Craniofacial Surgery

Potential In Vitro Tissue-Engineered Anterior Cruciate Ligament by Copolymerization of Polyvinyl Alcohol and Collagen Background and Purpose: Suitable tissue-engineered scaffolds to replace human anterior cruciate ligament (ACL) are well developed clinically as the development of tissue engineering. As water-soluble polymer compound, polyvinyl alcohol (PVA) has been wildly used as the materials to replace ACL. The aim of this study was to explore the feasibility of constructing tissue-engineered ACL by the copolymerization of PVA and collagen (PVA/COL). Methods: PVA and COL were copolymerized at a mass ratio of 3:1. The pore size and porosity of the scaffold were observed by electron microscope. The maximum tensile strength of the scaffold was determined by electronic tension machine. The cytotoxicity of the scaffold was evaluated by MTT assay. The morphology of ACL cells cultured on the surface of the scaffold was observed by inverted microscope. The degradation of the scaffold was recorded in the rabbit model. Results: The average pore size of the polymer scaffold was 100 to 150 μm and the porosity was about 90%. The maximum tensile strength of the scaffold material was 8.10 ± 0.28 MPa. PVA/COL could promote the proliferation ability of 3T3 cells. ACL cells were successfully cultured on the surface of PVA/COL scaffold, with natural growth rate, differentiation, and proliferation. Twenty-four weeks after the plantation of scaffold, obvious degradations were observed in vivo. Conclusion: The model of in-vitro tissue-engineered ACL was successfully established by PVA/COL scaffolds. Address correspondence and reprint requests to Zongsheng Yin, The First Affiliated Hospital of AnHui Medical University, No. 218, JiXi Road, ShuShan District, HeFei 230032, Anhui, People's Republic of China; E-mail: yzs12368@126.com Received 18 November, 2019 Accepted 8 July, 2020 The authors report no conflicts of interest. Supplemental digital content is 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 Website (www.jcraniofacialsurgery.com). © 2020 by Mutaz B. Habal, MD.

Assessment of Freestyle Local Facial Perforator Flaps for Coverage of Facial Defects Objective: To assess local freestyle facial perforator flaps in the reconstruction of small to medium-sized facial defects. Materials and methods: In a case series, local freestyle perforator flaps were used in Suez Canal University Hospital to reconstruct 28 facial defects in 26 patients between 2017 and 2019. Adequate perforators were identified near those defects and flaps were designed as propeller or VY advancement. Four scales from the FACE-Q (satisfaction with facial appearance, satisfaction with the outcome, psychological function, and appearance-related psychosocial distress) and 2 scales from the SCAR-Q (Appearance scale and Symptom scale) were used as well as the observer part of the Patient and Observer Scar Assessment Scale. The mean follow up period was 10 months. Results: Complete reconstruction was achieved in all cases with a high rate of patient satisfaction which was assessed by FACE-Q and SCAR-Q. Moreover, observer assessment by Patient and Observer Scar Assessment Scale score showed high patient satisfaction with the scars with a mean (SD) 15.5 (3.4) and there was a positive correlation between subjective and objective: results (r2 from 0.27 to 0.41, P < 0.01). Regarding complications, bulkiness occurred in 2 flaps, congestion in 2 flaps, dehiscence in 1 flap, and tip necrosis in 5 flaps. Accordingly, secondary intervention in the form of medicinal leech therapy was used in 3 flaps, delayed closure for the dehisced flap and debulking for 1 flap. Conclusions: Local freestyle perforator flap reconstruction is one of the recommended techniques for small to medium-sized facial defects which gives a high aesthetic outcome and patient satisfaction. Address correspondence and reprint requests to Mohamed A. Ellabban, MD, Suez Canal University Hospitals and Medical School, 4.5 Ring Road, Ismailia, Egypt; E-mail: mohamed.ellabban@med.suez.edu.eg Received 14 May, 2020 Accepted 1 June, 2020 The authors report no conflicts of interest. Supplemental digital content is 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 Website (www.jcraniofacialsurgery.com). © 2020 by Mutaz B. Habal, MD.

Post-Cranioplasty Complications: Lessons From a Prospective Study Assessing Risk Factors Complication rate related with cranioplasty is described as very high in most of relevant studies. The aim of our study was to try to identify possible factors, that could predict complications following cranioplasty. The authors hypothesized that some physical characteristics on the preoperative brain computed tomography (CT) scan can be predictive for complications. The authors carried out a prospective observational study. All patients were adults after decompressive craniectomy, planned for cranioplasty and had a brain CT scan the day before cranioplasty. Our data pool included demographics, reason of craniectomy, various radiological parameters, the time of cranioplasty after craniectomy, the type of cranioplasty bone flap, and the complications. Twenty-five patients were included in the study. The authors identified statistically significant correlation between time of cranioplasty after craniectomy and the complications, as well as between the type of cranioplasty implant and the complications. There was statistically significant correlation between complications and the distance of the free brain surface from the level of the largest skull defect dimension – free brain surface deformity (FBSD). Moreover, the correlation between FBSD and the time of cranioplasty was statistically significant. It seems that for adult patients with unilateral DC the shorter time interval between craniectomy and cranioplasty lowers the risk for complications. The risk seems to be decreased further, by using autologous bone flap. Low values of the FBSD increase the risk for complications. This risk factor can be avoided, by shortening the time between craniectomy and cranioplasty. Address correspondence and reprint requests to Eleni Tsianaka, MD, Department of Neurosurgery, University Hospital of Larissa, Viopolis, 41111, Larissa, Greece; E-mail: ariadniq@yahoo.gr Received 18 August, 2020 Accepted 18 November, 2020 The authors report no conflicts of interest. Supplemental digital content is 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 Website (www.jcraniofacialsurgery.com). © 2020 by Mutaz B. Habal, MD.

Palatal Re-Repair With Z-Plasty in Treatment of Velopharyngeal Insufficiency of Syndromic and Nonsyndromic Patients With Cleft Palate Background: Velopharyngeal insufficiency (VPI) often results from palatal shortening or insufficient levator function after cleft palate repair. Aims: To assess the efficacy of palatal re-repair with Z-plasty in treatment of VPI for patients with isolated cleft palate (ICP). Methods: This retrospective analysis comprised 130 consecutive patients who had ICP with VPI that required Z-plasty as secondary surgery between 2008 and 2017. Pre- and post-operative evaluation of velopharyngeal function was done perceptually and instrumentally by Nasometer. Results: Median patient age at Z-plasty was 6.8 years (range 3.0–20.1). Of the 130 patients, preoperatively VPI was severe in 73 (56%), mild-to-moderate in 55 (42%), and borderline in 2 (2%). Postoperatively, 105 (81%) of patients achieved adequate (normal or borderline) velopharyngeal competence and 16 (12%) required second operation for residual VPI. The success rate was 84% in nonsyndromic patients, 79% in nonsyndromic Pierre Robin sequence patients, and 58% in syndromic patients. In syndromic children, the speech outcome was significantly worse than in nonsyndromic children (P = 0.014). Complications included wound healing problems in 3 patients (2%), mild infection in 1 patient (1%), postoperative bleeding in 1 (1%), and postoperative fistula in 2 (2%). Conclusion: Palatal re-repair with Z-plasty is a safe operation for VPI correction in patients with ICP with a success rate of 81%. In syndromic patients, the procedure did not seem to work as well as in nonsyndromic patients. Address correspondence and reprint requests to Veera Ahti, MD, Helsinki Cleft and Craniofacial Center, Department of Plastic Surgery, Helsinki University Hospital, Finland; E-mail: veera.ahti@hus.fi Received 4 September, 2020 Accepted 18 November, 2020 The authors report no conflicts of interest. Supplemental digital content is 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 Website (www.jcraniofacialsurgery.com). © 2020 by Mutaz B. Habal, MD.

Are Backyard Waterslides as Dangerous as Public Waterslides: A Review of 1,823 Head and Neck Injuries The purpose of this study was to describe the characteristics and compare the severity of head and neck injuries between public and backyard waterslides. This was a 20-year cross-sectional study of the National Electronic Injury Surveillance System. Injuries from waterslides were included in this study if they involved the head, face, eyeball, mouth, neck, or ear. Patient and injury characteristics were compared by the type of waterslide using chi-squared and independent sample tests. A total of 1823 injury reports were identified (39.8% backyard waterslides and 60.2% public waterslides). The mean age at the time of injury was 13.2 years, and the majority of patients were white (74.2%) males (55.1%). The most common primary diagnoses were laceration (28.4%) and internal organ injury (27.2%). A greater proportion of backyard injuries involved the head (P < 0.01) and resulted in concussions (P < 0.01) or fractures (P = 0.04). The overall admission rate from the ED was 3.5%, and no fatalities were noted. There were no significant differences in admission rates between injuries from backyard and public slides. Fatal or serious head and neck injuries appear to be uncommon with waterslide injuries. Backyard waterslides pose a greater likelihood of cranial injury, and this may relate to differences in riding habits between public and private waterslides. Address correspondence and reprint requests to Kevin C. Lee, DDS, MD, Division of Oral and Maxillofacial Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, 630 West 168th Street, New York, NY 10032; E-mail: kcl2136@cumc.columbia.edu Received 27 September, 2020 Accepted 4 November, 2020 The authors report no conflicts of interest. Supplemental digital content is 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 Website (www.jcraniofacialsurgery.com). © 2020 by Mutaz B. Habal, MD.

Application of Virtual Endoscopy in Microvascular Decompression of Trigeminal Neuralgia Purpose: The main purpose of this study is to evaluate the accuracy of virtual endoscopy (VE) in microvascular decompression (MVD) for the treatment of trigeminal neuralgia (TN). Methods: A total of 30 TN patients aged 42 to 70 years were recruited from January 2015 to January 2019, and all patients were confirmed to have severe neurovascular compression (NVC) (≥degree 2) by magnetic resonance tomographic angiography (MRTA). Preoperative MRTA and enhanced CT were performed, and the data were imported into Stlview software for VE simulation of MVD. The reliability of VE, real endoscopy, and MRTA in evaluating the degree and position of MVD in TN patients was compared. Results: Virtual endoscopy is more reliable than MRTA in evaluating the degree of NVC, but both of them are reliable in determining the position of NVC in TN patients. Conclusions: Virtual endoscopy can be used in MVD for the treatment of TN, including preoperative diagnosis and risk evaluation, intraoperative guidance, and postoperative evaluation. Address correspondence and reprint requests to Minjie Chen, MD, Oral Surgery Department, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; E-mail: 407102560@qq.com Received 7 October, 2020 Accepted 1 November, 2020 The authors report no conflicts of interest. Supplemental digital content is 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 Website (www.jcraniofacialsurgery.com). © 2020 by Mutaz B. Habal, MD.

Examination of the Safe Zone in Mandibular Ramus Osteotomies In the surgical procedures such as osteotomy to be applied to ramus of the mandible, care should be taken not to damage the inferior alveolar nerve (IAN). The safe zone, which is the area above and behind the mandibular foramen (MF), is the ramus of mandible area, where these surgeries can be performed without damaging the inferior alveolar neurovascular bundle. It was aimed to determine the safe zone in the ramus of mandible in the cone-beam computed tomography (CBCT) images of individuals. The CBCT images of 300 Turkish individuals between the ages of 18 to 65 were bilaterally and retrospectively evaluated. Three parameters on the sagittal and two parameters on the axial plane were measured. Additionally, two ratios were calculated which determined the superior and posterior part of the safe zone through the measured parameters. In this study, the safe zone was determined as the area where 55% of the upper part and 49% of the posterior part of the mandibular ramus. Determining the safe zone in surgical procedures to be applied to the ramus of mandible will help protect the neurovascular structures passing through the MF, reduce complications and increase the success rate of the surgical procedure. However, it is seen that there are few studies on this subject in the literature and there are some differences between these studies. The authors think that preoperative CBCT screening will be safer for each patient in the mandibular ramus osteotomies and more studies should be done on different populations to determine standard values. Address correspondence and reprint requests to Ilhan Bahşi, MD, PhD, Department of Anatomy, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey; E-mail: dr.ilhanbahsi@gmail.com Received 8 October, 2020 Accepted 9 November, 2020 The authors declare no conflict of interest. Supplemental digital content is 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 Website (www.jcraniofacialsurgery.com). © 2020 by Mutaz B. Habal, MD.

Accessory Cranial Suture Leading to Abnormal Head Shape Accessory cranial sutures have been described in the literature and are most commonly associated with the parietal bone. These sutures are typically identified incidentally and there have been no reported cases of accessory cranial sutures leading to abnormal head shape. The authors present the case of a 3-month-old patient with multiple congenital anomalies and an accessory parietal suture leading to abnormal head shape. The patient was successfully treated with cranial orthotic therapy. To our knowledge, this is the first reported case of an accessory cranial suture leading to abnormal head shape. Address correspondence and reprint requests to Garrison A. Leach, MD, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013-8890; E-mail: garrison.a.leach@gmail.com Received 9 October, 2020 Accepted 11 November, 2020 The authors report no conflicts of interest © 2020 by Mutaz B. Habal, MD.

Secondary Cervicofacial Soft Tissue Reconstruction With Upper Trapezius Myocutaneous Flap in "Frozen Neck" With Bone Flap and Reconstructive Plate Exposure A frozen neck is a scarred neck with severe fibrosis with a loss of tissue planes secondary to prior irradiation with or without surgery. The purpose of this study was to evaluate the outcomes of cervicofacial reconstruction in patients with soft tissue defects and bone flap and reconstruction plate exposure with the upper trapezius myocutaneous flap. Fifteen oncologic patients with prior surgery and radiotherapy developed soft tissue dehiscence with bone and osteosynthesis material exposure. All patients had either a frozen neck or a vessel-depleted neck. The soft tissue defects were reconstructed, the osteosynthesis material was removed and the bone flap exposure was covered in all patients. One patient developed a seroma and 1 patient reported wound dehiscence. In terms of esthetic results, 6 patients referred a good esthetic result, whereas 8 patients referred a fair result and 1 patient a poor result. Two patients with prior radical neck dissection reported a poor functional result in the ipsilateral shoulder, previously to secondary reconstruction. Functional neck dissection was performed in 10 patients, 8 patients referred a good functional outcome and 2 patients reported a fair result. The upper trapezius flap is an extremely reliable source for secondary cervicofacial soft tissue reconstruction in "frozen neck." In comparison with other locoregional flaps, the upper trapezius flap fulfills all aesthetic and functional criteria for secondary cervicofacial soft tissue reconstruction. Address correspondence and reprint requests to Carlos Navarro Cuéllar, MD, PhD, Maxillofacial Surgery Department, Hospital General Universitario Gregorio Marañón, c/ Doctor Esquerdo 46, 28007, 28036, Madrid, Spain; E-mail: cnavarrocuellar@gmail.com Received 1 November, 2020 Accepted 18 November, 2020 The study and review of the medical records and data collection, and the subsequent analysis of the data collected is endorsed by the Hospital Ethics Committee at Gregorio Marañón General Hospital. The authors have obtained patient's permission. The authors have no conflicts of interest to disclose. Supplemental digital content is 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 Website (www.jcraniofacialsurgery.com). © 2020 by Mutaz B. Habal, MD.

Skeletal Stability and Airway Changes After Maxillary Advancement Using a Rigid External Distraction System in Non-Growing Cleft Patients Distraction osteogenesis (DO) is a highly effective technique for correction of severe maxillary hypoplasia, especially in patients with orofacial clefts and craniofacial syndromes. The purpose of this retrospective, longitudinal study was to assess long-term airway alterations after maxillary advancement using a rigid external distraction system (RED) in non growing cleft patients. Fifteen cleft patients (8 males and 7 females) aged from 14 to 25 years were included in this study. All of them were treated with a rigid external distraction system for maxillary advancement after a high Le Fort I osteotomy. To analyse airway changes lateral cephalograms were obteined before distraction (T0), immediately after distraction (T1) and 1 to 3 years and 3 months after distraction (T2). All the measurements were describled by means of median, minimum and maximum. In order to evaluate differences between each time interval, a Wilcoxon test associated to a Delta Cliff test was used to evaluate the effect size (level of significance adopted was 5%). A significant maxillary advancement and increased upper airway antero-posterior dimensions were observed after the distraction osteogeness process, as demonstrated by the difference between T1 and T0. No significant relapse at T2 was found. Lower airway and the airway at tip of uvula region did not display significant alterations. A significant maxillary advancement and increased antero-posterior upper airway dimension was measured immediately after maxillary distraction with rigid external distraction in non growing cleft patients. The findings were stable three years after distraction. Address correspondence and reprint requests to Alvaro Alfredo Figueroa, DDS, MS, Rush Craniofacial Center 1725 West Harrison Street, Suite 425, Chicago IL 60612, KLS Martin, Jacksonville, FL; E-mail: alvaro_figueroa@rush.edu Received 29 April, 2020 Accepted 14 August, 2020 AAF reports reciept of royalties from KLS Martin; the remaining authors report no conflicts of interest. Supplemental digital content is 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 Website (www.jcraniofacialsurgery.com). © 2020 by Mutaz B. Habal, MD.

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