Craniofacial Surgery

Resection of Septal Adenoid Cystic Carcinoma and Primary Reconstruction of the Surgical Defect via Open Rhinoplasty Adenoid cystic carcinoma is one of the most common minor salivary gland malignancies of the head and neck region. However, adenoid cystic carcinoma of the nasal septum is extremely rare. The authors herein report a case of a septal adenoid cystic carcinoma in a 68-year-old man who complained of nasal bleeding and nasal obstruction for several months. Diagnostic nasal endoscopy revealed a protruding mass arising from the anterosuperior part of the nasal septum. The tumor was removed with a safety margin using the open rhinoplasty approach and primary reconstruction of the surgical defect was performed using septal cartilage. Histopathology indicated an adenoid cystic carcinoma with cribriform pattern. Two years postoperatively, there was no evidence of recurrence, the functional and cosmetic results were good, and the patient was satisfied with the treatment outcome. Address correspondence and reprint requests to Myeong Sang Yu, MD, PhD, Department of Otolaryngology, Asan Medical Centre, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul 05505, Republic of Korea; E-mail: entyums@amc.seoul.kr Received 25 March, 2019 Accepted 19 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Zygomatic Rotation-Advancement: A New Concept for the Correction of Exorbitism in Patients With Syndromic Craniosynostosis Background: The exophthalmos and class III malocclusion seen in Crouzon syndrome can be treated by Le Fort III advancement/distraction. However, reconstructive options for zygomatic retrusion are limited. The authors describe the repair of isolated exorbitism in a patient with Crouzon syndrome, via bilateral zygomatic rotation-advancement. Methods: A 34-year-old woman with Crouzon syndrome complained of exorbitism and malar hypoplasia. Four years prior, she declined Le Fort III advancement and underwent orthodontic/orthognathic correction of malocclusion. Radiographs were used to develop a computerized surgical plan. Bilateral periorbital osteotomy with advancement/rotation of the zygomatic process was performed using custom osteotomy guides and plates. Images obtained immediately postoperative and 3- and 19-month postoperative were compared to assess surgical stability, accuracy, and soft tissue changes. Results: Decreased globe exposure and increased malar prominence have improved facial balance. Superimposed pre- and postoperative radiographs demonstrate bilateral advancement of the zygomatic body and inferior orbital rim. Superimposition of immediate postoperative and 19-month radiographs showed no relapse. Soft tissue histogram showed increased prominence of the malar eminence, lateral orbital rim, and cheek. Conclusions: Zygomatic rotation-advancement proved a safe, effective, stable, and predictable treatment for isolated malar hypoplasia in a patient with Crouzon syndrome. Virtual planning can enhance novel complex craniofacial procedures. Address correspondence and reprint requests to Roberto L. Flores, MD, Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, 222 East 41st St, New York, NY, 10017; E-mail: Roberto.Flores@nyulangone.org Received 2 March, 2018 Accepted 25 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Review of "The Current State of Surgical Ergonomics Education in U.S. Surgical Training-A Survey Study" by Epstein S et al. in Ann Surg 269: 778-784, 2019 No abstract available

Cranial Suture Anchor Temporalis Resuspension: A New Technique to Reconstruct Temporal Hollowing After Craniotomy Introduction: Proper temporalis resuspension following craniotomy or craniectomy is necessary to prevent significant temporofacial deformity. Several methods of temporalis reconstruction have been described with varying success; currently there are no reports of suture anchor utilization. Methods: A patient is presented displaying successful temporalis resuspension using suture anchor fixation. An incision was made in the temporal hair-bearing scalp to access and lengthen the retracted temporalis under direct visualization. Stab incisions were then made in the scalp to expose the superior temporal line, where suture anchors were placed for muscle fixation. After confirming appropriate vectors for muscle resuspension, 1 suture arm was passed through a subgaleal tunnel to capture the temporalis and the other was fixated to the temporoparietal skull. The suture anchors were secured and the incisions were closed in layers. Results: A 36-year-old female with history of decompressive craniectomy for hemorrhagic stroke presented with significant temporal hollowing. Her temporalis was retracted with a noticeable defect on frontal view and bulging over the zygomatic arch. The patient underwent temporalis resuspension as described with durable correction resembling her premorbid state. The buried suture anchors were nonpalpable. Conclusion: Temporal hollowing after craniotomy is a difficult contour deformity to correct. In the presented patient, reconstruction with temporalis elevation and suture anchor resuspension was found to be an effective technique with excellent cosmetic outcome. The efficiency of suture anchor placement, postoperative maintenance of muscle tension, and nonpalpable profile of the buried suture anchors suggest comparable efficacy to plate fixation and suture-only techniques. Address correspondence and reprint requests to Oluwaseun A. Adetayo, MD, 43 New Scotland Ave, Albany, NY 12208; E-mail: adetayo@amc.edu Received 11 July, 2018 Accepted 22 February, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Challenges in Microsurgical Reconstruction for Craniofacial Osteomyelitis With Resultant Osteonecrosis Introduction: Chronic osteomyelitis is characterized by compromised blood supply and eventual osteonecrosis. Definitive treatment requires aggressive resection of affected bone. The resultant defect poses a unique challenge to reconstructive surgeons. Much of the literature on craniofacial osteomyelitis focuses on infection eradication, rather than subsequent reconstruction. This article reports representative cases from our experience with free flap reconstruction for defects secondary to chronic osteomyelitis of the craniofacial skeleton. Methods/Results: The authors selected 5 of the most difficult reconstructive cases of craniofacial osteomyelitis from our experience in a single tertiary referral institution with a follow-up of at least 6 months. Three of the 5 cases arose in the setting of previous head and neck cancer treated with resection and radiation therapy. One case had a previous surgical craniotomy complicated by osteomyelitis and multiple failed alloplastic reconstructions. The final case was due to multiple gunshots to the head, with subsequent cerebral and cranial abscess (>1000cc). In each case, the defect was successfully treated with free tissue transfer. Two cases required creation of recipient vessels with an arteriovenous loop. Conclusions: Free tissue transfer provides a versatile and effective tool in the reconstruction of extensive craniofacial osteomyelitis defects. Furthermore, the addition of vascularized tissue can protect against further episodes of osteomyelitis. Finally, arteriovenous loops can be employed successfully when prior radiation and infection of the wound bed precludes the use of local recipient target vessels. Address correspondence and reprint requests to Brian R. Gastman, MD, 9500 Euclid Ave, Desk A60, Cleveland, OH 44195; E-mail: sinclan@ccf.org Received 12 September, 2018 Accepted 20 March, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Fully Automatic Robot-Assisted Surgery for Mandibular Angle Split Osteotomy With the development of computer-assisted surgery, preoperational design is detailed in software. However, it is still a challenge for surgeons to realize the surgical plan in the craniofacial surgery. Robot-assisted surgery has advantages of high accuracy and stability. It is suitable for the high-stress procedures like drilling, milling, and cutting. This study aims to verify the feasibility for automatic drilling without soft tissues in model test based on an industrial robot platform. This study chose the data from digital laboratory in Shanghai 9th People's Hospital. The mandibular was reconstructed in software and surgical plan was also designed. Then, the coordinate data was input to the robot's software and matrix conversion was calculated by 4 marked points. The trajectory generation was calculated by inverse kinematics for target coordinates and robot coordinates. The model was fixed and calibrated for automatic drilling. At last, the accuracy was calculated by optic scanning instrument. The installment and preparation cost 10 minutes, the drilling procedure cost 12 minutes. The outside position error was (1.71 ± 0.16) mm, the inside position error was (1.37 ± 0.28) mm, the orientation error was (3.04 ± 1.02) °. Additionally, a total of 5 beagles were tested, with an accuracy error of (2.78 ± 1.52) mm. No postoperative complications occurred. This is the first study reported for robot-assisted automatic surgery in craniofacial surgery. The result shows it is possible to realize the automatic drilling procedure under the condition of no interference like soft tissues. With the development of artificial intelligence and machine vision, robot-assisted surgery may help surgeons to fulfill more automatic procedures for craniofacial surgery. Address correspondence and reprint requests to Gang Chai, MD, PhD, College of Medical Instruments, Shanghai University of Medicine & Health Sciences, No. 257, Zhouzhu Highway, Pudong District, Shanghai, China; Department of Plastic and Reconstructive Surgery, Maternal and Child Health Care Hospital of Hainan Province, Haikou 570206, China; Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital, School of Medicine, Shanghai Jiao Tong University, 639 Zhi Zao Ju Rd, Shanghai, 200011, China; e-mail: chaig1081@sh9hospital.org Received 16 October, 2018 Accepted 3 March, 2019 MS and YC contributed equally to this study. This work was supported by Shanghai Municipal Education Commission–Gaofeng Clinical Medicine Grant Support (20161420), Science and Technology Department of Hainan Province (ZDYF2018022), the project of science and technology commission of Shanghai municipality (18DZ2201900, 19441912300, 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.

Chimeric Lateral Arm Free Flap to Treat Pharyngocutaneous Fistula After Total Laryngectomy Pharyngocutaneous fistula is a major complication after total laryngectomy, leading to a severe adverse impact for the patient and social activity. The reported incidence ranges from 9% to 25% in the last decade. In this paper, the authors present our experience using chimeric lateral arm free flap for reconstruction of the pharyngo-esophageal segment. Eight patients with pharyngocutaneous fistula were treated with this technique. The flap has 2 skin islands, each one supplied by a perforator coming from the main pedicle. One skin island is used as a patch for pharynx closure and the other is used for anterior soft tissue coverage. The follow-up period ranged from 8 months to 3 years. All flaps survived. There was 1 small fistula that was sutured. External skin wound dehiscence was present in 1 case and it was secondary closed by itself. All patients were able to eat by mouth and there were no signs of stricture. The authors preferred this type of flap because both defects are simultaneously closed and each skin paddle is supplied by a perforator coming from the main pedicle. It has a better color match than other free flaps. The skin island is thin and remains thin even after the patients gain weight. Address correspondence and reprint requests to Magdalena Chirila MD, PhD, Emergency District Hospital, Ear Nose and Throat Department, 4-6 Clinicilor Str., 400006, Cluj-Napoca, Romania; E-mail: chirila_magda@yahoo.com Received 14 January, 2019 Accepted 1 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.

Comparative Analysis of the Healing Effects of the Transplanted Cell Sheets to the Experimentally Injured Maxillary Sinuses Background: In our study, the authors aimed to obtain a live and functional sinus epithelium with mesenchymal stem cells and nasal mucosa epithelial cells from rabbits which are cultured in temperature-responsive culture plates to get a single-layer. Methodology/Principal: Twenty-two female New Zealand rabbits were included in the study. Two of them were used to obtain mesenchymal stem cells. A total of 40 maxillary sinuses were randomly divided into 5 groups: control group which is used to investigate normal rabbit maxillary mucosa,secondary healing group,mesenchymal stem cell graft group,differentiated mesenchymal stem cell group, andnasal mucosal graft group. The animals were sacrificed at the 28th day after the surgery. Scanning electron microscopy, transmission electron microscopy, and immunohistochemical investigations were performed. Results: With these investigations, it was shown that; all graft groups were histologically better than secondary healing group and when the authors compared the graft groups, differentiated mesenchymal stem cell group were the best. Conclusion: Our study results showed that endoscopic sinus surgery and treatment with cell sheets, which were generated in temperature-responsive culture dishes, had more functional respiratory epithelium. Address correspondence and reprint requests to Ahmet Kara, MD, Sakarya University Training and Research Hospital, 54000, Korucuk, Sakarya, Turkey; E-mail: doktor.kbb@hotmail.com Received 19 February, 2019 Accepted 23 April, 2019 This study has been funded by the Turkey Scientific and Technological Research Center (TUBITAK project number: 113S871). The research protocol was approved by the Kocaeli University Animal Ethics Committee (KOU HADYEK3/7 2013). This was presented at 15th Turkish Rhinology, 7th National Otology-Neurology, and National Head and Neck Congress, April 4–7, 2019; Ankara, Turkey. The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Rigid External Le Fort I Distraction Followed by Secondary Bone Grafting for Maxillary Advancements in Patients With Cleft Lip and Palate Introduction: Maxillary hypoplasia after cleft lip and palate (CLP) repair can result in significant functional and aesthetic impairments. Le Fort I osteotomy & advancement and Le Fort I distraction osteogenesis are standard treatment options for individuals with CLP-associated midface retrusion. However, both of these modalities continue to be associated with a high relapse rate. This study describes surgical outcomes of a 2-stage technique utilizing distraction osteogenesis combined with bone grafting and rigid fixation, which may optimize skeletal stability by reducing relapse. Methods: A retrospective review of CLP patients with severe maxillary hypoplasia evaluated by a single surgeon from 2003 to 2014 was performed. Twenty-one subjects were identified that underwent maxillary advancement via a 2-stage technique: (1) Le Fort I external rigid distraction using a HALO device, followed by (2) autologous iliac crest bone graft application and plate-fixation. Post-operative cephalograms were taken on average 1-year following surgery. Results: Twelve subjects met the inclusion/exclusion criteria. A distraction rate of 1 mm/day was achieved with an average of 14 mm of maxillary advancement. Average increase in SNA was +9.03°, with an increase from 71.84° to 80.88° (normal = 82.0°, P value <0.0001), with no significant change in SNB, and a +9.63° change in ANB from −7.76° to 1.88° (normal = 1.6°, P value <0.0001). Conclusions: The described 2-step procedure had similar cephalometric improvements as compared to distraction osteogenesis alone. However, successive bone grafting and rigid fixation as a second procedure may help ameliorate relapse risk and optimize the correction of maxillary hypoplasia in susceptible populations. Address correspondence and reprint requests to Anthony P. Tufaro DDS, MD, University of Oklahoma Health Sciences Center, Department of Surgery, Division of Plastic Surgery, Chief of Plastic Surgery, 800 Stanton L. Young Blvd, Suite 8300, Oklahoma City, OK 73104; E-mail: anthony-tufaro@ouhsc.edu Received 31 July, 2018 Accepted 24 March, 2019 Dr. Mundinger receives research funding from KLS Martin and is on the advisory board for Polarity TE. The other authors have no other conflicts of interest 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.

Evaluation of the Effects of Low-Level Laser Therapy on Diabetic Bone Healing The aim of the present study was to evaluate the effects of low-level laser therapy (LLLT) and biphasic alloplastic bone graft material on diabetic bone healing. Induction of diabetes was performed in 14 male Sprague-Dawley rats by intraperitoneal injection of a 50 mg/kg dose of streptozotocin. Two bilaterally symmetrical non-critical-sized bone defects were created in the parietal bones in each rat. Right defects were filled with biphasic alloplastic bone graft. Rats were randomly divided into 2 groups, with 1 group receiving 10 sessions of LLLT (GaAlAs, 78.5 J/cm2, 100mW, 0.028 cm2 beam). The LLLT was started immediately after surgery and once every 3 days during postoperative period. At the end of treatment period, new bone formation and osteoblast density were determined using histomorphometry. Empty (control), graft-filled, LLLT-treated and both graft-filled and LLLT-treated bone defects were compared. New bone formation was higher in the graft treatment samples compared with the control (P = 0.009) and laser samples (P = 0.029). In addition, graft–laser combination treatment samples revealed higher bone formation than control (P = 0.008) and laser (P = 0.026) samples. Osteoblast density was significantly higher in the laser treatment (P <0.001), graft treatment (P = 0.001) and graft–laser combination treatment (P <0.001) samples than control samples. In addition, significantly higher osteoblast density was observed in the graft-laser combination treatment samples compared to the graft treatment samples (P = 0.005). The LLLT was effective to stimulate osteoblastogenesis but failed to increase bone formation. Graft augmentation for treatment of bone defects seems essential for proper bone healing in diabetes, regeneration may be supported by the LLLT to enhance osteoblastogenesis. Address correspondence and reprint requests to Nurettin Diker, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bezmialem Vakif University, Adnan Menderes Bulvari, Vatan Caddesi, 34093 Fatih, Istanbul, Turkey; E-mail: ndiker@bezmialem.edu.tr, dikernurettin7tp@gmail.com Received 22 January, 2019 Accepted 24 April, 2019 This study was funded by a Baskent University Research Fund (project no. D-DA 13/09). The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com