The Possible Role of Color Doppler and Pulse Wave Doppler Ultrasound in the Diagnosis of Cutaneous Lymphangioma Circumscriptum Cutaneous lymphangioma circumscriptum (CLC) is an uncommon congenital lymphatic malformation. Its dermoscopic features have been reported, however, if blood has infiltrated the lacunas, a pink hue overwhelms the lacunar structures, rendering dermoscopic features indistinguishable. In addition, dermoscopy cannot assess the subcutaneous extent of the lesion before surgery. The high-frequency array transducer Sonography with a high-frequency transducer is excellent in its resolution to evaluate skin lesions and is unaffected by infiltration of blood. Here, the authors report the use of ultrasound (color Doppler and pulse wave Doppler) for the diagnosis and management of CLC. An 18-year-old man presented 10 years previously with an asymptomatic 0.5 × 0.7 cm cluster of dark reddish vesicular lesions on his buttock. The lesions had recently increased in size and number. There was associated pachyderma. The lesions were hyperechoic and well defined on grayscale ultrasound and hypervascular on color Doppler ultrasound. Cluster cystics of lymphatic spaces were found throughout the whole dermis, especially in the papillary dermis. The lymphatic channels extended downwards to the reticular dermis and the superficial layer of the subcutaneous tissue. The pathological findings revealed lymphangiomas invading the subcutaneous tissue. The flat endothelial cells were partly positive for D2-40, which is a marker of lymphatic endothelial cells. Ultrasound was able to delineate the margins of the lesions. Diagnosis of CLC using preoperative color Doppler and pulse wave Doppler could reduce unnecessary repeated pre- and postoperative biopsies. Address correspondence and reprint requests to Li-Gang Cui, Department of Ultrasound, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing 100191, China; E-mail: cuiligang_bysy@126.com Received 23 August, 2018 Accepted 14 July, 2019 This report was supported by a grant from the National Science and Technology Infrastructure Program (No. 2016YFC0104902). The authors declare no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Metastasis of Prostate Adenocarcinoma in the Mandible: Rare Occurrence in Maxillary Bones Objective: This article describes the case report of a prostate adenocarcinoma in the mandible. Background: Prostate adenocarcinoma is a malignant tumor common in men from the fourth decade of life. The occurrence of oral metastatic lesions is rare. Case Report: A 78-year-old male patient was referred to the oral and maxillofacial surgery service of the Pontifical Catholic University of Rio Grande do Sul for complaints of painless volume increase in the mandible. The diagnosis through the association of clinical, radiographic, and histopathological examination with the patient's health history determined that the lesion was prostatic adenocarcinoma metastasis. Conclusion: Despite the rare occurrence of metastases in the oral region, the dental surgeon should be aware of the possibility for correct diagnostic conduction and, subsequently, the institution of treatment in the early stages of disease. Address correspondence and reprint requests to Eduardo Madruga Lombardo, MSc, Department of Oral and Maxillofacial Surgery, Dentistry School, School of Health Sciences, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil; E-mail: eduardomlombardo@gmail.com Received 24 June, 2019 Accepted 16 July, 2019 The present work was carried out with the support of the Coordination of Improvement of Higher Education Personnel—Brazil (CAPES—Coordenação de Aperfeiçoamento de Pessoal de Nível Superior)—Financing Code 001. 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). The dataset supporting the conclusions of this article are included within the article as an additional files attached. © 2019 by Mutaz B. Habal, MD.

Filler Migration and Florid Granulomatous Reaction to Hyaluronic Acid Mimicking a Buccal Tumor Hyaluronic acid is among the most commonly used cosmetic fillers. Although considered biocompatible and safe, it may rarely cause a wide range of complications. The authors report a case of migration of hyaluronic acid concomitant with granulomatous inflammatory response that mimicked a buccal tumor. A 52-year-old female presented with a solid painless mass of the right buccal area. The patient denied any history of trauma and cosmetic procedures of the affected area. Skin and mucosal membrane were intact and the lesion was firm and well fixed in the deep plane. Due to worrisome clinical presentation and the patient's history of breast cancer, the lesion was excised radically. Histopathological examination revealed multiple granulomas surrounding amorphous lakes of hyaluronic acid. During repeated, thorough anamnesis the patient admitted having underwent lip augmentation and nasolabial fold correction with HA two years before, after which the filler must have migrated posteriorly. Physicians need to be aware of various complications associated with cosmetic fillers as they may mimic severe clinical conditions. Address correspondence and reprint requests to Maciej Kaczorowski, MD, Department of Pathomorphology and Oncological Cytology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland; E-mail: maciejdkaczorowski@gmail.com Received 22 July, 2019 Accepted 25 July, 2019 MK and KN equal contributors The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Surgical Approach in a Patient With Agnathia-Otocephaly Complex: Three-Stage Mandibular Distraction Protocol Agnathia-otocephaly complex (AOC) is a rare malformation complex of the first pharyngeal arch that is characterized by agnathia/dysgnathia, microstomia, aglossia/hypoglossia and variable displacement of the ears. Only 11 post-infancy patients with severe AOC have been described in the literature, and the incidence of this malformation complex is estimated to be 1 per 70,000 births. In this brief clinical study, the authors describe the case of an 18-year-old female diagnosed with AOC who underwent a 3-step mandibular distraction protocol with an external distraction device. The surgical protocol the authors used was unique in that we first placed a tissue expander in the submental area to enlarge the skin envelope in an effort to mitigate skeletal relapse from soft tissue forces. Furthermore, the way in which the authors slowed the activation of the distraction device to allow for soft tissue healing behind the pins was a novel component of the patient's treatment. The 3-step mandibular distraction protocol the authors present in this study increased the length of the mandible by 20 mm, and nearly doubled the size of the patient's mandible from an initial volume of 3.62 cm3 to a post-operative volume of 6.89 cm3. Future surgeries will aim to improve the function of our patient's expanded mandible. Most important of all, the surgical treatment authors are presenting led to a significant improvement in our patient's physical appearance and 3d quality of life. Address correspondence and reprint requests to Michael S. Golinko, MD, FACS, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2900 Children's Way, Doctors Office Tower 9th Floor, Nashville, TN 37232; E-mail: Michael.golinko@vumc.org Received 26 January, 2019 Accepted 7 August, 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.

Langerhans Cell Histiocytosis in an Adult: A Discussion of Epidemiology and Treatment Options Langerhans cell histiocytosis (LCH) is a rare disorder defined by the abnormal proliferation of Langerhans cells. While LCH can present at any age, it is classically described as a pediatric condition, and is therefore overlooked in the adult patient. Additionally, depending on tumor burden and location, LCH can manifest with a host of oral and systemic symptoms which further confuses the clinical presentation and ultimate diagnosis. The authors present a unique report of an elderly Hispanic male diagnosed with mandibular LCH who sought primary tumor excision after neoadjuvant chemotherapy. In this study, a fibula-free flap was used for subsequent reconstruction. The purpose of the study is 2-fold: to highlight the variability of LCH in both patient symptomatology and demographics, as well as the role of plastic reconstructive surgery in definitive LCH management, particularly in the setting of single system unifocal disease. Address correspondence and reprint requests to Howard Tz-ho Wang, MD, 7703 Floyd Curl Drive, MSC 7844, San Antonio, TX 78229; E-mail: wanght@uthscsa.edu Received 3 February, 2019 Accepted 12 July, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Orbital Blowout Fracture and Orbital Emphysema caused by Nose Blowing A 76-year-old man presented with 1 day history of eyelid swelling and decreased vision on the left side. History reveals nose blowing the night prior to the occurrence of the symptoms. Initial examination of the left eye showed decreased visual acuity, increased intraocular pressure, and limited ocular motility with presence of air bubbles under the bulbar conjunctiva. Imaging studies showed medial orbital wall fracture with severe emphysema. The patient was observed for a week and no active surgical intervention was performed. Thereafter, spontaneous resolution of symptoms was observed. Eyelid swelling, dramatic improvement in visual acuity, intraocular pressure, and extraocular movements were noted. Address correspondence and reprint requests to Yasuhiro Takahashi, MD, PhD, Department of Oculoplastic, Orbital & Lacrimal Surgery, Aichi Medical University Hospital, 1-1 Yazako-Karimata, Nagakute, Aichi 480-1195, Japan; E-mail: yasuhiro_tak@yahoo.co.jp Received 19 February, 2019 Accepted 2 August, 2019 The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. © 2019 by Mutaz B. Habal, MD.

Platysmaplasty: Is it Possible to Pull the Platysma Effectively in the Medial or Lateral Direction? The aim of this study was to investigate whether it is possible to pull the platysma effectively in the medial or lateral direction (medial platysmaplasty and lateral platysmaplasty) and to explore the anatomical basis of those findings. Six hemifaces from 3 fresh cadavers were dissected. After skin removal, the platysma was pulled upward and in the medial or lateral direction with the ulnar side of the palm. Its mobility was checked. In 2 volunteers, using wooden bar, the skin overlying platysma was pulled in superomedial and superolateral direction. The platysma ran diagonally from the acromio-deltoid region to the perioral and submental area. In all hemifaces, the platysma was attached to the mandible along its course. The platysma inserted into the mandibular body. At its medial portion (approximately halfway medially from the mentum to the angle; 4–5 cm), the attachment was so firm that it could not be moved horizontally. The posterolateral portion of the platysma was indirectly attached to the mandible and movable. In cadaver, platysma did not move much when it was pulled in the medial direction. In the lateral direction, however, platysma did move well. In living body, when skin overlying platysma was pulled in superomedial direction and superolateral direction, 3 points marked on mandibular border moved about 1.5–2.0 cm and 2.0–2.5 cm respectively. It is thought that medial platysmaplasty can correct anterior neck deformities and redistribute neck skin mainly in the submental area, while that lateral platysmaplasty can pull the cheek skin in superolateral direction. Address correspondence and reprint requests to Kun Hwang, MD, PhD, Department of Plastic Surgery, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 22332, Korea; E-mail: jokerhg@inha.ac.kr Received 12 May, 2019 Accepted 14 July, 2019 This study was supported by a grant from National Research Foundation of Korea (NRF-2019083873). The authors have no conflict of interest to declare. 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.

Nasal Bone Osteoma Approach Osteoma is a benign osteogenic lesion that arises most frequently in the craniomaxillofacial region. Rarely, it can appear on the outer side of nasal bone and cause aesthetic problems. The authors present an unusual case of outer side nasal bone osteoma with a brief review of its main clinical presentations, diagnostic studies, and treatment options. Address correspondence and reprint requests to André D’Avanço de Morais, MD, Federal University of Paraná, 111 Ferdinando Demarchi Street, São Bernardo do Campo, São Paulo, Brazil; E-mail: andssguy@gmail.com Received 16 May, 2019 Accepted 29 July, 2019 Statement on the Declaration of Helsinki and the Ethical Conduct of Clinical Studies: All procedures performed involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The authors have no conflicts of interest to disclose. © 2019 by Mutaz B. Habal, MD.

The Role of Transoral Robotic Surgery for Parapharyngeal Space: Experience of a Tertiary Center The parapharyngeal space (PPS) is an anatomically and functionally complex region of the craniofacial district. Tumors that originate from this region are rare, and surgery is currently the best practice in the vast majority of cases with different surgical approaches being reported in the literature. Recently, mini-invasive robotic/endoscopic techniques have begun to emerge as effective alternatives in selected cases. In this work, we retrospectively analyzed 17 patients affected by PPS tumors, and managed by transoral robotic surgery (TORS) as a therapeutic or diagnostic procedure. TORS was used alone or combined with a transcervical approach for huge lesions of the PPS, at risk of fragmentation (curative intent). TORS also permitted biopsies of unknown lesions of the PPS to be conducted (diagnostic intent) otherwise unreachable without performing a mandibulotomy. All patients treated with curative intent benefited from radical surgery. No major complications were observed, and tumor fragmentation occurred only in 2 of 17 patients (11.8%). All patients receiving TORS with diagnostic intent were successfully referred to nonsurgical treatments based on the final histhopathological findings. This work also demonstrated TORS to be effective and safe on a larger group of patients compared to our preliminary study in 2016. TORS provides good oncological and functional outcomes when used with curative intent and is an effective diagnostic tool in cases of suspicious lesions of the PPS. Address correspondence and reprint requests to Mohssen Ansarin, MD, Chief of Department of Otolaryngology Head and Neck Surgery, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy; E-mail: mohssen.ansarin@ieo.it Received 4 June, 2019 Accepted 11 July, 2019 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). The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Comparison of Orbital Preadipocyte Adipogenesis Between Pediatric and Adult Graves Ophthalmopathy To investigate the difference of adipogenesis in orbital preadipocytes between pediatric and adult Graves ophthalmopathy (GO) under lipopolysaccharide (LPS)-induced inflammation in vitro. Orbital preadipocytes from pediatric and adult GO patients during eyelid or orbital surgery were cultured. The orbital preadipocytes in pediatric and adult GO were divided into group A and group B. In group A, pediatric and adult orbital preadipocytes were differentiated in adipogenesis media without LPS intervention, respectively. In group B, pediatric and adult orbital preadipocytes were incubated in culture medium containing 1 mg/L LPS for 48 hours before stimulation to differentiate into mature adipocytes in adipogenesis media. The expressions of adipogenic transcription factors, PPAR-γ and C/EBP-α, were determined by real-time polymerase chain reaction on day 7. On day 14, the cells were stained with oil red O to observe the intracellular lipid accumulation. In group A without LPS intervention, the pediatric orbital preadipocytes showed increased expression of PPAR-γ, C/EBP-α, and intracellular lipids accumulation than the adult orbital preadipocytes. In a group B with LPS intervention, both pediatric and adult preadipocytes showed higher rates of adipogenesis than in group A. Additionally, the increase in adipogenesis was greater in the pediatric preadipocytes. The pediatric orbital preadipocytes demonstrated increased adipogenesis than adult preadipocytes in GO without LPS-induced inflammation. Adipogenesis of the pediatric orbital preadipocytes was more affected and upregulated as compared to that of the adult preadipocytes by LPS-induced inflammation. Address correspondence and reprint requests to Jung Hyo Ahn, MD, PhD, Department of Ophthalmology, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Pusan National University, 20 Geumo-ro, Mulgum, Yangsan, Gyeongnam 50612, South Korea; E-mail: jhahn77@daum.net Received 5 June, 2019 Accepted 11 July, 2019 HYC and JHJ have equally contributed are co-first authors. This study was supported by the Research Institute for Convergence of Biomedical Science and Technology (30-2015-023), Pusan National University Yangsan Hospital. The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.