Long-Term Outcomes of the Minimal Skin Incision Technique for Correcting Severe Microform and Minor-Form Cleft Lip With Philtrum Reconstruction Through the Intraoral Incision Background: Because the traditional technique is known to cause visible scarring, it is challenging to yield optimal outcomes while treating a severe type of microform and minor-form cleft lip. The authors present a new refined technique with minimal skin incision and philtrum formation through an intraoral incision. Methods: The surgical technique involves single Z-plasty or double or triple unilimb Z-plasty to restore an elevated cupid's bow peak and overlapping of an orbicularis oris muscle flap to create the philtrum through an intraoral incision. Cleft lip nasal deformity was corrected with reverse-U incision and V-Y plasty. Results: Eighteen patients were operated between September 2008 and June 2017. Patient age at the time of surgery ranged from 3 to 12 months. The duration of follow-up ranged from 12 months to 7 years (mean, 36 months). The elevated cupid's bow was corrected by performing single Z-plasty in 6 patients, double unilimb Z-plasty in 7 patients, and triple unilimb Z-plasty in 5 patients. In all cases, the notch or elevated cupid's bow was corrected, the surgical scar was minimal, and philtrum reconstruction was satisfactory. Minor scar revision was performed in 4 patients. Cleft lip nasal deformity was corrected in fifteen patients. Conclusions: The technique adopted here causes minimal scarring, facilitates the formation of an anatomical philtrum, preserves the continuity and function of the muscle, and presents sufficient elevation of the philtral column. Address correspondence and reprint requests to Byung Chae Cho, MD, PhD, Department of Plastic and Reconstructive Surgery, Kyungpook National University, School of Medicine, 807 Hoguk-ro, Buk-gu, Daegu 41404, Republic of Korea; E-mail: bccho@knu.ac.kr Received 12 May, 2019 Accepted 15 August, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

The Comparison of Pierre Robin Sequence and Non-Syndromic Cleft Palate Introduction: The aim of this study was to evaluate pre-operative nutritional status, associated syndromes and abnormalities, and post-operative outcomes of patients with Pierre Robin Sequence (PRS) versus those with non-syndromic isolated cleft palate (CIP). Methods: Between January 1995 and December 2013, patients with a cleft palate Veau I-II according to the Veau classification with and without PRS who underwent primary repair were retrospectively analyzed. The nutrition status, age at the time of palatoplasty, additional anomalies, gestational complications, and post-operative speech abnormalities and outcomes were evaluated. Results: A total of 59 patients with PRS (PRS group) and 132 patients without PRS (non-PRS group) were included in the study. Of all patients, 92 were males and 99 were females with a mean age of 14 ± 4.18 (range, 6 to 26) years. The rate of gestational complications, enteral nutrition, complete cleft, additional anomalies, and velopharyngeal insufficiency was significantly higher in the PRS group (P < 0.05). However, the incidence of fistulas and age at the time of palatoplasty did not significantly differ between the groups. Conclusion: Based on our study results, enteral nutrition, respiratory problems, pregnancy complications, velopharyngeal insufficiency, and additional anomalies, but not post-operative palatal fistulas, are more frequently seen in patients with PRS. Although pre-operative care and treatment and rehabilitation in patients with PRS are more complicated than those with the CIP, our experience demonstrates that meticulous repair and follow-up can minimize complications, such as fistulas. Address correspondence and reprint requests to Fatma Nihal Durmus Kocaaslan, MD, Fevzi Çakmak Mah. Muhsin Yazicioğlu Cad. No. 10, 34899, Pendik, Istanbul, Turkey; E-mail: dr-nihal@hotmail.com Received 13 June, 2019 Accepted 11 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.

Sebaceous Nevus of the Scalp Excisions of scalp nevus sebaceous (NS) presents a unique challenge due to limited soft tissue laxity, hair-bearing skin, and convex surfaces which often leave the surgeon and patient underwhelmed with the reconstructive outcome. In this study, the authors conducted an institutional review board-approved retrospective review of patients who underwent excision of pathologically proven scalp primary NS from 2003 to 2017 at our institution to better define the reconstructive outcomes and options for treatment of pediatric scalp NS. 92 patients were included in the study, 54 males (58.7%) and 38 females (41.3%). The average age at surgery was 7.24 years (0.5–16.0; SD 4.7). Local tissue undermining/galeal scoring with primary closure (LTUGS) was used for lesions with average surface area of 3.6 cm2, rotational or transposition flaps (RF/TF) for lesions averaging 4.3 cm2, completed serial excision for lesions averaging 13.9 cm2, and tissue expansion (TE) for lesions averaging 21 cm2 (P <0.001). One or more poor outcomes were experienced by 35 patients (38%), with a significant difference between the surgical groups; LTUGS 37.2% (29/78), RF/TF 60% (3/5), serial excision 100% (3/3), TE 0% (0/6) (P = 0.022). Univariant binary regression analysis within the LTUGS and RF/TF groups showed that lesion size was a significant predictor of poor outcomes (P = 0.012). All specimens in this study were negative for carcinoma. Therefore, most pediatric nevus sebaceous of the scalp can be managed by a single-phase procedure though risk of poor outcomes increase with nevus size with high rates of poor outcomes even with small lesions. Address correspondence and reprint requests to Lori K. Howell, MD, Division of Plastic & Maxillofacial Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd. Los Angeles, CA 90027; E-mail: lhowell@chla.usc.edu Received 10 May, 2019 Accepted 17 August, 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.

Behavioral Disorders of Preschool Children With Non-Syndromic Craniosynostosis Craniosynostosis is the premature closure of one or more cranial sutures that results in an abnormal skull shape. This condition has been associated with cognitive problems of different levels of severity in all developmental stages in a substantial percentage of children. However, the study of behavioral problems related to this condition has been scarce. The objective of this study was to determine if a sample of Mexican preschoolers with non-syndromic craniosynostosis had more clinical and adaptive behavioral problems than those of their peers. We assessed the behavior of 24 participants between 3 and 5 years of age with non-syndromic craniosynostosis as well as those of 27 healthy children. We used the Behavioral Assessment System for Children (BASC) parent's questionnaire. There were no significant differences between groups for any of the BASC scales, although a small proportion of children from both groups had high, clinically significant, scores on some of the Clinical, Adaptive and Global scales. While the relationship between craniosynostosis and behavioral problems is not clear, it is important to continue to assess conduct at several ages to detect possible problems that could be overlooked by the developmental characteristics during the preschool stage. Address correspondence and reprint requests to Ma. Guillermina Yáñez-Téllez, PhD, Neuroscience project, Faculty of Higher Studies Iztacala, National Autonomous University of Mexico, Avenida de los Barrios Número 1, Colonia Los Reyes Iztacala. Tlalnepantla, Estado de México, C.P. 54090, Mexico; E-mail: mgyt@unam.mx Received 30 May, 2019 Accepted 20 August, 2019 This work was supported by the National Council of Science and Technology with the scholarship of Julieta Moreno Villagómez for PhD studies (Scholarship number 261233). The authors have no conflicts of interests to disclose. 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.

Anthropometric Research of Metric Characters in Zygomatic Complex Region Objectives: To get and analyze the metric data of zygomatic region for the plasty of zygoma. Materials and Methods: A total of 108 dry skulls in Chinese Han population were randomly collected and measured. The metrical data were divided into 4 parts, including the relative position of contour height of zygomatic bone, the relative prominence of zygomatic bone, the relative prominence of zygomatic arch, and the angle of the zygomatic bone and arch. Results: The measurements in the 4 parts showed significantly difference between male and female (P < 0.05). For relative position of contour height of zygomatic bone group, the data of male is significantly bigger than female (P < 0.05). For relative prominence of zygomatic bone/zygomatic arch group, zygoma/zygomatic arch of male significantly protruded more than female (P < 0.05). Conclusion: The location of male zygoma is more protruding than female. The female zygoma is squarer than male and marginal process is helpful in zygomatic plasty. Clinical Relevance: These studies show and analyze the metric data of zygomatic region in Chinese Han population for the plasty of zygoma. These different characters between males and females could be helpful in zygomatic plasty of Chinese Han population based on this research. Address correspondence and reprint requests to Qingbin Zhang, DDS, PhD, Director, Key Laboratory of Oral Medicine, Guangzhou Institute of Oral Disease, Stomatology Hospital of Guangzhou Medical University, 39 Huangsha Road, Liwan District, Guangzhou, Guangdong Province, China; E-mail: doctorqingbin@hotmail.com Received 16 March, 2019 Accepted 7 August, 2019 ZZ, JW, and QM contributed equally to this work. The work was supported by Natural Science Foundation of Guangdong Province, China (no: 2018A030313759), Southern Medical University (PY2017N036), and Medical Scientific Research Foundation of Guangdong Province, China (A2018358). 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.

A Preliminary Dynamic Investigation on Velopharyngeal Movements During Blowing: A New Approach for Evaluation Purpose: To explore an alternative approach to evaluate velopharyngeal function on those speakers with compensatory misarticulation. Method: Nasopharyngeal endoscopy was used to observe the velopharyngeal movement on 26 adult Mandarin speakers during articulation and different nonverbal state, including SCPS, DCPS, and ABS. Results: There were significant differences for the rate of velopharyngeal incompetence (RVPI) among the 4 different states. The RVPI was least for the Articulation State, followed by the Air Blowing and DCPS. The RVPI was largest for the SCPS. Conclusion: The result indicated that the ABS may be used as an alternative approach to evaluate the velopharyngeal function instead of the articulation samples while patients cannot make clear articulation due to compensatory misarticulation habits. It merits further study on nonverbal activities, which could lay a foundation for exploring more effective approach for evaluation of the velopharyngeal function. Address correspondence and reprint requests to Shi Xinghui, MDS, No. 136, Hanzhong Road, Gulou District, Nanjing, Jiangsu Province, China; E-mail: sxhandqq@163.com Received 21 October, 2018 Accepted 12 August, 2019 Data collecting was funded by Grant BE2017732 from Jiangsu Science and Technology Department. The author reports no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Automated Lesion Segmentation and Quantitative Analysis of Nevus in Whole-Face Images Background: Nevus is very common; however, melanoma is slightly related to the deterioration of nevus because of its vulnerability to solarization, friction, aging, heredity, and other factors. Early diagnosis is essential for melanoma treatment, since patients have a high survival rate with early detection and treatment. Computer-aided diagnosis has been applied in the differential diagnosis of melanoma and benign nevi and achieved high accuracy, but it does not suit the screening of nevi because most studies are based on dermoscopy with a narrow field of vision and performed by professional doctors. Therefore, this study aimed to present the accuracy and effectiveness of our algorithm. Methods: Based on whole-face images of patients, the authors used logistic regression and the Newton method to detect the nevus region. Then, Python and OpenCV were employed to detect the lesion edge and compute the area of the regions. A multicenter clinical trial with a sample size of 600 was then conducted to evaluate the effectiveness of the algorithm. Results: The algorithm detected 2672 nevi from 600 patients, in which there were 195 patients of missed diagnosis and 310 patients of misdiagnosis. The Kappa value between 2 groups was 0.860 (>0.8). Paired t-test showed no significant difference between 2 groups’ area results (P = 0.265, P > 0.05). Conclusion: Within the limitations of this study, the authors demonstrated a high agreement between algorithm's detection and doctor's diagnosis. Our new algorithm has great effectiveness in nevus detection, edge segmentation, and area measurement. Address correspondence and reprint requests to Yan Zhang, MD, and Haisong Xu, MD, Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, No. 639 Zhizaoju Road, Pudong District, 200011, Shanghai, China; E-mails: zhangy1330@sh9hospital.org, xuhaisongmd@qq.com Received 29 June, 2019 Accepted 16 August, 2019 WC and YC are co-first authors and contributed equally to the work. This work was supported by the project of Science and Technology Department of Hainan Province (ZDYF2018022), Science and Technology Commission of Shanghai municipality (17411952800, 18441904500). 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.

Compartment Syndrome of the Temporal Muscle The authors report a patient with masticator space abscess due to an ascending infection following a wisdom tooth extraction. They administered antibiotics and did an incision and drainage; however, osteomyelitis of the mandible and compartment syndrome of the temporal muscle complicated the course. The authors suggest a physiopathology and discuss the management of this study. Address correspondence and reprint requests to Gian Battista Bottini, MD, DMD, Department of Oral and Maxillofacial Surgery, University Hospital of the Private Medical University Paracelsus, Müllner Hauptstrasse 48, A-5020 Salzburg, Austria; E-mail: g.bottini@salk.at Received 1 May, 2019 Accepted 5 September, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Reconstruction With Fibula Musculocutaneous Flap in a Patient With Extensive Maxillary Osteoradionecrosis The authors reported a case of extensive maxillary osteoradionecrosis. The maxilla was resected and reconstructed with fibula musculocutaneous flap. It was the first reported that the osteoradionecrotic maxilla was reconstructed with free vascularized bone. The musculocutaneous flap might be a better choice of maxillary osteoradionecrosis reconstruction instead of the simple soft-tissue flap. Address correspondence and reprint requests to Yue He, PhD, Department of Oral Maxillofacial—Head and Neck Oncology, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, Shanghai, China; National Clinical Research Center for Oral Disease, Shanghai, China; Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, No. 639, Zhi Zao Ju Road, Shanghai 200011, China; E-mail: zfshuo@163.com Received 19 August, 2019 Accepted 9 September, 2019 FZ, XL, ZL, and YH contributed equally to this article. This work is funded by The National Natural Science Foundation of China (NSFC: 81271112, 81570949). The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Review of “Multisource Evaluation of Surgeon Behavior is Associated With Malpractice Claims” by Lagoo J et al in Ann Surg 270: 84–90, 2019 No abstract available