Use of Irradiated Homologous Costal Cartilage in Rhinoplasty: Complications in Relation to Graft Location

Background: Nasal septal cartilage and conchal cartilages are preferred sources of grafts in augmentation rhinoplasty. Rib cartilage can also be used, but it may evoke a patient's concerns about a scar and an extensive surgery. In such cases, irradiated homologous costal cartilage (IHCC) can be a useful alternative. However, controversy still exists in many literatures regarding complications with use of IHCC. Therefore, the authors reviewed our experiences with IHCC in rhinoplasty and analyzed the complications in relation to graft location. Methods: A retrospective chart review was made of all patients who underwent rhinoplasty with IHCC between 2007 and 2015. A total of 323 patients were included. The authors considered the cases that required revision surgery for external aesthetic changes as complications. The authors defined major complications, including resorption, infection, fracture, or warping. Results: The total complication rate was 8%. Two fractures (0.6%), 4 fragmentation (1.2%), 4 resorptions (1.2%), 4 infections (1.2%), and 2 warpings (0.6%) were noted. Most of these complications occurred for the septal extension graft. Other complications, including 1 nasal obstruction, 2 visible contours, 3 caudal septal deviations, and 4 cases of unfavorable results (patient unsatisfactions), were noted. Conclusions: Based on the outcomes of this study, the authors concluded that IHCC is a useful and reliable source of cartilage graft and can serve as an alternative graft material for rhinoplasty. However, care must be taken in use of IHCC graft in areas under tension such as septal extension graft, though its complication rate is low. Address correspondence and reprint requests to Yeon-Jun Kim, MD, JW Plastic Surgery Center, Samsin Building, 836 Nonhyeon-ro, Gangnam-gu, Seoul 135-893, Korea; E-mail: kimyj.md@gmail.com Received 18 April, 2017 Accepted 10 January, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Longitudinal Follow-up of Individuals With Cleft Lip Using Three-Dimensional Stereophotogrammetry

The usefulness of three-dimensional (3D) stereophotogrammetry for treating cleft lip (CL) has been well documented. However, there are only a few reliable anthropometric analyses in infants with CL because at this age they cannot assume a resting facial position. Since 2014, we have used a handheld 3D imaging system in the operating room to obtain optimal images of infants with CL and palate under general anesthesia. Currently, 168 infants with a unilateral cleft, 50 infants with bilateral clefts, and 47 infants with an isolated cleft palate are being followed up in this way for a maximum of 30 months. Most patients ≥3 years of age are cooperative and allow staff to obtain 3D images without sedation. We plan to follow them until adulthood, obtaining 3D images at every intervention. Each year, >150 infants can be added to this ongoing longitudinal study. Using an archive of these digital images, various retrospective studies can be attempted in the future, which include comparisons of the long-term outcomes of various surgical techniques and interventions at different time intervals. This is the first 2-year preliminary report of a 20-year longitudinal study. Address correspondence and reprint requests to Daichi Morioka, MD, Department of Plastic and Reconstructive Surgery, Showa University, 1–5–8 Hatanodai, Shinagawa, Tokyo 142–8866, Japan; E-mail: dmorioka@gmail.com Received 11 June, 2017 Accepted 8 January, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Conservative Treatment for Delayed Infection After Cranioplasty With Titanium Alloy

Cranioplasty (CP) is considered a low-risk operation in the field of neurosurgery following decompression craniectomy. Nevertheless, CP is still burdened by surgical complications, among which early or late infections are the most common outcome-threatening ones. Most of infection cases occur within a week after CP. Except that, implant-associated scalp infection is the most common complication, and leads to implant removal in many patients with refractory and recurrent infection. The authors reported a patient presenting with epidural infection about 3 months after titanium implant and cured by anti-infective treatment for 2 weeks. Address correspondence and reprint requests to Kang Zhang, MD, PhD, Nanhu Road No. 23, Nanjing 210017, China; E-mail: nzykangzhang@yeah.net Received 4 December, 2017 Accepted 9 January, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Large-Scale Study of Long-Term Vertical Skeletal Stability in a Surgery-First Orthognathic Approach Without Presurgical Orthodontic Treatment: Part II

The surgery-first approach (SFA) is a new paradigm in orthognathic surgery. In our experience over the last 10 years, SFA, particularly for the correction of the class III dentofacial deformity and facial asymmetry, has demonstrated high success rates without any major complications. However, many craniofacial surgeons remain concerned about the skeletal stability of SFA. In the present study, the authors aimed to compare the traditional and SFA with regard to the long-term outcomes of vertical skeletal stability using large-scale data. The authors enrolled patients with skeletal class III dentofacial deformities who had undergone and completed orthognathic surgery between December 2007 and December 2015. The inclusion criteria were based on the presurgical simulation of the dental model, and the authors predicted the potential of the SFA based on this preoperative simulation model. Patients with cleft-related syndromes, and those who had undergone orthognathic surgeries for facial asymmetry or class II deformity were excluded. A total of 104 and 51 class III patients were enrolled in the surgery-first and traditional orthodontics-first groups, respectively. Satisfactory results were achieved in all 155 patients with dentofacial deformity. The initial preoperative measurements of cephalometric analysis, particularly vertical skeletal stability, were similar and well maintained after the procedure in both groups. In conclusion, the SFA without any presurgical orthodontic treatment for correcting dentofacial deformities can achieve similar long-term vertical stability results to the orthodontic treatment-first approach. Address correspondence and reprint requests to Jong Woo Choi, MD, PhD, Associate Professor, Department of Plastic and Reconstructive Surgery, University of Ulsan College of Medicine, Seoul Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea; E-mail: pschoi@amc.seoul.kr Received 3 May, 2017 Accepted 8 January, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Delayed Diagnosis of Gorlin–Goltz Syndrome: The Importance of the Multidisciplinary Approach

Gorlin–Goltz syndrome (GGS), also known as nevoid basal cell carcinoma syndrome, is an autosomal dominant inherited disorder with high penetrance and variable expressivity. The classic triad originally described by Gorlin and Goltz in 1960 is composed of multiple nevoid basal cell carcinomas (NBCCs), odontogenic keratocysts (OKCs) in the jaws and bifid ribs. in 1977, this triad was modified by Rayner et al, and to GGS diagnosis, the OKCs had to appear in combination with calcification of the cerebellar falx or palmar and plantar pits. It may occur that although GGS syndrome is a well-known condition, only the specific symptom could be observed by different specialists. Therefore, the patient cannot be placed in an always complex clinical panel. The authors introduce an example in this report. In the present case, the patient had NBCCs, OKCs, and probably other signs of GGS since 1998, and has been treated for this conditions separated, without a diagnosis of a syndromic condition. A 54-year-old white woman was referred to the oral medicine service due to cyst located in the right mandibular body. She had history of skin cancer and undergone surgeries and radiotherapies for the lesions treatment, scars on the skin face due to the lesions removed, and a new ulcerated lesion on the back of was diagnosed. In addition, the patient presented frontal and parietal bossing leading to increased cranial circumference, hypertelorism, strabismus, broad base, and mandibular prognathism. To the image examination, skull radiography revealed calcification of the falx cerebri; on chest X-ray bifid rib was observed and spine radiography showed vertebral osteophytes. Panoramic radiograph showed a well-defined bilocular radiolucent image located in posterior and anterior mandibular region. The whole elements induced us to investigate the patient's past medical history, which revealed that since 1998 had the diagnosis of NBCC and OKC. A multidisciplinary approach becomes necessary for the diagnosis and follow-up of patients with GGS, considering the complexity of the clinical manifestations. Therefore, it is of primary importance for dental surgeons and dermatologists to know the signs and symptoms of GGS to perform early diagnosis and to avoid progression of the oral cysts or metastasis of the skin lesions. Address correspondence and reprint requests to Fábio Roberto de Souza Batista, DDS, Department of Surgery and Integrated Clinic, Division of Oral and Maxillofacial Surgery, São Paulo State University (UNESP), School of Dentistry, Araçatuba, São Paulo 16015-050, Brazil; E-mail: fabiorsbatista@gmail.com Received 13 December, 2017 Accepted 9 January, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Root Fracture as Complication of Surgically Assisted Rapid Maxillary Expansion

A 23 year old male patient was submitted to surgical assisted rapid maxillary expansion (SARME). There were any postoperative complications until the finish of orthodontic expansion process. However, in the 30th postoperative day, patient mentioned pain in upper central incisor. Periapical radiography evidenced a root fracture of central upper right incisor. After endodontic treatment, the fractured apex was removed. After 3 years of follow-up, the patient finished orthodontics, and the damaged tooth was in good aspect. Apical fracture is an unexpected complication of SARME. However, follow-up and correct treatment lead to a good prognosis for tooth maintenance. Address correspondence and reprint requests to Pedro Henrique de Azambuja Carvalho, DDS, PhD Student, Dental School at Araraquara – UNESP, 1680th Humaitá Street, 1680,– Araraquara, São Paulo – Brazil; E-mail: carvalhopha@outlook.com Received 22 November, 2017 Accepted 8 January, 2018 The authors report no conflicts of interest. © 2018 by Mutaz B. Habal, MD.

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Localization of the Maxillary Ostium in Relation to the Reduction of Depressed Nasomaxillary Fractures

The aim of this study was to elucidate the precise location of the maxillary ostium using computed tomography for the reduction of depressed nasomaxillary fractures. Computed tomography images (61 males, 42 females; age range, 3–97 years) were analyzed. Coronal sections were cut every 3 mm. The primary maxillary ostium (PMO) was located 24.7% ± 3.9% of bizygomatic distance (BZD) lateral to septum. The horizontal distance of the PMO significantly increased with age (P = 0.032). The PMO was located 53.3% ± 8.0% of nasal length (NL) above superior surface of the palatal bone (SP). The vertical-to-horizontal ratio of the PMO decreased with age (P = 0.013). The PMO was located 30.3 ± 4.3 mm posterior to the tip of nasal bone. The PMO was located 24.6 ± 4.8 mm posterior to the anterior nasal spine (ANS). The ANS-PMO distance significantly increased with age (P = 0.027). The hiatus semilunaris (HS) was located 11.9% ± 3.2% of BZD lateral to septum. The HS was located 62.4% ± 10.3% of NL above SP. The vertical distance of the HS significantly decreased with age (P = 0.019). The accessory maxillary ostium (AMO) was located 14.9% ± 2.8% of BZD lateral to septum. The horizontal distance of the AMO significantly increased with age (P = 0.027). The AMO was located 44.8% ± 6.9% of NL above SP. The vertical distance of the AMO significantly decreased with age (P 

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