Veau III and Veau IV Cleft Palate: Do Peri-Operative Complications Differ? Objective: The Veau classification represents the most commonly used system for characterizing cleft palate severity. Conflicting evidence exists as to how increasing Veau classification affects outcomes. This study compared perioperative outcomes between Veau III and IV cleft palate repairs. Methods: The National Surgical Quality Improvement Program Pediatric (NSQIP-P) database was used to identify cleft palate repairs between 2012 and 2016 using CPT codes. Patients with alveolar bone grafts were excluded. Veau III (unilateral) and Veau IV (bilateral) cleft palate repairs were identified using International Classification of Disease code 9 and 10 (ICD-9 and -10 codes. Patient demographics, comorbidities, and adverse events were compared between the cohorts. Results: A total of 5026 patients underwent cleft palate repair between 2012 and 2016. Of the 2114 patients with identifiable Veau classification, 1302 had Veau III cleft palates and 812 had Veau IV cleft palates. The Veau IV cleft palate patient population was older (377.8 versus 354.1 days, P < 0.001) and had significantly more comorbidities including a higher incidence of chronic lung disease (P = 0.014), airway abnormalities (P = 0.001), developmental delay (P = 0.018), structural central nervous system deformities (P < 0.001), and nutritional support (P < 0.001). Veau IV cleft palate repairs also had longer operative times (153.2 versus 140.2 minutes, P < 0.001). Despite significant differences in comorbidities and perioperative factors, there were no differences in 30-day complications, readmissions, or reoperation rates between Veau III and IV cleft palate repairs. Conclusions: Patients undergoing Veau IV cleft palate repair have a significantly greater number of comorbidities than Veau III cleft palate repairs. Despite differences in patient populations, 30-day surgical outcomes are comparable between the cohorts. Address correspondence and reprint requests to Michael Alperovich, MD, MSc, Department of Surgery, Section of Plastic and Reconstructive Surgery, Yale School of Medicine, 330 Cedar Street, Boardman Building, 3rd Floor, New Haven, CT 06510; E-mail: michael.alperovich@yale.edu Received 26 January, 2019 Accepted 15 July, 2019 Author Roles: FC, BS: study design, data collection, statistical analysis, tables, manuscript preparation and revisions; EJM, BA: study design, data collection & analysis, manuscript preparation and revisions; KSG, MD: study design, tables, manuscript preparation and revisions; MA, MD, MSc: principle investigator, study design, tables, manuscript preparation and revisions. The authors report no conflicts of interest. NSQIP Disclosure: The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. 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.

A Relationship Between the Supratrochlear Nerve and Trochlea: Anatomical Study and Application to Migraine Headaches Supratrochlear nerve (STN) is a terminal branch of the frontal nerve arising from the ophthalmic nerve (V1). Compression of the STN by adjacent structures might result in migraine headaches. The aim of this study was to explore the relationship of the STN and trochlea for a better understanding of potential entrapment of the STN. Nineteen orbits from ten fresh-frozen cadaveric heads were dissected. The relationship of the STN and the trochlea was classified into three types: In type I, the STN passed lateral to the trochlea; In type II, the STN passed through the trochlea; In type III, the STN passed medial to the trochlea. Type I was found in 52.6% (10/19 sides), type II was found in 42.1% (8/19 sides), and type III was seen in 3.4% (1/19 sides). In type III, both the STN and infratrochlear nerve were identified as separate branches. The authors propose a new classification of the pathway of the STN based on its relationship with the trochlea. This study might shed light on headaches emanating from this region. Address correspondence and reprint requests to Joe Iwanaga, DDS, PhD, Seattle Science Foundation, 550 17th Ave, James Tower, Suite 600, Seattle, WA 98122; E-mail: joei@seattlesciencefoundation.org Received 4 April, 2019 Accepted 16 July, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Fabrication of Nasoalveolar Molding Devices for the Treatment of Cleft Lip and Palate, Using Stereolithography Additive Manufacturing Processes and Computer-Aided Design Manipulation Software Introduction: Nasoalveolar molding (NAM) is a presurgical orthopedic treatment modality that attempts to reorient misaligned bony and soft tissue structures in patients with clefting of the lip and palate. The NAM devices are implemented prior to surgical intervention in order to minimize the gap across the cleft and thereby reduce tension across the eventual repair. Currently, NAM devices are fabricated in a laboratory and then refined chairside by the provider. The present article describes the potential of three-dimensional (3D) printing and computer-aided design (CAD) software for the fabrication of NAM devices. Material and methods: A workflow was developed to demonstrate the use of 3D printing and CAD software to design NAM devices. This workflow encompasses scanning an impression into CAD software, performing a series of manipulations, and then printing the digital model. Results: To test the workflow, a cleft palate plaster model was scanned into CAD software. Through a series of linear and angular freeform manipulations of the body, the model was modified to display a cleft with a reduced alveolar gap. Sequential molding devices were produced which would gradually apply pressure to targeted areas of hard and soft tissue until the cleft is minimized. The resulting devices are printed using a stereolithography printer. Conclusions: The use of 3D printing and CAD software shows promise in improving the accuracy, speed, and cost-effectiveness of designing NAM devices. The accuracy and flexibility from digitally visualizing the manipulations made to an appliance before its creation can result in a more personalized device for the patient. Address correspondence and reprint requests to Sofia Ahsanuddin, BA, 50 E. 98th St. Apt. 3E-4 New York, NY 10029; E-mail: sofia.ahsanuddin@icahn.mssm.edu Received 20 June, 2019 Accepted 16 July, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Lymphangioma in the Buccal Mucosa Lymphangiomas are benign hamartomatous tumors which are characterized by abnormal proliferation of lymphatic vessels. They are lymphatic malformations which are commonly localized to head and neck region. They are rare located in the oral cavity and tongue, lips, buccal mucosa, soft palate, floor of the mouth are mostly affected. Address correspondence and reprint requests to Dr Mustafa Yalçin, PhD, Üniversite Blv., Diş Hekimliği Fakültesi, 27310 Şehitkamil, Gaziantep, Turkey; E-mail: mustafayalcin.omfs@gmail.com Received 19 February, 2019 Accepted 20 March, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Contemporary Concepts of Primary Dynamic Facial Nerve Reconstruction in the Oncologic Patient Transection of the facial nerve and its branches during extensive ablative procedures in the oncologic patient causes loss of control of facial mimetic muscles with severe functional and aesthetic sequelae. In such patients with advanced tumorous disease, copious comorbidities, and poor prognosis, rehabilitation of the facial nerve has long been considered of secondary priority. However, recent advances in primary facial nerve reconstruction after extensive resection demonstrated encouraging results focusing on rapid and reliable restoration of facial functions. The authors summarize 3 innovative approaches of primary dynamic facial nerve reconstruction by using vascularized nerve grafts, dual innervation concepts, and intra-facial nerve transfers. Address correspondence and reprint requests to Holger Jan Klein, University Hospital Zurich, Division of Plastic Surgery and Hand Surgery, Raemistrasse 100, 8091 Zurich, Switzerland; E-mail: klein.holger@gmail.com Received 17 February, 2019 Accepted 21 March, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Fourteen Years After Delayed Replantation of an Avulsed Permanent Tooth: Clinical Features and Outcomes This article reports a clinical case of a boy who underwent an avulsion of the upper right central incisor at 8 years old. The avulsed tooth was kept in the socket for 11 years after replantation. The clinical and radiographic findings after 14 years revealed a complete root resorption, but alveolar bone volume is adequate for future implantation from the recent tomography scans view, even in labial area where alveolar bone morphology is poor. Address correspondence and reprint requests to Yaqin Zhu, DDS, MD, Department of General Dentistry; and Xudong Wang, DDS, MD, Department of Oral and Maxillofacial Surgery, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China; E-mail: qunlou87@hotmail.com Received 3 March, 2019 Accepted 16 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Oncoplastic Lower Eyelid Reconstruction Analysis Background: Oncoplastic lower eyelid reconstruction is a challenging task due to the complicated structure of the eyelid and requirement of high operative accuracy. Poorly treated defects result in ectropion and ptosis which may lead to keratitis and corneal ulceration. Previous related studies do not include a detailed comparison of the common reconstructive methods of the lower eyelid in terms of results and complication rates. Objective: The authors aim to demonstrate whether the choice of reconstruction affects the aesthetic and functional outcome of oncoplastic lower eyelid reconstruction. Methods & Materials: The authors performed a 10-year retrospective review of all oncoplastic lower eyelid reconstructions carried out in our hospital. Information on patient background, diagnosis and the choice of reconstructive method were evaluated. Postoperative photographs of each patient were then subjectively evaluated for color match, cosmesis, quality of shape, symmetry, and overall appearance. The authors hypothesized that the outcome is related to the main trajectory of the flap. Patients treated with local flaps of horizontal and vertical trajectories were then compared in terms of outcome and complication rates. Results: Reconstructions based on a horizontal trajectory compared with a vertical trajectory resulted with lower rates of ectropion and ptosis occurrence. The results were statistically significant. Address correspondence and reprint requests to Ayato Hayashi, MD, PhD, 2-1-1 Tomioka, Urayasu-shi Chiba, 279-0021, Japan; E-mail: ayhayasi@juntendo.ac.jp Received 7 March, 2019 Accepted 30 March, 2019 All authors have no conflicts 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.

Modified Bilateral Pi Craniectomy Technique for Reduction Cranioplasty: Novel Technique Objective: Severe hydrocephalic macrocephaly can cause significant morbidity in infants due to positioning difficulties, skin breakdown, and poor cosmesis. Many surgeons over the past decades have described a variety of surgical techniques of reduction cranioplasty. In this article, the authors describe a novel technique for skull reduction cranioplasty with modified bilateral Pi craniectomy. Methods: Anterior coronal and posterior lambdoid bone cuts are performed to extend inferiorly toward the sqamous bone. Last bone cuts are made connecting the parasagittal burr holes bilaterally, thus isolating and de-roofing of the sagittal suture. Bilateral peninsular bone flaps are reduced medially aiming to approximate the upper borders of both flaps. Edges of frontal and occipital bone can be resected and shaved to achieve smooth round contour of the reconstruct. The final reconstruct can be fixated with metal meshes. Results: In our technique, modified bilateral Pi craniectomy is simple and effective reduction cranioplasty technique, as the technique does not require bone graft resection and reconstruction of the grafts making the time of the surgery short with decreased possible complications. Also, the amount of bone resection, bone bending, and shaving of the bone edges can be controlled and adjusted during the. An important issue is that this technique avoids posterior skull reconstruction which is more risky, as many patients are bed ridden with secondary compressed and flat occiput. Conclusions: Modified bilateral Pi craniectomy is a simple and effective technique for cranial vault reduction, especially in flat-occiput cases. Good understanding of the structural abnormality and the pathophysiological mechanisms of the possible complications is very important for performing proper surgical reconstruction. Address correspondence and reprint requests to Bashar Abuzayed, MD, The Specialty Hospital, P.O. Box 930186, Amman, Jordan; E-mail: sylvius@live.com Received 18 March, 2019 Accepted 29 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Efficacy of Extracorporeal Shockwaves Therapy on Peripheral Nerve Regeneration Purpose: This study was conducted to determine the effects of different doses and methods of extracorporeal shock wave treatment (ESWT) on the sciatic nerve regeneration of rat model using unbiased quantitative stereological techniques and to know which method and dose were effective. Methods: Twenty-five Wistar albino rats were used in the experiment. All animals were randomly divided into 5 groups. To the 1st group (control, n = 5) ESWT and surgery were not applied. To 2nd group (E300*2, n = 5), twice doses of 300 impulses uESWs (unfocused) were applied. To 3rd group (E500*2, n = 5), twice doses of 500 impulses uESWs (unfocused) were applied. To 4th group (E300*2, n = 5), twice doses of 300 impulses of fESWs (focused) were applied. To 5th group (E500*2, n = 5), twice doses of 500 impulses of fESWs (focused) were applied. Rats were sacrificed and nerve samples analyzed on the 22nd day following the operation. Results: There is a variable increase in the axon numbers among the shockwave treated groups in compare to the control group. The focused groups showed better improvement and the 300-focused group has shown the highest regeneration rate. Conclusion: The authors found that ESWT promotes nerve regeneration, increases the thickness of the myelin sheath and that the most effective result is in the 300 shock wave. Address correspondence and reprint requests to Dilek Sağir, PhD, Nursing Department, Health College, Sinop University, Sinop-Turkey; E-mail: bio_dilek@hotmail.com Received 22 March, 2019 Accepted 19 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.

Follow-Up of an Implant-Supported Rehabilitation After Long-Term Use of Alendronate Considering the higher number of bisphosphonate prescriptions worldwide and the risk of medicine-related osteonecrosis of the jaws (MRONJs) associated with these drugs, this study aims to report a patient who had weekly used sodium alendronate for 7 years and was submitted to an implant-supported rehabilitation. The alendronate intake was interrupted by the physician 1 year prior to the beginning of the procedures until the whole dental treatment was finished. Moreover, the bone markers procollagen type 1 N-terminal propeptide and C-terminal cross-linking telopeptide of type 1 collagen were also evaluated and showed the following values, respectively: 150 pg/mg and 27.3 μg/L. The rehabilitation consisted of a careful extraction of teeth 34 and 48, external hexagon implants placement at 34, 36, 37, 46, and 47 sites and cone morse at 41 tooth region. During implants insertion, portions of the bone were collected. It was also performed, a gingival graft at 41 region. After 4 months, it was installed the provisional crowns and 1 year later, the definitive ones. It was observed success of the dental rehabilitation, without any clinical or radiographic signs of MRONJ. Moreover, mandibular bone showed normality aspects, with several osteocytes. Although, alendronate use was restarted after the rehabilitation had been finished, the 2-year follow-up has proved the success of the treatment. Based on these findings, it is possible to consider that the clinical protocol ensured the success of the dental rehabilitation, even with the long-term use of a bisphosphonate. Address correspondence and reprint requests to Ana Paula de Souza Faloni, DDS, PhD, Avenida Maria Antônia Camargo de Oliveira, 170, Vila Suconasa, 14807-120 Araraquara, SP, Brazil; E-mail: apfaloni@gmail.com Received 8 May, 2019 Accepted 23 May, 2019 The authors contributed equally to the study. The authors report no conflicts of interest © 2019 by Mutaz B. Habal, MD.