on the photoelastic analysis of a customized prosthesis of the jaw for a patient diagnosed with osteonecrosis. A resin model was manufactured as follows: DICOM files were processed in ScanIP software to obtain an STL file that was used to generate an antagonist model of the healthy section of the jaw using CATIA software, then, models were printed in Acrylonitrile Butadiene Styrene (ABS). Following the resin casting technique, the printed model of the jaw was used to construct a resin model, which is tested to determine its mechanical behavior. After carrying out the photoelastic analysis, it was found that the assembly process generates stress concentration zones. Here, the stress reaches a maximum value after the application of a bite force of 130.9 N in the premolars. In this study near the premolars, 3 stress concentration zones were identified and overlap of stress fields is reveled. The results show the importance of planning in the design and assembly process to obtain the best results in the reconstruction, reducing in this way the risk of a surgical reoperation due to problems of rupture or loosening of the prosthesis. Address correspondence and reprint requests to Pablo Moreno-Garibaldi, PhD, Universidad de las Americas Puebla, Puebla, Mexico; E-mail: pmg170588@gmail.com Received 31 January, 2019 Accepted 5 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 Impact of Ethnicity on Craniosynostosis in the United States While many studies have examined potential risk factors for nonsyndromic craniosynostosis, there have been no publications to date investigating the role of ethnicity in the United States. The current study was undertaken as the first multi-center investigation to examine the relationship between ethnicity and nonsyndromic craniosynostosis, looking at both overall prevalence as well as potential correlation between ethnicity and pattern of affected suture site. A chart review of patients diagnosed with nonsyndromic craniosynostosis treated at four major children's hospitals was performed to obtain ethnicity data. Analysis was preformed based on ethnic group as well as suture site affected. To account for potential One regional selection bias, the KID database (1997–2012) was utilized to identify all cases of craniosynostosis on a national level. This data was analyzed against birth rates by ethnicity obtained from CDC WONDER natality database. Amongst the 2112 cases of nonsyndromic craniosynostosis at all institutions, Caucasians and African Americans were consistently the predominant ethnic groups. There was a statistically significant difference in the distribution of affected suture type with African Americans more likely to present with unicoronal synostosis and Caucasians more likely to present with metopic synostosis (P = 0.005). The national data revealed that there were more cases of craniosynostosis in Caucasians and fewer in African Americans than expected when compared to population birth rates. Our findings demonstrate that the Caucasian race is associated with increased rates of synostosis. Address correspondence and reprint requests to Kamlesh Patel, MD, Washington University in Saint Louis, Plastic and Reconstructive Surgery, 660 South Euclid Avenue, Campus Box 8238, St. Louis, MO 63110; E-mail: Kamlesh.Patel@wustl.edu Received 10 February, 2019 Accepted 17 August, 2019 Research reported in this publication was supported by the Washington University Institute of Clinical and Translational Sciences grant UL1 TR000448 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH) and Children's Discovery Institute. 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.

Reconstruction of a Huge Residual Palatal Cleft Closure of large oronasal fistula (ONF) in cleft patients is a challenge for patients and surgeons. The extent of functional impairment has psychologic, social, and developmental consequences. The ONF affects the feeding and speech of patients. Keys to repairing fistulas in this region are a 2-layer, tension-free closure, and an attentive suturing technique. In this article, the details and effectiveness of 2-flap palatoplasty are presented. Address correspondence and reprint requests to Kevser Sancak, Ankara Üniversitesi, Diş Hekimliği Fakültesi, Beşevler, Ankara, Turkey; E-mail: kvsrttnclr@gmail.com Received 19 February, 2019 Accepted 11 June, 2019 This patient was presented at 11th World Cleft Lip/Palate and Craniofacial Conference (ICPF) at Wuhan, China held between 10 and 13 October 2017. Ethics approval is not required. The authors have the patient's permission to publish this report, but information that could identify her has been excluded. The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Cranial Fossa Volume in Differing Subtypes of Apert Syndrome Background: Based on an established classification system of Apert syndrome subtypes, detailed regional morphology and volume analysis may be useful to provide additional clarification to individual Apert cranial structure characteristics, and treatment planning. Methods: Computed tomography scans of 32 unoperated Apert syndrome and 50 controls were included and subgrouped as: type I, bilateral coronal synostosis; type II, pansynostosis; type III, perpendicular combination synostosis. Three-dimensional analysis of craniometric points was used to define structural components using Materialise Mimics and 3-Matics software. Results: Occipitofrontal circumference of all subtypes of Apert syndrome patients is normal. Intracranial volumes of types I and II were normal, but type III was 20% greater than controls. Middle cranial fossa volume was increased in all 3 types, with the greatest increase in type II (86%). Type II developed a 69% increase in anterior cranial fossa volume, whereas type III had 39% greater posterior cranial fossa volume. Increased cranial fossa depth contributed most to above increased volume. The anteroposterior lengths of middle and posterior cranial fossae were reduced in type I (15% and 17%, respectively). However, only the anterior cranial fossa was significantly shortened in type III. Conclusions: Occipitofrontal circumference and overall intracranial volume is not always consistent in individual subunits of Apert syndrome. Detailed and segmental anterior, middle, and posterior cranial fossae volumes and morphology should be analyzed to see what impact this may have related to surgical planning. Address correspondence and reprint requests to John A. Persing, MD, Division of Plastic and Reconstructive Surgery—Yale School of Medicine, 330 Cedar Street, 3rd floor Boardman Building, New Haven, CT 06520; E-mail: john.persing@yale.edu Received 1 March, 2019 Accepted 24 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.

Outcomes of Surgical Management of Palatal Fistulae in Patients with Repaired Cleft Palate Background: The palatal fistula is an important surgical challenge within the longitudinal follow-up of patients with repaired cleft palate as the success rate of palatal fistula reconstruction by adopting several surgical techniques is variable and often unsatisfactory. The purpose of this retrospective study was to report the clinical outcomes of an algorithm for the surgical management of palatal fistulae in patients with repaired cleft palate. Methods: Consecutive patients (n = 101) with repaired cleft palate and palatal fistula-related symptoms who were treated according to a specific algorithm between 2009 and 2017 were included. Based on the anatomical location (Pittsburgh fistula types II–V), amount of scarring (minimal or severe scarred palate), and diameter of the fistula (≤5 mm or >5 mm), 1 of 3 approaches (local flaps [62.4%], buccinator myomucosal flaps [20.8%], or tongue flaps [16.8%]) was performed. For clinical outcome assessment, symptomatic and anatomical parameters (fistula-reported symptoms and residual fistula, respectively) were combined as follows: complete fistula closure with no symptoms; asymptomatic narrow fistula remained; or failure to repair the fistula (“good,” “fair,” or “poor” outcomes, respectively). Surgical-related complication data were also collected. Results: Most patients (91.1%) presented “good” clinical outcomes, ranging from 86.2% to 100% (86.2%, 100%, and 100% for local flaps, buccinator flaps, and tongue flaps, respectively). All (8.9%) “fair” and “poor” outcomes were observed in fistulae reconstructed by local flaps. All “poor” (5%) outcomes were observed in borderline fistulae (4–5 mm). No surgical-related complications (dehiscence, infections, or necrosis) were observed, except for an episode of bleeding after the 1st stage of tongue flap-based reconstruction (1.0%). Conclusion: A high rate of fistula resolution was achieved using this algorithm for surgical management of palatal fistulae in patients with repaired cleft palate. Address correspondence and reprint requests to Rafael Denadai, MD, Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Av Adolpho Lutz, 100, Caixa Postal 6028, Campinas, São Paulo CEP 13084-880, Brazil; E-mail: denadai.rafael@hotmail.com Received 9 March, 2019 Accepted 11 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.

Comparison of Lengthening Temporalis Myoplasty and Free-Gracilis Muscle Transfer for Facial Reanimation in Children Background: Lengthening temporalis myoplasty (LTM) and cross-face nerve graft with free gracilis muscle transfer (CFNG-FGMT) are the 2 most common procedures used to restore dynamic facial animation and improve facial symmetry. There has not been direct comparison or consensus. Here, the authors compare our experience with respect to muscle activity, symmetry, and excursion. Methods: A retrospective review was performed of patients with facial palsy who had CFNG-FGMT or LTM from 2008 to 2016 at a single institution. Postoperative surface EMG was recorded at maximum open smile. Normal and paralyzed sides of the face were analyzed with Facial Assessment by Computer Evaluation software. Commissure excursion and symmetry was assessed. Results: Six patients with LTM and 10 with CFNG-FGMT met inclusion criteria. Muscle activity was 1st identified in LTM patients after 3 months (47.42 mV, P < 0.001) and CFNG-FGMT patients after 3 months (28.30 mV, P < 0.001) compared to immediate postoperative period. Relative to preoperative excursion, there was significant increase of 3.33 mm in commissure excursion seen at the 0 to 3 month period for LTM patients (P = 0.04). Commisure excursion for CFNG-FGMT was seen later, in the 3- to 6-month postoperative period (4.01, P = 0.024). During smile, CFNG-FGMT patients had better symmetry than unilateral LTM patients. In bilateral LTM patients, there was no significant change in symmetry. Conclusion: Dynamic facial animation improved in both surgical groups. The LTM demonstrates a faster rate of muscle recruitment compared to CFNG-FGMT. After 3 months, both LTM and CFNG-FGMT groups had comparable excursions. A decision-making algorithm is presented. Address correspondence and reprint requests to Phuong D. Nguyen, MD, Division of Plastic and Reconstructive Surgery, University of Texas Health Science Center at Houston, 6431 Fannin St, MSB 5.218, Houston, TX 770030; E-mail: pdnguyendoc@gmail.com Received 1 April, 2019 Accepted 1 July, 2019 This study was presented at the 13th International Facial Nerve Society Meeting in Los Angeles, CA on August 6, 2017 and the American Society of Plastic Surgeons Meeting in Orlando, FL on October 8, 2017. 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.

An Accurate Volumetric Analysis Method for Evaluating Outcomes of Alveolar Cleft Reconstruction An accurate volumetric analysis method for evaluating the outcomes of different types of alveolar cleft reconstruction is essential because it can help determine which graft material is more effective, confirm favorable times for alveolar bone grafting, and improve surgical techniques. This study aimed to introduce a novel method of precisely calculating the bone formation ratio using computer-aided engineering after surgery. A patient with a unilateral alveolar cleft who was treated with anterior iliac crest bone grafting was enrolled in this study. Helical computed tomography scans were performed preoperatively and 12 months postoperatively. The Digital Imaging and Communications in Medicine (DICOM) data were reconstructed as three-dimensional images and saved in the STL format by using Mimics software. STL data were processed by Geomagic Wrap 2017, using the Boolean operation, the newly formed bone of the alveolar was segmented by identifying the differences between the preoperative and the postoperative three-dimensional images. For this patient, the mean volume of the newly formed bone was 0.387 cm3, the morphology was clear, the bone formation ratio was 41.4%, the mean time required for calculating the newly formed bone volume was 23 minutes, and the bone survival ratio was 38.7%. This method is a clinically practical, accurately measurement and time-saving method to evaluate the outcome of alveolar cleft reconstruction. Both the volumetric assessment and morphological analysis of the newly formed bone could be determined in a precise manner. Address correspondence and reprint requests to Yong Q. Wang, MD, Center for Cleft Lip and Palate Treatment, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Ba-da-chu, Beijing 100144, China; E-mail: surgeonfrank@163.com Received 15 May, 2019 Accepted 6 June, 2019 BL and SXC are co-first authors. BL and SXC wrote the manuscript and performed the operations. BHL helped with the data analysis. YQW designed the project and oversaw the collection of results. This study was supported by Beijing Municipal Science and Technology Commission (Z181100001718188) and Health Science Promotion Project of Beijing (2018-TG-56). 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.