FIGURE 1. Flow chart of the selection process. BRIEF CLINICAL STUDIES The Risk of Blepharoptosis in Contact Lens Wearers Kun Hwang, MD, PhD � and Joo Ho Kim, MDy Abstract: The aim of this systematic review was to summarize and evaluate the risk of blepharoptosis in contact lens wearers. In a PubMed search, 393 papers were found using the terms ‘‘lens and ptosis.’’ The abstracts were read and 16 full text articles were reviewed. Among them, 5 articles were analyzed. Five studies were subgrouped and a meta-analysis of these data suggested there is an increased risk of blepharoptosis in hard contact lens wearers over nonwearers (n¼ 7426, OR, 17.38, 95% CI¼ 3.71–81.29, P< 0.00001). One study was subgrouped and these data suggested there is also an increased risk of blepharoptosis in soft contact lens wearers over nonwearers (n¼ 90, OR, 8.12, 95% CI¼ 2.68– 24.87, P< 0.0002). Patients wearing rigid contact lenses should be advised of the risk of ptosis, and a history of contact lens use should be sought in all patients who have acquired ptosis as the previous authors have recommended. Key Words: Blepharoptosis, contact lenses, meta-analysis any plastic surgeons think that prolonged contact lens wear M potentially causes acquired ptosis. Although several papers been written, only 1 study attempted to determine the risk of developing blepharoptosis due to wearing hard contact lenses.1 Moreover, no systematic review of this subject is available. The aim of this systematic review was to summarize and evaluate the risk of blepharoptosis in contact lens wearers. METHODS In a PubMed search, 393 papers were found using the terms ‘‘lens and ptosis.’’ Studies that did not allow an evaluation of blephar- optosis due to contact lenses were excluded. The abstracts were read and 16 full text articles were reviewed. Among them, 5 articles were analyzed (Fig. 1).1–5 No restrictions on language and publication forms were imposed. However, the resulting full text papers were mostly in English. All articles were read by 2 independent reviewers who extracted data from the articles. To summarize the effect of contact lens use on blepharoptosis, the data were summarized and the odds ratio (OR) between the contact lens wearers and nonwearers (control group) were calcu- lated. Weighted mean differences (WMD) and 95% confidence intervals (CI) were also calculated. A statistical analysis was performed with Review Manager (The Nordic Cochrane Centre). In case the number of nonwearers was not written in the paper, it was calculated from the percent of the wearers and nonwearers of the general population of the nation reported.6–8 Copyright © 2015 Mutaz B. Habal, MD. Unautho From the *Department of Plastic Surgery, Inha University School of Medicine; and yDepartment of Plastic Surgery, Inha University Hospital, Incheon, Korea. Received September 24, 2014. Accepted for publication April 7, 2015. Address correspondence and reprint requests to Kun Hwang, MD, PhD, Department of Plastic Surgery, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon 400-711, Korea; E-mail: jokerhg@inha.ac.kr The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001876 The Journal of Craniofacial Surgery � Volume 26, Number 5, July RESULTS The 16 potentially relevant full text articles were reviewed, of which 5 articles met our inclusion criteria (Fig. 1).1–5 Effect of Hard Contact Lens Use on Blepharoptosis Five studies were subgrouped and a meta-analysis of these data suggested there is an increased risk of blepharoptosis in hard contact lens wearers over nonwearers (n¼ 7426, OR, 17.38, 95% CI¼ 3.71–81.29, Z¼ 3.63, P¼ 0.00003, heterogeneity: x2¼ 97.77, P< 0.00001, I2¼ 96%) (Table 1, Fig. 2A). Effect of Soft Contact Lens Use on Blepharoptosis One study was subgrouped and these data suggested there is also an increased risk of blepharoptosis in soft contact lens wearers over nonwearers (n¼ 90, OR, 8.12, 95% CI¼ 2.68–24.87, Z¼ 3.70, P< 0.0002) (Table 1, Fig. 2B). DISCUSSION All the studies analyzed were retrospective database studies because no randomized controlled study was available for contact lens use. Kitazawa indicated that there was a significant association between hard contact lenses and blepharoptosis. The history of wearing hard contact lenses was significantly higher in patients (90.2%) versus controls (31.6%). Hard contact lens wearers had a 20 times increased risk of ptosis (odds ratio: 19.9; 95% confidence interval: 6.32–62.9) compared with the nonwearing subjects. In the other 4 papers, the number of nonwearers was not written in the paper, and therefore, the numbers were calculated from the percent of wearers and nonwearers of the general population of the nation reported. The criteria adopted in Kitazawa’s study were based on the definition by Small who defined ptosis as an MRD of 1.5 mm or less since Japanese subjects at this level can exhibit a droopy eye look.9 The criteria used by the other studies included an MRD of less than 2.8 or 2.5 mm.4,10 The mechanism as causation for the blepharoptosis in contact lens wearers has been postulated by Bosch: first, simultaneous, antagonistic action of the orbicularis, and levator muscle while squeezing the eyelids to remove the lens, second, forceful rubbing of the lens and subsequent stretching of upper eyelid structures during failed attempts at lens removal, third, repeated and similar although less forceful rubbing of the lens during blinking, fourth, irritation, leading to edema, and fifth, irritation leading to blephar- ospasms.10 To date, most authors have agreed with the aponeuro- genic etiology that chronic manipulation of the upper lid during rized reproduction of this article is prohibited. 2015 e373 mailto:jokerhg@inha.ac.kr http://dx.doi.org/10.1097/SCS.0000000000001876 TABLE 1. Summary of Retrospective Database Studies Included Author (Year) Total Group Size (n¼ eyelids) Ptosis Without Ptosis Results (OR [CI])Intervention Group (n) Control Group (n) Intervention Group (n) Control Group (n) Hard Lens Kersten 1995 3652 61 96 25 3470 88.20 [53.08, 146.53] Thean 2003 1054 19 398 11 626 2.72 [ 1.28, 5.77] Bleyen 2011 316 31 12 9 264 75.78 [29.57, 194.18] de Silva 2011 2544 31 792 15 1706 4.45 [ 2.39, 8.29] Kitazawa 2013 178 92 10 24 52 19.93 [ 8.85, 44.91] Soft Lens Bleyen 2011 108 10 12 8 78 8.12 [ 2.68, 24.67] CI, confidence interval; OR, odds ratio. FIGURE 2. Meta-analysis of the effect of contact lens wearing on blepharoptosis. A, hard contact lens, B, soft contact lens. From the �Private practice in oral implantology, Eduardo Anitua Foundation; and yClinical Researcher, Eduardo Anitua Foundation, Vitoria, Spain. Received February 4, 2015. Accepted for publication March 1, 2015. Address correspondence and reprint requests to Dr. Eduardo Anitua, Eduardo Anitua Foundation; C/ Jose Maria Cagigal 19, 01007 Vitoria, Spain. E-mail: eduardoanitua@eduardoanitua.com E.A. is the Scientific Director of BTI Biotechnology Institute, Vitoria, Spain. He is the head of the Foundation Eduardo Anitua, Vitoria. A.M.-F. M.H.A. is a scientist at BTI Biotechnology Institute, Vitoria. The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001839 Brief Clinical Studies The Journal of Craniofacial Surgery � Volume 26, Number 5, July 2015 rigid lens removal is responsible for inducing an aponeurotic disinsertion.10–12 Recently, Bleyen suggested that not only hard contact lens use but also soft contact lens use may be associated with ptosis. He insisted that the prolonged use of hard contact lenses most likely carries a higher risk than that for soft contact lenses for developing this disorder.5 He recommend advising patients with blepharoptosis and contact lens users to discontinue contact lens use for 3 months and if the ptosis does not resolve, ptosis surgery can be planned. Our meta-analysis implies that hard contact lens wearers (OR, 17.38) or a soft contact lens wearers (OR, 8.12) have an increased risk of blepharoptosis than nonwearers. Patients wearing rigid contact lenses should be advised of the risk of ptosis, and the history of contact lens use should be sought in all patients with acquired ptosis as previous authors have recom- mended.2,3 ACKNOWLEDGMENT This work was supported by a grant from INHA University (INHA- Research Grant). REFERENCES 1. Kitazawa T. Hard contact lens wear and the risk of acquired blepharoptosis: a case-control study. Eplasty 2013;13:e30 2. Kersten RC, de Conciliis C, Kulwin DR. Acquired ptosis in the young and middle-aged adult population. Ophthalmology 1995;102: 924–928 3. Thean JH, McNab AA. Blepharoptosis in RGP and PMMA hard contact lens wearers. Clin Exp Optom 2004;87:11–14 4. de Silva DJ, Collin JR. Outcome following surgery for contact lens-induced ptosis. Ophthal Plast Reconstr Surg 2011;27:186–189 5. Bleyen I, Hiemstra CA, Devogelaere T, et al. Not only hard contact lens wear but also soft contact lens wear may be associated with blepharoptosis. Can J Ophthalmol 2011;46:333–336 6. Edwards K, Keay L, Naduvilath T, et al. A population survey of the penetrance of contact lens wear in Australia: rationale, methodology and results. Ophthalmic Epidemiol 2009;16:275–280 Copyright © 2015 Mutaz B. Habal, MD. Unautho e374 7. Nichols J. Contact Lenses 2008. Contact Lens Spectrum 2009; 1:24. Available at: http://www.clspectrum.com/article.aspx?article=102473. Accessed on: November 1, 2011 8. British Contact Lens Association. ACLM market report 2013: technical summary. Available at: https://www.bcla.org.uk/topics/aclm-releases- 2013-contact-lens-market-report. Accessed on: September 1, 2014 9. Small RG, Sabates NR, Burrows D. The measurement and definition of ptosis. Ophthalmic Plast Reconstr Surg 1989;5:171–175 10. van den Bosch WA, Lemij HG. Blepharoptosis induced by prolonged hard contact lens wear. Ophthalmology 1992;99:1759–1765 11. Epstein G, Putterman AM. Acquired blepharoptosis secondary to contact-lens wear. Am J Ophthalmol 1981;91:634–639 12. Frueh BR. The mechanistic classification of ptosis. Ophthalmology 1980;87:1019–1021 Implant Site Under-Preparation to Compensate the Remodeling of an Autologous Bone Block Graft Eduardo Anitua, DDS, MD,�y Alia Murias-Freijo, DDS,�y and Mohammad Hamdan Alkhraisat, DDS, PhDy Abstract: Autologous bone block grafting is an efficient technique to thicken an atrophied residual alveolar ridge. A variable degree of resorption, however, occurs due to graft remodeling. In this study, we hypothesize that under-preparation of implant socket would permit the dental implant to act as a bone expansor and thus compensate for the contraction in the augmented ridge width. rized reproduction of this article is prohibited. # 2015 Mutaz B. Habal, MD http://www.clspectrum.com/article.aspx?article=102473 https://www.bcla.org.uk/topics/aclm-releases-2013-contact-lens-market-report https://www.bcla.org.uk/topics/aclm-releases-2013-contact-lens-market-report mailto:eduardoanitua@eduardoanitua.com http://dx.doi.org/10.1097/SCS.0000000000001936 The Journal of Craniofacial Surgery � Volume 26, Number 5, July 2015 Brief Clinical Studies For that reason, 10 patients received an autologous bone block graft that was obtained from the ramus of the mandible. Residual alveolar ridge width was measured on CBCT scans obtained before surgery (T0), after 2 months of healing (T1), after 4 months of healing just before implant placement (T2), and after 4 months of implant placement (T3). The thickness of the alveolar ridge was initially increased from 2.5� 1.4 to 6.1� 2.0 mm. Before implant insertion, this width was decreased to 5.6� 2.1 mm. The last measurement after implant insertion indicated an increase to 7.3� 1.8 mm. In comparison to the measurements at T1, a loss of about 0.5 mm of the augmented width occurred. But, this loss was compensated by an increment of 1.2 mm at T3 (after implant insertion) if related to the measurement at T1. Neither gingival dehiscence nor block exposure was observed. Within the limitations of this study, under-prep- aration of implant socket could make the ridge expansion possible during implant insertion and thus to compensate the remodeling of autologous bone block graft. Key Words: Autologous, block graft, bone graft, remodeling, ridge augmentation xcessive mechanical load has been attributed to the likelihood of E prosthetic complications such as abutment screw loosening/ fracture, porcelain chipping, prosthesis fracture/failure, and crestal bone loss.1 Improper implant positioning is one of the main factors that would result in excessive mechanical load because it compli- cates the prosthetic restoration.2 For that reason, prosthetic-driven implant positioning has been established to minimize such a pro- blem.3 In an atrophied alveolar crest, ridge bone augmentation is necessary to correctly position the implant. Bone block grafts are one of these procedures that are indicated when severe bone atrophy is present.4 This reconstructive tool includes the harvesting of a bone block from a donor site and fixing the graft by screws at a recipient site. The main intraoral donor sites are the symphysis and the ramus of the mandible. The easy access and the possibility of obtaining bone blocks without debilitating the mandible makes the symphysis a suitable donor area.5–7 Donor site morbidity, although very much lower than extra-oral sites, was reported to include pain, functional limitations, swelling, and altered sensation in the mental and lower lip area.8 Temporary paresthesia after chin graft harvesting surgery ranged from 10% to 50%8,9 and in 1 study impaired nerve function was considered permanent in 15 out of 22 patients who suffered altered sensation.8 The ramus of the mandible is another target that allows easier surgery10 and the possibility of obtaining bone blocks of sufficient dimensions to rehabilitate vertical and horizontal alveolar bone loss.10 This donor site showed lesser postoperative complications than the symphysis area.7,8 Patients could, however, suffer from swelling, and difficulty during mouth opening and chewing. Altered sensation was lower (ranged from 0% to 5%) and usually it was not persistent when compared with the symphysis.8,9 This study was conducted to test the hypothesis that implant insertion could serve to further expand the horizontal ridge aug- mentation and thus compensate for volume changes due to auto- logous graft remodeling. Patients in need of horizontal ridge augmentation were recruited. Bone surgery was performed to obtain a bone block graft from the ramus of the mandible. Alveolar ridge width was measured on CBCT scans obtained before surgery, before implant insertion and after implant insertion. Copyright © 2015 Mutaz B. Habal, MD. Unautho # 2015 Mutaz B. Habal, MD METHODS This article was written following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines11 and included patients treated at private dental clinic in Vitoria, Spain. Patients included in the study fulfilled the following criteria: both sexes, patients with horizontal ridge atrophy that impair implant placement, and bone augmentation by an autologous bone graft. The exclusion criteria were the no insertion of dental implants at the augmented site, and ASA III–IV. A retrospective cohort study design was used. Ten patients received a bone block graft in maxilla and mandible were included and evaluated. Outcome Criteria To challenge the hypothesis of the study, demographic and anamnesis data were obtained from patients’ records. For residual alveolar ridge width, CBCT scans were imported to a visualizing software (BTI scan IV, BTI Biotechnology Institute, Vitoria, Spain). The CBCT scans were visualized in a sagittal section and ridge width was measured at a distance of 3–5 mm from the ridge crest. An anatomical landmark was identified for each scan. Measure- ments on the 3 CBCT scans were performed at the same distance from an anatomical landmark. CBCT scans were obtained using a Sirona GALILEOS 3D scanner (Sirona, Bensheim, Hesse, Germany) using the standardized positioning protocol (the occlusal plane parallel to the ground and the midsagittal plane perpendicular to the ground) and an irradiation protocol of 42 mAs and 80 kV. The scans were obtained before surgery (T1), after horizontal bone augmentation (T2), just before implant insertion (T3) and at several months after implant insertion (T4). Early implant failure was evaluated by considering as failure any implant lost due to failure to achieve osseointegration, as indicated by implant mobility, radiolucency around the implant, pain, and/or supporation. Surgical Procedures Plasma rich in growth factors (PRGF-Endoret) was prepared from citrated whole blood according to the instructions of the manufacturer (BTI Biotechnology Institute). Under local anesthesia, a full-thickness flap was reflected to expose the alveolar crest and to evaluate the amount the graft needed to be harvested. Then, a mucoperiosteal flap was reflected to expose the ramus of the mandible and a bone block was harvested by piezoelectric surgery (BTI-ultrasonic)12 and copious irrigation. The removed bone block was stored in fraction 2 of PRGF-Endoret to increase cell survival and maintain the hydration of the bone.13 The Onlay graft was screw-fixed at the recipient site. The space between the Onlay graft and the alveolar process was filled with autologous bone particulate mixed with fraction 2 of PRGF-Endoret. Otherwise, a PRGF- Endoret clot prepared from fraction 2 (F2) was used as the sole filling material. PRGF membrane prepared from fraction 1 (F1) was then placed to cover the surgical site before flap closure with monofilament 5/0 suture. If tension was observed upon flap closure a periosteal relieving incision was practised to achieve tension-free flap suturing. After several months of healing, the implant site was prepared by bone drilling at low velocity (150 rpm) without irrigation and the diameter of the last drill was inferior to the diameter of the implant to be placed. The implant was then inserted with a surgical motor at an insertion torque of 25 N cm and then continued manually to finish the implant placement. rized reproduction of this article is prohibited. e375 FIGURE 1. Changes in the thickness of the residual alveolar ridge. T0: preoperatice thickness, T1: thickness after 2 months of surgery, T2: thickness just before implant placement, and T3: after 4 months of implant placement. Brief Clinical Studies The Journal of Craniofacial Surgery � Volume 26, Number 5, July 2015 Statistical Analysis Descriptive statistics were performed when necessary con- sidering the implant and the patient as a unit of analysis. Absolute and relative frequency distributions were calculated for qualita- tive variables and mean values and standard deviations for quantitative variables. SPSS v15.0 for Windows statistical soft- ware package (SPSS Inc, Chicago, IL) was used for the statistical analysis. RESULTS Ten patients participated in this study of whom 8 were women. The patients’ mean age was 58� 16 years (range: 24–74 years). Bone ridge augmentation was performed in the maxillary anterior region (7 patients), maxillary premolar region (2 patients), and mandibular premolar region (1 patient) (Fig. 1). No graft exposure was observed during the healing period. The basal residual width was 2.5� 1.4 mm (range: 0.5– 4.10 mm). The augmented ridge width at T1 (2.5� 2.8 months since surgery) was 6.1� 2.0 mm (range: 2.9–9.9 mm) (Fig. 2). This width was 5.6� 2.1 mm (range: 2.7– 8.4 mm) at T2 (4.0� 1.1 months since surgery). Dental implants were inserted in the augmented bone after 4.5� 1.2 months (range: 3–6 months) of surgery. The width of the augmented ridge was then measured after 4.2� 1.2 months (range: 2–5 months) since implant insertion (T3). The last width was 7.3� 1.8 mm (range: 5.1– 9.1 mm). The time between the surgery and the last measurement was 8.7� 1.5 months (range: 7–11 months). In comparison to the measurements at T1, a loss of about 0.5 mm of the augmented width occurred (Figs. 1 and 2). But, this loss was compensated by an increment of 1.2 mm at T3 (after implant insertion) if related to the measurement at T1 (Fig. 2). DISCUSSION The outcomes of this study confirm the efficiency of autologous bone block graft in horizontal ridge augmentation. Contraction in Copyright © 2015 Mutaz B. Habal, MD. Unautho FIGURE 2. The thickness of the residual alveolar ridge measured on CBCT scans obtained before surgery (A), after surgery (B), before implant placement (C) and after implant placement (D). e376 the augmented ridge, however, occurred during the healing process due to graft remodeling. Interestingly, the action of dental implant insertion into the augmented bone compensated the loss and caused a further increment in the width of the residual alveolar ridge. The autologous bone block from the ramus of the mandible was efficient to thicken the residual alveolar ridge by approximately 4 mm. Volume changes due to graft remodeling are, however, one of the disadvantages of bone block grafts.5,14 Graft remodeling could be influenced by the embryonic origin of the harvested bone. Intramembranous bone graft seems to maintain its volume, whereas endochondral bone graft undergoes variable degrees of resorption over a variable period of time.9,15,16 In an analysis based on a cone beam computerized scan (CBCT) obtained after 10 and 180 days after graft placement, a mean graft resorption of 18.38% was reported.17 In another study, the contraction in the horizontal bone augmentation with a bone block from the ramus of the mandible was from 4.6� 0.73 to 4.0� 0.77 mm.18 In one meta-analysis of the volume changes after maxillary sinus augmentation, the weighted mean average resorption was 48� 23% when calculated for con- trolled studies and a wide variation in graft resorption was observed between individuals.19 These data would indicate the importance of taking measures to compensate for the loss in graft volume. Overaugmentation and the use of bone substitutes could be a useful tool for compensating graft remodeling.19 In this study, we have tested the effect of implant insertion at the augmented bone to compensate for the loss in the augmented ridge width. For that reason, under-preparation of the implant socket was performed so that the dental implant, when inserted into the bone socket, could act as a bone expansor. The last measurement of the alveolar ridge width indicated an increase of 1.2 mm when com- pared with the width after the placement of an autologous bone block graft. This outcome indicates the possibility of ridge expan- sion by implant insertion to compensate the dimensional loss in horizontal ridge augmentation. The thickness of the alveolar ridge was measured on CBCT scans obtained at different time points. Different studies have documented that linear measurements on cone-beam CT scan are accurate and reproducible.20,21 One of the complications of bone ridge augmentation is graft exposure. The use of fibrin membrane has been efficient to prevent graft/implant exposure and to avoid undesirable outcomes.22 Plasma rich in growth factors employs fibrin scaffold and endogen- ous growth factors that orchestrate tissue healing to promote adequate tissue regeneration and to reduce tissue inflammation.23,24 This study is limited by its retrospective design, sample size, and the absence of a control group. As for any retrospective study, there is a dependence on the availability and accuracy of medical/dental records and it is difficult to control bias and confounders. There is no randomisation nor blinding. This study is uncontrolled that put restrictions on the extrapolation of the results of this study. The outcomes, however, justify the performance of further studies with a larger sample size to establish sound conclusions about the efficacy of dental implant insertion to compensate the graft remo- deling. REFERENCES 1. Anitua E, Alkhraist MH, Pinas L, et al. Implant survival and crestal bone loss around extra-short implants supporting a fixed denture: the effect of crown height space, crown-to-implant ratio, and offset placement of the prosthesis. Int J Oral Maxillofac Implants 2014;29:682–689 2. Brunski JB. Biomechanical factors affecting the bone-dental implant interface. Clin Mater 1992;10:153–201 rized reproduction of this article is prohibited. # 2015 Mutaz B. Habal, MD From the �Department of Plastic and Reconstructive Surgery, Kinki University Faculty of Medicine, Osaka-sayam, Osaka; and yDepartment of Ophthalmology, Aichi Medical University, Nagakute, Aichi, Japan. Received February 5, 2015. Accepted for publication March 1, 2015. Address correspondence and reprint requests to Shinichi Asamura, Depart- ment of Plastic and Reconstructive Surgery, Kinki University Faculty of Medicine, 377-2 Ohno-higashi, Osaka-sayama, Osaka 5898511, Japan. E-mail: asamura@med.kindai.ac.jp The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001840 The Journal of Craniofacial Surgery � Volume 26, Number 5, July 2015 Brief Clinical Studies 3. Nevins M, Mellonig JT. The advantages of localized ridge augmentation prior to implant placement: a staged event. Int J Periodontics Restorative Dent 1994;14:96–111 4. Anitua E, Alkhraisat MH, Miguel-Sanchez A, et al. Surgical correction of horizontal bone defect using the lateral maxillary wall: outcomes of a retrospective study. J Oral Maxillofac Surg 2014;72:683–693 5. Koole R, Bosker H, van der Dussen FN. Late secondary autogenous bone grafting in cleft patients comparing mandibular (ectomesenchymal) and iliac crest (mesenchymal) grafts. J Craniomaxillofac Surg 1989;17(Suppl 1):28–30 6. Misch CM, Misch CE. The repair of localized severe ridge defects for implant placement using mandibular bone grafts. Implant Dent 1995;4:261–267 7. Raghoebar GM, Meijndert L, Kalk WW, et al. Morbidity of mandibular bone harvesting: a comparative study. Int J Oral Maxillofac Implants 2007;22:359–365 8. Clavero J, Lundgren S. Ramus or chin grafts for maxillary sinus inlay and local onlay augmentation: comparison of donor site morbidity and complications. Clin Implant Dent Relat Res 2003;5: 154–160 9. Brugnami F, Caiazzo A, Leone C. Local intraoral autologous bone harvesting for dental implant treatment: alternative sources and criteria of choice. Keio J Med 2009;58:24–28 10. Wood RM, Moore DL. Grafting of the maxillary sinus with intraorally harvested autogenous bone prior to implant placement. Int J Oral Maxillofac Implants 1988;3:209–214 11. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 2007;370:1453–1457 12. Anitua E. Implant Surgery and Prosthesis: A New Perspective Vitoria: Puesat al dia puplicaciones; 1996 13. Anitua E, Prado R, Orive G. Bilateral sinus elevation evaluating plasma rich in growth factors technology: a report of five cases. Clin Implant Dent Relat Res 2012;14:51–60 14. Kusiak JF, Zins JE, Whitaker LA. The early revascularization of membranous bone. Plast Reconstr Surg 1985;76:510–516 15. Breine U, Branemark PI. Reconstruction of alveolar jaw bone. An experimental and clinical study of immediate and preformed autologous bone grafts in combination with osseointegrated implants. Scand J Plast Reconstr Surg 1980;14:23–48 16. Zins JE, Whitaker LA. Membranous versus endochondral bone: implications for craniofacial reconstruction. Plast Reconstr Surg 1983;72:778–785 17. Alerico FA, Bernardes SR, Fontao FN, et al. Prospective tomographic evaluation of autogenous bone resorption harvested from mandibular ramus in atrophic maxilla. J Craniofac Surg 2014;25:e543–e546 18. Acocella A, Bertolai R, Colafranceschi M, et al. Clinical, histological and histomorphometric evaluation of the healing of mandibular ramus bone block grafts for alveolar ridge augmentation before implant placement. J Craniomaxillofac Surg 2010;38:222–230 19. Shanbhag S, Shanbhag V, Stavropoulos A. Volume changes of maxillary sinus augmentations over time: a systematic review. Int J Oral Maxillofac Implants 2014;29:881–892 20. Tchorz JP, Poxleitner PJ, Stampf S, et al. The use of cone beam computed tomography to predetermine root canal lengths in molar teeth: a comparison between two-dimensional and three-dimensional measurements. Clin Oral Investig 2014;18:1129–1133 21. Kosalagood P, Silkosessak OC, Pittayapat P, et al. Linear measurement accuracy of eight cone beam computed tomography scanners. Clin Implant Dent Relat Res 2014;doi: 10.1111/cid.12221 22. Torres J, Tamimi F, Alkhraisat MH, et al. Platelet-rich plasma may prevent titanium-mesh exposure in alveolar ridge augmentation with anorganic bovine bone. J Clin Periodontol 2010;37:943–951 23. Anitua E, Alkhraisat MH, Orive G. Perspectives and challenges in regenerative medicine using plasma rich in growth factors. J Control Release 2012;157:29–38 24. Anitua E, Sanchez M, Orive G. Potential of endogenous regenerative technology for in situ regenerative medicine. Adv Drug Deliv Rev 2010;62:741–752 Copyright © 2015 Mutaz B. Habal, MD. Unautho # 2015 Mutaz B. Habal, MD What Is the Best Way to Handle the Involutional Blepharoptosis Repair? Yoshitaka Wada, MD, PhD,� Takahiro Hashimoto, MD,� Hirohiko Kakizaki, MD, PhD,y Noritaka Isogai, MD, PhD,� and Shinichi Asamura, MD, PhD� Abstract: There are many different operations to correct involu- tional blepharoptosis (IB); however, the outcome of the corrective surgery is rather unpredictable, regardless of the procedure employed. A reasonably predictable outcome can be achieved with careful intraoperative evaluation of the condition, with measuring of the margin reflex distance-1 (MRD-1) in supine position of the patients. With these prepositions, we collected data that indicated that our approach can achieve a predictable outcome. This was a prospective study of 21 consecutive patients (8 men and 13 women) involving 42 eyelids with IB. IB was defined as an MRD-1 of<2 mm. All 21 patients were informed of the purposes of the study, and underwent levator aponeurosis advancement. The MRD-1 was measured intraoperatively with the patients in a supine position and in the 3-month postoperative inspection with the patients in a sitting position. Statistical analyses using paired t-tests were performed. From intraoperative measurement, mean MRD-1 values were 4.31 mm on the right side (range 3.0–4.5) and 4.29 mm on the left side (range 3.5–5.0). Three months after the operations, mean MRD-1 values were 3.07 mm on the right side (range 1.5–4.0) and 3.07 mm on the left side (range 2.0–4.0). Compared with the intraoperative MRD-1 measurements, those of the postoperatives were significantly 1.2 mm reduced (right: P< 0.01, left: P< 0.01). The intraoperative measurement of MRD-1 without changing position of patients could result in successful outcome of the oper- ation. Key Words: Dry eye, involutional blepharoptosis, levator aponeurosis advancement, the margin reflex distance-1, visual field nvolutional blepharoptosis (IB) is a common complaint among I the elderly population seeking plastic surgery. The definition of the IB is an excessively low-lying upper eyelid margin that can interfere with the visual field.1 IB repair to obtain adequate visual field by levator aponeurosis advancement is successful in most rized reproduction of this article is prohibited. e377 mailto:asamura@med.kindai.ac.jp http://dx.doi.org/10.1097/SCS.0000000000001936 Brief Clinical Studies The Journal of Craniofacial Surgery � Volume 26, Number 5, July 2015 instances; however, the postoperative eyelid height is not uniformly predictable.2–7 The main factor in this unpredictable correction seems to be dependent upon insufficient intraoperative evaluation. If we can accurately predict postoperative eyelid height using measurement obtained during surgery, we could achieve an increase in the rate of steady outcomes. Several reports have examined the relationship between the measurements of pre- and postoperative eyelid height.5–11 Most surgeons recommended measuring eyelid height while patients are in the sitting position during surgery.6–8,11,12 Conversely, some surgeons prefer to avoid the sitting position during surgery mainly because it is extremely difficult to maintain a sterile operative field as patients tend to shift about when transitioning to a sitting posture, leading to possible compromise of the sterile field and a consequent increase in the risk of bacterial exposure. We examined intraoperative eyelid heights using the margin reflex distance-1 (MRD-1)13 to investigate relationships between measurements of pre- and postoperative eyelid heights. Therefore, the establishment of MRD-1 results from our study can lead to the successful correction of the IB without changing patient’s position from supine to upright position. PATIENTS AND METHODS This was a prospective study of 21 consecutive patients (8 men and 13 women) involving 42 eyelids with IB. IB was defined as an MRD-1 of<2 mm. The age range of patients was 70–94 years, with a mean age of 77 years. All 21 patients were informed of the purposes of the study, and underwent external levator superioris aponeurosis advancement.7,14 Local anesthesia was given using 1% lidocaine, 2 mL, with 1/100,000 epinephrine. The upper eyelid skin was incised for about 40 mm along the wrinkle line approximately 5 to 6 mm from the eyelid margin, and then the redundant skin, including orbi- cularis oculi muscle, was excised. The subcutaneous skin tissues and orbicularis oculi muscle were dissected, and then the edges of the external levator superioris aponeurosis and superior tarsus were identified. Orbital septum and preaponeurotic fat were dissected from the aponeurosis and retracted superiorly. The aponeurosis was detached from the tarsus, and the aponeurosis was separated from the Müller muscle. The aponeurosis was almost completely freed from their neighboring tissue. Then, the aponeurosis was advanced and fixed firmly at about half the height of the tarsus with a single 6–0 nylon horizontal mattress suture. In addition, the center of the aponeurosis was fixed on the slightly medial site of the fissure, that is, just over the pupil during eyelid opening. If adjusted undercorrection or over- correction occurred, advancement was adjusted until an adequate eyelid height was obtained. Thereafter, 2 other sutures were added to obtain a natural curve of the eyelid. The intraoperative measurement was performed before skin closure, and amount of advancement was adjusted until adequate eyelid height, which was set to 3.5 to 5.0 mm of MRD-1, was achieved (Fig. 1). After Copyright © 2015 Mutaz B. Habal, MD. Unautho FIGURE 1. The intraoperative measurement was performed before skin closure, and amount of advancement was adjusted until adequate eyelid height, which was set to 5.0 mm of MRD-1, was achieved. MRD-1¼margin reflex distance-1. e378 establishing intraoperative MRD-1 with a central suture, another two 6–0 nylon sutures were added to fix the aponeurosis tightly to the tarsus. Fixation for a double fold was made, and the skin was closed 6–0 nylon interrupted sutures. The MRD-1, which represents the distance from the central papillary light reflex to the upper eyelid margin, was measured intraoperatively with the patients in a supine position and in the 3-month postoperative inspection with the patients in a sitting position. Statistical analyses using paired t-tests were performed to compare values of intraoperative measurement in the supine positions and values in the postoperative 3 months on the right and left sides, respectively. All operations and MRD-1 measurements were performed by a single surgeon (S.A.). RESULTS From intraoperative measurement, mean MRD-1 values were 4.31 mm on the right side (range 3.0–4.5) and 4.29 mm on the left side (range 3.5–5.0). Three months after the operations, mean MRD- 1 values were 3.07 mm on the right side (range 1.5–4.0) and 3.07 mm on the left side (range 2.0–4.0) in Table 1. Compared with the intraoperative MRD-1 measurements, those of the postoperatives were significantly 1.2 mm reduced (right: P< 0.01, left: P< 0.01). In terms of visual field, each patient was requested to answer the question, A–D, assessing the results of the procedure: A) excellent improved, B) moderately improved, C) slightly improved, D) same as before the operation. The survey result was as follows: A) 10 patients (47%), B) 7 patients (33%), C) 2 patients (10%), D) 2 patients (10%). For both the patients of Class C, technically it was almost impossible to establish the intraoperative MRD-1 to be 4.5 mm. The 2 patients who were classified to be Class D, and diagnosed to have astigmatism, much improved their visual field after changing the eyeglasses. Preoperative diagnosis performed by an ophthalomogist identified 8 patients with dry eyes, only 1 of which continuing to complain of dacryorrhea postoperatively; this was adequately resolved with simple eye drop treatment. Preoperatively, 2 patients complained of persistent headache, which was much improved after the operation. Likewise, in the 5 patients complaining of stiff shoulders, all patients noticed marked improved postoperatively. DISCUSSION Throughout the operation, the patients with IB remained in the supine position and precise measurement of the MRD was done in this position. The postoperative MRD-1 was measured with the patient in the sitting position and the postoperative MRD-1 measurement is on average 1.2 mm less than the MRD-1 measured intraoperatively. Provided that the intraoperative measurement of the MRD-1 is 4.5 mm before suturing of the skin is completed, our approach proved to be effective in not only improving visual field, but also preventing ocular surface complications. The etiology of IB may be multifactorial, and the histopatho- logical findings show significantly excessive fatty tissue both of the levator palpebrae superioris aponeurosis and levator muscle that are observed at the time of corrective surgery.15–21 Further- more, it may be implicated as an etiological factor. Regardless of the operation used for this condition, some failures must be expected rized reproduction of this article is prohibited. TABLE 1. Pre-, Intra-, and Postoperative MRD-1. Compared with the Intra- operative MRD-1 Measurements, Those of the Postoperatives Were Significantly 1.2 mm Reduced Pre Intra Post R (range, mm) 0.71 (-1.0–2.0) 4.31 (3.0–4.5) 3.07 (1.5–4.0) L (range, mm) 0.93 (-1.0–2.0) 4.29 (3.5–5.0) 3.07 (2.0–4.0) # 2015 Mutaz B. Habal, MD FIGURE 2. A, The preoperative view. B, The postoperative view. If MRD-1 is greater than 4.5 mm, it is not uncommon that their grandchildren frequently complain that the grandparent’s facial feature is quite odd, given the faces of the older generation have wrinkled, except the appearance of their eyes being much younger. MRD-1¼margin reflex distance-1. FIGURE 3. A, The preoperative view. B, The postoperative view. If MRD-1 is greater than 2.5 mm, there is no visual disturbance for routine daily living. MRD- 1¼margin reflex distance-1. The Journal of Craniofacial Surgery � Volume 26, Number 5, July 2015 Brief Clinical Studies simply because the etiology is unknown at present. Ninety patients had MRD-1 intraoperative measurement greater than 4.5 mm; how- ever, 2 patients had less than 4.5 mm MRD-1 in this study. There are 3 main approaches to correct IB: the first is targeted on the external levator superioris aponeurosis, the second on Müller muscle, and the third involving both.1–12 If the procedure is targeted on the Müller muscle, the lidocaine with epinephrine, which stimulates sympathetic nerves in the Müller muscle, is constricted with epinephrine so that the eyelid height decreases.9,22,23 When the effect of the local anesthetic, however, fades away postoperatively, the upper eyelid droops and eyelid height are expected to increase. There may be possible overcorrection of IB, provided that this theory is correct. With the hypothesis, our choice of the IB surgery is mainly focused on the external levator superioris aponeurosis. The results of surgical repair for IB were greatly improved over the years following the popularization of the technique of external levator superioris aponeurosis repair using local anesthesia by Jones et al.2 Many surgeons deliberately overcorrect the ptotic eyelid by approximately 1 mm, expecting a modest decrease in eyelid height postoperatively with the resolution of the local anesthetic-induced paralysis of the orbicularis muscle and other associated muscles.22 Nevertheless, infallible prediction of the final eyelid position remains an elusive goal. MRD-1 needs to be considered in supine position during intrao- perative measurement to obtain the desired postoperative eyelid height. Several years ago, the first author elected not to change the patient’s position during IB repair, because not only it is cumber- some for some elderly patients, but also it seemed not to affect the final outcome. Swelling and weights of the anterior lamella of the eyelids may interfere with intraoperative MRD-1 measurement. After suturing the skin, as the MRD-1 is affected by swelling and weight of the anterior lamella, the operating surgeon must recognize the difference in MRD between standing and supine positions.12,23 The swollen eyelids disappeared almost completely within 3 months, at which time we could ignore weight from the anterior lamella.11,24 The MRD-1 measurement should be done when the effects of the surgery have subsided at least 3 months after the surgery. The common pitfall of surgical intervention is postoperative dry eye, irrespective of the choice of the surgical method. An excessive advancement of levator aponeurosis frequently leads to an eyelid– eyeball dissociation.24 The upper eyelid must move toward the lower corneal limbus going over the top of the corneal convex during eyelid closure, the upper eyelid with downward inclination toward the lower corneal limbus, and finally the upper and lower eyelids are approximated together. In normal physiological closure of the upper eyelid, after it reaches the apex of the eyeball, it moves backward along the curvature of the eyeball and maintains close contact between the 2 structures. Less careful attention is paid to dry eye symptomatology as an operator. Any surgeon dealing with IB must pay attention to this common complication when the surgical intervention is contemplating IB.8,24,25 Cosmetically, Japanese surgeons tend to be more interested in making larger eyes. In other words, the postoperative MRD-1 is more likely to be greater than 5 mm.26 To accomplish this MRD-1 for the older generation with IB, it is not uncommon that their grandchildren frequently complain that the grandparent’s facial feature is quite odd, given the faces of the older generation have wrinkled except the appearance of their eyes being much younger (Fig. 2). If MRD-1 is greater than 2.5 mm, there is no visual disturbance for routine daily living.27 Among Japanese adults, the fissure height is 8.8 mm for men and is 8.2 mm for female, and in the senior population, it is 7.9 and 6.7 mm, respectively.28 MRD-1 3 mm seems to be adequate for patients with IB (Fig. 3). There are 2 common ways to evaluate IB; 1 is the levator function (LF) to judge the proper amount of fissure height in eyelid Copyright © 2015 Mutaz B. Habal, MD. Unautho # 2015 Mutaz B. Habal, MD opening, and the other is assessing the MRD-1. In general, an LF more than 5 mm is an indication for levator advancement.29,30 If less than 5 mm, alternative surgical methods must be used. In this study, IB is defined to satisfy 3 criteria: the MRD-1 is less than 2 mm, the LF is greater than 5 mm, and the age is older than 70. Proportional to the increase of the aging population in developed countries, the incidence of IB is dramatically increasing. Also, the elderly population tends to have a reduced amount of lacrimal fluid and dysfunction of the Meibaum glands, incidentally increasing the risk of dry eyes. In terms of maintenance of the normal ocular surface condition, it may be a reasonable assumption that patients with IB can be a natural compensatory phenomenon to prevent the dry eye. The goal of IB treatment is not only the improvement of the visual field, but also the maintenance of the appropriate conditions of the ocular surface. REFERENCES 1. Chang S, Lehrman C, Itani K, et al. A systematic review of comparison of upper eyelid involutional ptosis repair techniques: efficacy and complication. Plast Reconstr Surg 2012;129:149–157 2. Jones LT, Quickert MH, Wobig JL. The cure of ptosis by aponeurotic repair. Arch Ophthalmol 1975;93:629–634 3. Older JJ. Levator aponeurosis surgery for the correction of acquired ptosis: analysis of 113 procedures. Ophthalmology 1983;90: 1056–1059 4. Berris CE. Adjustable sutures for correction of adult-acquired ptosis. Ophthal Plast Reconstr Surg 1988;4:171–173 5. Liu D. Ptosis repair by single suture aponeurotic tuck: surgical technique and longterm results. Ophthalmology 1993;100: 251–259 6. Anderson RL, Dixon RS. Aponeurosis ptosis surgery. Arch Ophthalmol 1979;97:1123–1128 7. McCuuley TJ, Kersten RC, Kulwin DR, et al. Outcome and influencing factors of external levatorpalpebraesuperioris aponeurosis advancement for blepharoptosis. Opthtal Plastic Reconstr Surg 2003;19:388–393 8. Tucker SM, Verhulst SJ. Stabilization of eyelid height after aponeurotic ptosis repair. Ophthalmology 1999;106:517–522 9. Bartley GB, Lowry JC, Hodge DO. Results of levator-advancement blepharoptosis repair using a standard protocol: effect of epinephrine- induced eyelid position change. Trans Am Ophthalmol Soc 1996;94:165–173 10. Berlin AJ, Vestal KP. Levator aponeurosis surgery. A retrospective review. Ophthalmology 1989;96:1033–1037 11. Linberg JV, Vasquez RJ, Chao G. Aponeurotic ptosis repairunder local anesthesia. Ophthalmology 1988;95:1046–1052 12. Takahashi Y, Kakizaki H, Mito H, et al. Value of intraoperative eyelid height measurement in sitting and supine positions during blepharoptosis repair. Opthtal Plastic Reconstr Surg 2007;2:119–121 13. Karesh JW. Diagnosis and management of acquired blepharoptosis and dermatochalasis. Facial Plast Surg 1994;10:185–201 14. Sarver BL, Putterman AM. Margin limbal distance to determine amount of levator resection. Arch Ophthalmol 1985;103:354–356 rized reproduction of this article is prohibited. e379 Brief Clinical Studies The Journal of Craniofacial Surgery � Volume 26, Number 5, July 2015 15. Shirado M. Dyslipidaemia and age-related involutional blepharoptosis. J Plastic Reconstr Aethentic Surg 2012;65:e146–e150 16. Sanke RF. Relationship of senile ptosis to age. Ann Ophthalmol 1984;16:928–931 17. Shore JW, McCord CD Jr. Anatomic changes in involutional blepharoptosis. Am J Ophthalmol 1984;98:21–27 18. Cahill KV, Buerger GF Jr, Johnson BL. Ptosis associated with fatty infiltration of Müller’s muscle and levator muscle. Ophthal Plast Reconstr Surg 1986;2:213–217 19. Watanabe A, Araki B, Noso K, et al. Histopathology of blepharoptosis induced by prolonged hard contact lens wear. Am J Ophthalmol 2006;141:1092–1096 20. Ahmadi AJ, Saari JC, Mozaffarian D, et al. Decreased carotenoid content in preaponeurotic orbital fat of patients with involutional ptosis. Ophthal Plast Reconstr Surg 2005;21:46–51 21. Pereira LS, Hwang TN, Kersten RC, et al. Levator superioris muscle function in involutional blepharoptosis. Am J Ophthalmol 2008;145:1095–1098 22. Older JJ. Upper lid blepharoplasty and ptosis repair using a transcutaneous approach. Ophthal Plast Reconstr Surg 1994;10:146–149 23. Castro E, Foster JA. Upper lid blepharoplasty. Facial Plast Surg 1999;15:173–181 24. Kakizaki H, Zako M, Mito H, et al. Intraoperative quantification using finger force for involutional blepharoptosis without postoperative lagophthalmos. Jpn J Ophthalmol 2006;50:135–140 25. Watanabe A, Kakizaki H, Selva D, et al. Short-term changes in tear volume after blepharoptosis repair. Cornea 2013;33:14–17 26. Yoza S. Blepharoplasty: surgical approach and indication. Pepars(Japanese) 2014;80:52–58 27. Meyer DR, Linberg JV, Powell SR, et al. Quantitating the superior visual field loss associated with ptosis. Arch Ophthamol 1989;107:840–843 28. Noda M. Age change of the eyelid and skin. Tubota K (ed), Prac Ophthamol (Japanese) 2008;18–22 29. Pobert GS, Nelson RS, Donna B. The measurement and definition of ptosis. Ophthal Plast Reconstr Surg 1989;5:171–175 30. Ettl A, Prinlinger S, Kramer J, et al. Functional anatomy of the levator palpebrae supriosus muscle and its connective tissue system. Br J Ophthamol 1996;80:702–707 Effectiveness and Safety of Selective Neck Dissection in Lymph Node-Positive Squamous Cell Carcinoma of the Head and Neck Mustafa Polat, MD,� Fatih Celenk, MD,� Elif Baysal, MD,� Cengiz Durucu, MD,� Seval Kul, PhD,y Semih Mumbuc, MD,� and Muzaffer Kanlikama, MD� Copyright © 2015 Mutaz B. Habal, MD. Unautho From the *Department of Otorhinolaryngology; and yDepartment of Bio- statistics, Gaziantep University Faculty of Medicine, Gaziantep, Turkey. Received February 10, 2015. Accepted for publication March 7, 2015. Address correspondence and reprint requests to Mustafa Polat, MD, ENT Specialist, Department of Otorhinolaryngology, Gaziantep University Faculty of Medicine, Gaziantep, Turkey; E-mail: polatmusti@yahoo.com The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001849 e380 Abstract: The aim of this study was to investigate the effectiveness and safety of selective neck dissection in patients with lymph node- positive head and neck squamous cell carcinoma to determine regional control and survival rates. Eighty patients with lymph node-positive head and neck squamous cell carcinoma who under- went selective dissection were included in the study. Regional control, survival rates, and factors affecting survival were analyzed. Regional control was 90%, disease-specific survival was 93.4%, and the overall survival rate was 87.25%. T stage, N stage, age, and extracapsular spread were included in hazard regression models. None of the factors were statistically significant. Selective neck dissection is an effective and oncologically safe treatment option in selected cases. T stage, N stage, and extracapsular spread had no significant impact on disease-specific survival. Key Words: Head and neck, recurrence, selective neck dissection, survival ymph node metastasis significantly affects the prognosis and L survival of patients with head and neck squamous cell carci- noma. Radical or modified radical neck dissection has been the traditional surgical treatment for lymph node positive necks.1 However, comprehensive neck dissection has several important effects on quality of life of patients, including cosmetic and functional problems. Selective neck dissection aims at dissecting only high-risk areas of the neck and offers less morbidity and functional loss and better cosmetic results.2 Although the effec- tiveness of selective neck dissection has been well established in N0 head and neck cancers, its role remains controversial in cases with metastatic lymph nodes. There are published reports showing the effectiveness of selective neck dissection without compromising survival in the presence of lymph node metastasis.1–4 In this study, patients with histopathologically proven cervical lymph node metastasis from head and neck squamous cell carci- noma underwent selective neck dissection. The aim of this study was to investigate the effectiveness and safety of selective neck dissection in such a patient group to determine the regional control and survival rates. We also evaluated whether factors including T stage, N stage, and extracapsular spread were associated with regional failure and disease-specific survival. MATERIALS AND METHODS This retrospective study included 80 patients with lymph node- positive head and neck squamous cell carcinoma who underwent selective dissection between 2005 and 2011. Medical records of the patients were collected and included age, primary site of the tumor, follow-up period, stages of the primary and metastatic disease, recurrences, adjuvant therapies, and survival of the patients. All patients had clinically or histopathologically proven lymph node metastasis. However, staging of the necks was based on histopatho- logic examination. Histopathologic evaluation of the neck dissec- tion specimen included presence of extracapsular spread, perineural and vascular invasion, and number of lymph node metastases. All patients underwent a thorough head and neck examination and a flexible and/or rigid endoscopic examination. Preoperative computed tomography (CT) and ultrasonography were performed for lymph node staging. Distant metastases were ruled out by using positron emission tomography in suspicious cases. The type of selective neck dissection was determined according to the site of the primary tumor. In patients with oral cavity cancer, selective suprao- mohyoid neck dissection (levels I–III) was performed, whereas patients with laryngeal, oropharyngeal, or hypopharyngeal cancers rized reproduction of this article is prohibited. # 2015 Mutaz B. Habal, MD mailto:polatmusti@yahoo.com http://dx.doi.org/10.1097/SCS.0000000000001936 TABLE 1. Demographic and Clinical Parameters of the Patients Parameter No. (%) Mean age (range) 58.55� 12.33 (27–88) Male 71 (88.8%) Female 9 (11.2%) Primary site Larynx 57 (71.25%) Oral cavity 16 (20%) Hypopharynx 5 (6.25%) Oropharynx 2 (2.5%) T staging T1 15 (18.75%) T2 30 (37.5%) T3 17 (21.25%) T4 18 (22.5%) N staging N1 39 (48.75%) N2a 2 (2.5%) N2b 23 (28.75%) N2c 16 (20%) Total 80 (100%) TABLE 2. Distribution of Neck Recurrences According to the Primary Tumor and Neck Stages (P¼0.667 and 0.849, Respectively) Recurrence T Stage Yes No Total T1 n 1 14 15 % 6.7% 93.3% 100.0% T2 n 2 28 30 % 6.7% 93.3% 100.0% T3 n 3 14 17 % 17.6% 82.4% 100.0% T4 n 2 16 18 % 11.1% 88.9% 100.0% N1 n 8 72 80 n 3 36 39 % 7.7% 92.3% 100.0% N2a n 0 2 2 % 0% 100.0% 100.0% N2b n 3 20 23 % 13.0% 87.0% 100.0% N2c n 2 14 16 The Journal of Craniofacial Surgery � Volume 26, Number 5, July 2015 Brief Clinical Studies underwent selective lateral neck dissection (levels II–IV). In cases with multiple suspicious lymph nodes, lower levels (level IV and/or V) were also dissected and included in the specimen. The indication for unilateral or bilateral neck dissection was based on the site and stage of the primary tumor. Patients with stage N2, extracapsular spread, and perineural or vascular invasion received postoperative radiation therapy. All patients were followed for at least 2 years. Patients were followed up once a month in the first year, 6 times a year in the second year, and 4 times a year in the third year. Patients were assessed for recurrences and distant metastasis during scheduled visits using chest X-ray, CT, and positron emission tomography. Patients with a follow- up less than 24 months, a history of prior treatment for head and neck malignancy, malignancies other than squamous cell carcinoma recur- rence in the primary site, and N0 necks were excluded from the study. In addition, patients with N3 staged necks, obvious extracapsular extension, fixed metastatic lymph nodes, or invasion of surrounding structures underwent a comprehensive neck dissection and were also excluded from the study. To compare 2 independent groups, Student’s t tests or Mann- Whitney U tests (for continuous variables), and chi-squared tests (for categorical variables) were used. Survival probabilities were estimated using the Kaplan-Meier method. Hazard regression models were used for predictions for different factors. All univariate analyses were performed in SPSS for Windows version 22.0 (IBM Corp., Armonk, NY). A 2-sided P value <0.05 was defined as statistically significant. The study protocol was reviewed and approved by the institutional ethics committee. RESULTS Between 2005 and 2011, 80 patients with histopathogically proven lymph node metastasis underwent selective neck dissection for treating head and neck squamous cell carcinoma. Bilateral neck dissection was performed in 62 patients, and ipsilateral neck dissection was performed in 18 patients. The age of the patients ranged from 27 to 88 (mean 58.55� 12.33). There were 71 (88.8%) male and 9 (11.2%) female patients. Primary tumor sites were the larynx in 57 (71.2%) patients, oral cavity in 16 (20%) patients, hypopharynx in 5 (6.25%) patients, and oropharynx in 2 (2.5%) patients. The primary tumor was clinically staged as T1 in 15 (18.75%) patients, T2 in 30 (37.5%) patients, T3 in 17 (21.25%) patients, and T4 in 18 (22.5%) patients. Regional metastasis was pathologically staged as N1 in 39 (48.75%) patients, N2a in 2 (2.5%) patients, N2b in 23 (28.75%) patients, and N2c in 16 (20%) patients. Extracapsular spread was observed in 18 (22.5%) patients. Demographic and clinical parameters of the patients are summarized in Table 1. Mean follow-up period was 49.2� 27.3 months (range 24–98). During the follow-up period, we observed 8 (10%) patients with neck recurrence. Two of the patients with recurrence were female, whereas 6 patients with recurrence were male. One (12.5%) patient with neck recurrence was younger than 40 years, 4 (50%) patients were between 40 and 65 years, and 3 (37.5%) patients were older than 65 years. The primary site of neck recurrences was the oral cavity in 1 (12.5%) patient, larynx in 6 (75%) patients, and oropharynx in 1 (12.5%) patient. In patients with hypopharyngeal cancer no recurrence was observed. Neck recurrence occurred in 11% of the patients with laryngeal cancer and 6.6% of the patients with oral cavity cancer. The distribution of neck recurrences according to the primary tumor stage was 1 (6.7%) patient with T1 tumor, 2 (6.7%) patients with T2 tumor, 3 (17.6%) patients with T3 tumor, and 2 (11.1%) patients with T4 tumor (Table 2). No significant difference was found according to the primary tumor stage with respect to neck recurrence (P¼ 0.667). Distribution of Copyright © 2015 Mutaz B. Habal, MD. Unautho # 2015 Mutaz B. Habal, MD neck recurrences according to neck stage was 3 (7.7%) patients with N1 neck, 3 (13%) patients with N2b neck, and 2 (12.5%) patients with N2c neck (Table 3). There was no significant difference according to the neck stage with respect to neck recurrence (P¼ 0.849). Neck recurrence was observed in 2 (11.1%) patients with extracapsular spread and 6 (9.7%) patients without extracap- sular spread. Extracapsular spread was not a significant risk factor for neck recurrence (P¼ 0.860). Patients with neck recurrence were treated with additional surgery and/or radiation therapy. Details of the neck failure are described in Tables 2–4. After 2 years follow-up, regional control was 90%, disease- specific survival was 93.4%, and overall survival rate was 87.25%. T stage, N stage, age, and extracapsular spread were included in hazard regression models. None of the factors were statistically significant. There was a marginally significant hazard ratio when T3 was compared with T1 (HR¼ 2.339 [0.978–5.595] P¼ 0.056). rized reproduction of this article is prohibited. e381 TABLE 3. Details of the Patients With Recurrence Parameters Neck Failures (%) Gender Male 2 (25%) Female 6 (75%) Age <40 years 1 (12.5%) 40–65 years 4 (50%) >65 years 3 (37.5%) Primary site Larynx 6 (75%) Oral cavity 1 (12.5%) Oropharynx 1 (12.5%) T staging T1 1 (12.5%) T2 2 (25%) T3 3 (37.5%) T4 2 (25%) N staging N1 3 (37.5%) N2b 3 (37.5%) N2c 2 (25%) Extracapsular spread Present 2 (25%) Absent 6 (75%) Total 8 (100%) Brief Clinical Studies The Journal of Craniofacial Surgery � Volume 26, Number 5, July 2015 DISCUSSION Cervical metastasis is one of the most important factors associated with the prognosis, regional control, and survival rates of patients with head and neck squamous cell carcinoma. Accordingly, treat- ment of the neck should be a part of treatment, particularly in patients with lymph node metastasis. Comprehensive neck dissec- tion is the standard treatment for node-positive cases. However, there is a trend toward reducing the extent of the neck procedures. There are many reports showing the efficacy and safety of selective neck dissection in patients with cervical metastasis. In a study comparing selective and comprehensive neck dissection in clini- cally positive necks, the authors found that the extent of neck dissection resulted in no difference in overall survival.1 Andersen et al2 performed 129 selective neck dissections in 106 patients and reported a regional recurrence rate of 9% and a regional control rate of 94.3%. Chepeha et al3 included 52 patients who underwent 58 selective neck dissections for cervical metastases Copyright © 2015 Mutaz B. Habal, MD. Unautho TABLE 4. Distribution of Neck Recurrences According to the Primary Tumor Stage (P¼0.667) Recurrence T Stage Yes No Total T1 n 1 14 15 % 6.7% 93.3% 100.0% T2 n 2 28 30 % 6.7% 93.3% 100.0% T3 n 3 14 17 % 17.6% 82.4% 100.0% T4 n 2 16 18 % 11.1% 88.9% 100.0% Total n 8 72 80 % 10.0% 90.0% 100.0% e382 from carcinoma of the upper aerodigestive tract and reported a 94% regional control rate. In a study conducted by Givi et al,4 108 patients underwent selective neck dissection and the authors reported 76.9% disease-specific survival and 14.8% regional recur- rence rates. In this study, we investigated the role of selective neck dissection in the presence of metastatic lymph-node(s) in 80 patients with head and neck squamous cell carcinoma. After 2 years follow-up, regional control was 90%, disease-specific survival was 93.4%, and overall survival rate was 87.25%. Our results were similar to those reported in the literature. Andersen et al reported that the primary tumor site, N stage, extracapsular spread, and postoperative irradiation have a signifi- cant impact on disease-specific survival.1 Givi et al4 found that T stage, oral cavity as the primary tumor site, number of positive nodes, surgical margins, and adjuvant treatment are significant predictors of disease-specific survival. We included T stage, N stage, age, and extracapsular spread in hazard regression models. None of the factors were significant predictors of disease-specific survival. T stage (T3 versus T1) had a marginally significant hazard ratio. The absence of a difference in survival between N stages and extracapsular spread status may be explained by the use of irradiation in patients with advanced stages and extracapsular spread. Another explanation is that we also added lower levels to the dissection specimen in cases with multiple suspicious lymph nodes. In our experience, we do not recommend selective neck dis- section in several circumstances, including N3-staged necks, obvious extracapsular extension shown by either preoperative CT or observed directly during the operation, fixed lymph nodes, and invasion of the surrounding structures. We excluded patients having these features from the present study. We believe that these conditions may increase regional recurrence rates. In addition, dissecting lower levels in cases with multiple suspicious lymph nodes may help to reduce recurrence. This study has several limitations that should be considered. One of them is the limited number of neck recurrences. Although a limited number of neck recurrences does not affect survival and regional control rates, it is difficult to draw conclusions regarding the impact of factors on survival. The best way to determine whether patients who undergo selective neck dissection are onco- logically safe is to compare them with those having comprehen- sive neck dissection. In this study, we did not include such a control group, which is another limitation of the study. However, the number of studies comparing comprehensive and selective neck dissection is very limited. In this study, we calculated regional control and survival rates and compared our results with those reported in the literature. Disease-specific survival, overall survival, and regional control rates were comparable with the literature. CONCLUSION According to our results, selective neck dissection is an effective and oncologically safe treatment option in patients with lymph node- positive head and neck squamous cell carcinoma. T stage, N stage, and extracapsular spread had no significant impact on disease- specific survival. Several factors, including N3 stage, obvious extra- capsular extension, invasion of the surrounding structures, and fixed nodes may compromise the success rates. Therefore, selective neck dissection is a safe and effective treatment option in selected cases. REFERENCES 1. Patel RS, Clark JR, Gao K, et al. Effectiveness of selective neck dis- section in the treatment of the clinically positive neck. Head Neck 2008;30:1231–1236 2. Andersen PE, Warren F, Spiro J, et al. Results of selective neck dissection in management of the node-positive neck. Arch Otolaryngol Head Neck Surg 2002;128:1180–1184 rized reproduction of this article is prohibited. # 2015 Mutaz B. Habal, MD The Journal of Craniofacial Surgery � Volume 26, Number 5, July 2015 Brief Clinical Studies 3. Chepeha DB, Hoff PT, Taylor RJ, et al. Selective neck dissection for the treatment of neck metastasis from squamous cell carcinoma of the head and neck. Laryngoscope 2002;112:434–438 4. Givi B, Linkov G, Ganly I, et al. Selective neck dissection in node- positive squamous cell carcinoma of the head. Otolaryngol Head Neck Surg 2012;147:707–715 Use of Postoperative Palatal Obturator After Total Palatal Reconstruction With Radial Forearm Fasciocutaneous Free Flap Euicheol C. Jeong, MD, � Young Ho Jung, MD,y and Jin-yong Shin, MD�z Abstract: A 67-year-old-male patient visited our hospital for a mass on the soft palate of approximately 5.0 � 6.0 cm in size. He was diagnosed with adenoid cystic carcinoma and reconstruction after total palate resection was planned. After ablative surgery, a radial forearm free flap procedure was successfully performed to cover the hard and soft palates. However, wound disruption occurred twice during the postoperative period. When a palate defect is reconstructed using a soft tissue free flap, flap drooping by gravitation and the flap itself can generate irregularity in the lower contour of the palate and, in the long-term, insufficiencies of velopharyngeal function, speech, and mastica- tion. To complement such functional and aesthetic problems caused by flap drooping, conventional prosthetics and new oper- ative techniques have been discussed. However, overcoming wound disruption caused by flap drooping in the acute postopera- tive period has not been discussed. In this case, the temporary use of a palatal obturator during the postoperative period was beneficial after soft tissue reconstruction of the palate. Key Words: Palatal obturator, palate reconstruction, radial forearm flap Copyright © 2015 Mutaz B. Habal, MD. Unautho From the � Department of Plastic Surgery, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea; yDepartment of Otorhinolaryngology, Head and Neck Surgery, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea; and zDepartment of Plastic and Reconstructive Surgery, College of Medicine, Seoul National University, Seoul, Republic of Korea. Received February 16, 2015. Accepted for publication March 22, 2015. Address correspondence and reprint requests to Jin-yong Shin MD, Depart- ment of Plastic Surgery, SMG-SNU Boramae Medical Center, Depart- ment of Plastic and Reconstructive Surgery, College of Medicine, Seoul National University, SMG-SNU Boramae Medical Center, Borame-ro 5- gil, Dongjank-Gu, Seoul 156–707, Republic of Korea; E-mail: gahaeja@naver.com The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001856 # 2015 Mutaz B. Habal, MD INTRODUCTION M ost defects of the palate are generated by ablative surgery for head and neck cancer. These defects are challenging for reconstructive surgeons. Reconstruction options are dependent on the size and the location of the palatal defect. Generally, for both hard and soft palate defects, free tissue transfer has been shown to be stable and excellent.1 If the resection involves only the soft and hard palates, with the alveolar ridge remaining, a radial forearm free flap procedure provides the best results. The radial forearm free flap is not bulky, is highly vascularized, has a long reliable pedicle, and can be folded over.2–4 Although successful reconstruction using a radial forearm free flap was performed in our case, wound disrup- tion occurred due to flap drooping, continuous movement, and bulkiness of the tongue. To protect the flap from gravitational force and external stimuli, we used a palatal obturator in the tertiary re- operation. The issue of wound disruption was solved after applying a palatal obturator; thus, we present the application of a palatal obturator as a novel method for protecting of radial forearm free flaps, which require stability. CLINICAL REPORT A 67-year-old male patient was admitted with the symptom of pain when swallowing. Malignant cancer invading the right nasal cavity, bilateral nasopharynx, and hard and soft palates was diagnosed (Fig. 1), and reconstruction after resection was planned. A total palatal defect including the soft and hard palates was generated by the ablative surgery performed for the malignant cancer of the soft palate, and the soft and hard palates were immediately reconstructed with a radial forearm fasciocutaneous free flap to restore nasal and oral separation (Fig. 2). Vascular anatomoses were generated with facial vessels in the neck, and the donor site of the flap was closed with a split thickness skin graft. All suture wounds in the oral and nasal sides had healed primarily with no complications in the first 2 postoperative weeks. However, wound disruption and downward prolapse of the flap were observed twice by oral examination in the postoperative follow-up period and both times they necessitated a revision operation. In the tertiary re-operation, a preformed palatal obturator for the protection of the repaired wounds and for anti-gravitational support was applied beneath the flap (Fig. 3). After applying the obturator, no further disruption was reported in the additional follow-up evaluations (Fig. 4). The patient was able to swallow soluble foods 3 weeks after the tertiary re-operation and was prepared for radiation therapy. DISCUSSION In this case, the entire soft palate and the hard palate, except the tooth-bearing alveolus, were resected. The defect of the hard palate, excluding the tooth-bearing alveolus, was classified as Okay Class IA. For soft and hard palate reconstruction, the only currently rized reproduction of this article is prohibited. FIGURE 1. Preoperative view. (A) Large mass on the soft palate with multiple pits. (B) Heterogeneously enhanced large mass filling the right nasal cavity, bilateral nasopharynx, hard and soft palates, and right parapharyngeal space. e383 mailto:gahaeja@naver.com http://dx.doi.org/10.1097/SCS.0000000000001936 FIGURE 2. Resection of tumor. (A) Extent of defect area is a full layer of the hard and soft palates, and the lower half of the nasal septum. (B) Schematic drawing of the palate defect. (C) Resected hard and soft palates with adjacent soft tissue in nasal cavity. (D) Folded radial forearm free flap for the reconstruction of the nasal septum and oral surface of the palate. FIGURE 3. (A, B) The obturator was designed to cover the entire palate. FIGURE 4. (A) Application of the palatal obturator. (B) Adequate wound healing was obtained during the first 3 postoperative weeks without any further disruptions. Brief Clinical Studies The Journal of Craniofacial Surgery � Volume 26, Number 5, July 2015 available materials are local flaps and prosthetic devices. The radial forearm fasciocutaneous free flap is versatile for soft tissue recon- struction of the palate and provides satisfactory separation between the oral and nasal cavity. In this case, a radial free flap was determined to be the appropriate reconstructive material, consider- ing the size of defect and the desired functional outcome.1–5 Wounds after soft tissue reconstruction of the palate using a radial free flap are so fragile that they can be disrupted during the early postoperative period due to their bulkiness, stimulation by tongue movement, and gravitational flap drooping. Thus, the authors chose a palatal obturator for managing wound disruption in this case. Palatal obturators completely occlude the nasal cavity from the oral cavity by maintaining a seal between the obturator bulb and the normal mucosal lining, thereby, restoring normal speech and swal- low functions. The palatal obturator used in this case is typically used in the treatment modality of small and medium-sized hard palate defects.1,3,6 For the treatment of palatal defects, the advantages of the palatal obturator include a shorter operative time, shorter hospital stay, and complete visualization of the cavity.7 A palatal obturator has often been used to compensate for hypernasality and nasal regurgitation in patients with cleft palates.8 Additionally, after maxillar reconstruction following maxillect- omy, a palatal obturator is usually used for aesthetic and functional purposes. The contour of the lower soft tissues after maxillectomy is Copyright © 2015 Mutaz B. Habal, MD. Unautho e384 dependent on the underlying framework. When the framework is lost, it should be replaced by an artificial denture. A conventional prosthesis is used for preventing floating and drooping of the transferred flap after wound healing. If instability of the obturator prosthesis occurs due to a gradual increase in the drooping force, surgical debulking or the placement of a newly designed movable obturator prosthesis is necessary.9 Treatment options for preventing downward prolapse of recon- structed flaps have been discussed previously. In 2003, a simple method of slit-shaped fenestration at the midline of the hard palate was performed in a maxillary reconstruc- tion to gain the efficient function of the prosthesis. The dispersion of pressure generated by fenestration at the midline of the hard palate decreased the downward force acting on the transferred flap. This method has the advantages of being simpler, less invasive, and less expensive than other methods.10 However, that method could not be used in the case presented here, because no remnant of the hard palate was present. Improvement of velopharyngeal function by the palmaris longus tendon sling approach has also been described. The suspension approach also helps to prevent flaps from being drawn far from the posterior pharyngeal wall.11 However, in the current case, no remnant tissues that could be used for the suspension of a tendon, such as levators or pharyngeal muscles, were present after the oncologic resection surgery. The above procedures for preventing flap drooping have been shown to preserve the stability of prostheses and to allow for proper speech and mastication functions. However, the abilities of these procedures to manage wounds during acute postoperative care have not been discussed previously. The palatal obturator has never been used for flap protection and wound management after palate reconstruction with free tissue transfer. In this case, the palatal obturator superseded the role of splint. The stably fixed obturator with a tooth as a pivot supported flap without generating pressure to prevent downward prolapse. Additionally, inevitable stimulus of the wounds by movement of the bulky tongue was prevented, and the hygiene of the flap was improved by blocking contaminating substances, such as oral secretions. No previous publications have discussed postoperative care for free flap reconstruction of the palate. Authors recommend the temporary use of a palatal obturator as a beneficial and unique option for preventing wound complications after this type of reconstruction. REFERENCES 1. Gupta V, Cohan DM, Arshad H, et al. Palatal reconstruction. Curr Opin Otolaryngol Head Neck Surg 2012;20:225–230 2. Germain MA, Hartl DM, Marandas P, et al. Free flap reconstruction in the treatment of tumors involving the hard palate. Eur J Surg Oncol 2006;32:335–339 3. Genden EM, Wallace DI, Okay D, et al. Reconstruction of the hard palate using the radial forearm free flap: indications and outcomes. Head Neck 2004;26:808–814 4. Kim JH, Chu HR, Kang JM, et al. Functional benefit after modification of radial forearm free flap for soft palate reconstruction. Clin Exp Otorhinolaryngol 2008;1:161–165 5. Van der Sloot PG. Hard and soft palate reconstruction. Curr Opin Otolaryngol Head Neck Surg 2003;11:225–229 6. Tirelli G, Rizzo R, Biasotto M, et al. Obturator prostheses following palatal resection: clinical cases. Acta Otorhinolaryngol Ital 2010;30:33–39 7. Davison SP, Sherris DA, Meland NB. An algorithm for maxillectomy defect reconstruction. Laryngoscope 1998;108:215–219 rized reproduction of this article is prohibited. # 2015 Mutaz B. Habal, MD The Journal of Craniofacial Surgery � Volume 26, Number 5, July 2015 Brief Clinical Studies 8. Gümüş HO, Tuna SH. An alternative method for constructing an obturator prosthesis for a patient with a bilateral cleft lip and palate a clinical report. J Esthet Restor Dent 2009;21:89–94 9. Murakami M, Nishi Y, Umezono M, et al. Fabrication of a movable obturator following maxillary reconstruction with slit-shaped fenestration. J Prosthodont 2015;24:254–259 10. Sakuraba M, Kimata Y, Ota Y, et al. Simple maxillary reconstruction using free tissue transfer and prostheses. Plast Reconstr Surg 2003;111:594–598 11. Lee MC, Lee DW, Rah DK, et al. Reconstruction of a total soft palatal defect using a folded radial forearm free flap and palmaris longus tendon sling. Arch Plast Surg 2012;39:25–30 Frontal Sinolith Dong Hoon Lee, MD, Tae Mi Yoon, MD, Joon Kyoo Lee, MD, and Sang Chul Lim, MD, PhD Abstract: Sinolith in the paranasal sinus is still a rare entity. A sinolith in the frontal sinus is extremely rare, and only 2 patients have been reported in the English literature. Herein, the authors present an additional patient of frontal sinolith in a 78-year-old woman. The patient was preoperatively diagnosed with fungus ball of the frontal sinus, based on radio-opaque densities on computed tomography. Endoscopic surgery was performed and surgical biopsy was interpreted as sinolith. Clinical manifestations of frontal sinolith, including imaging study findings, are discussed with a review of the literature pertaining to this condition. Despite its rarity, frontal sinolith should be considered in the differential diagnosis of radio-densities in the frontal sinus. Key Words: Frontal sinus, Sinolith, Computed Tomography inolith is a term usually used to describe a calculus in the frontal, S ethmoid, or sphenoid sinus, whereas the same pathology in the nasal cavity and maxillary sinus has been termed rhinolith or rhinolithiasis and antrolith or antrolithiasis, respectively.1–3 Sino- liths are, however, extremely rare, compared with rhinoliths or antroliths.1,3 Computed tomography (CT) findings of sinolith include a mass with metallic density or multiple calcifications, and sinolith should be considered in the differential diagnosis of calcified lesions in the paranasal sinuses on CT. To date, 2 patients of frontal sinolith have been reported in the English literature according to PubMed search. Herein, we present an additional patient of frontal sinolith mimicking fungus ball and a review of the literature pertaining to this condition. Copyright © 2015 Mutaz B. Habal, MD. Unautho From the Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Medical School and Hwasun Hospital, Hwasun, South Korea. Received January 15, 2015. Accepted for publication March 24, 2015. Address correspondence and reprint requests to Sang Chul Lim, MD, PhD, Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Medical School and Hwasun Hospital, 160 Ilsimri, Hwasun, Jeonnam 519-809, South Korea. E-mail: limsc@chonnam. ac.kr The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001858 # 2015 Mutaz B. Habal, MD CLINICAL REPORT A 78-year-old woman with a left infra-auricular mass was referred to our hospital. We performed CT of the neck for evaluation of the left parotid gland and neck. On CT, multiple calcified lesions in the right frontal sinus were detected incidentally (Fig. 1). Although the patient had intermittent nasal symptoms, such as rhinorrhea, anosmia, and headache, her symptoms were not severe enough to necessitate a medical checkup. The patient had no history of nasal surgery and facial trauma. Nasal endoscopic examination showed purulent dis- charge from the right middle meatus draining into the choana. A presumptive diagnosis of fungus ball in the frontal sinus was made, based on multiple calcifications on CT. Endoscopic sinus surgery was performed. The right frontal ostium was enlarged with powered instrumentation, and purulent secretion and a brittle mass were removed. Histopathological examination of the brittle mass in the right frontal sinus was consistent with sinolith. Histopatholo- gical findings obtained using Gomori methenamine silver (GMS) stain and periodic acid-Schiff (PAS) stain did not show fungi. No fungi were found to grow in the fungus culture. This patient was finally diagnosed as sinolith in the right frontal sinus. The post- operative course was uneventful. The patient was found to be free of lesions during follow-up examinations. DISCUSSION Contrary to rhinolithiasis of the nasal cavity, the occurrence of a sinolith is very rare.1–3 Through literature search using PubMed with terms such as ‘‘frontal sinus,’’ ‘‘sinolith,’’ ‘antrolithiasis,’’ ‘‘antro- lith,’’ and combinations of these terms, 8 patients of sinoliths were retrieved from the English literature1–7; 4 patients of ethmoid sinus sinolith, 2 patients of sphenoid sinus sinolith, and 2 patients of frontal sinus sinolith.7 Frontal sinus is an extremely rare location of a sinolith. The etiology of sinolith has not been clearly established. It has been known that sinolith develops from an exogenous or endogen- ous nidus.3 Endogenous niduses include tooth, bone chip, blood clots, purulent secretion, and mucus fungal element.8 On the contrary, exogenous niduses include various foreign materials such as cotton, cellulose, and paper. Long-standing infection, fungal infection, poor sinus aeration and drainage, and presence of a foreign body are predisposing factors for sinolith.1–3 During the review of the literature, previously reported patients of frontal sinolith were not related to the presence of a foreign body and the predisposing factors were radiation (n¼ 1) and chronic para- nasal sinus inflammation (n¼ 2). Most patients with sinoliths present with symptoms such as facial pain, nasal obstruction, purulent discharge, postnasal drip, epistaxis, and headache.1,2,6 These symptoms and signs usually depend on coexisting infection of the involved sinus. Headache and postnasal drip were reported as symptoms of frontal sinolith.5 Some patients can, however, be asymptomatic and are diagnosed inci- dentally by radiologic examination, as our patient.4 CT is very helpful to establish the diagnosis of sinolith.1,6 CT may aid in the preoperative diagnosis of sinolith and provide useful information about the location, size, and relation to surrounding structures.1,6 On CT, a dense, irregular, but a well-defined mass or masses are usually seen, as observed in the previously 2 reported patients. Our patient was, however, preoperatively diagnosed as fungal sinusitis due to multiple calcifications in the frontal sinus. It rized reproduction of this article is prohibited. FIGURE 1. Coronal CT scan with enhancement revealed multiple calcified lesions (red arrow) in the right frontal sinus. e385 mailto:limsc@chonnam.ac.kr mailto:limsc@chonnam.ac.kr http://dx.doi.org/10.1097/SCS.0000000000001936 From the Department of Ophthalmology, Eye Hospital of Wenzhou Medical University, Wenzhou, China. Received February 11, 2015. Accepted for publication March 7, 2015. Address correspondence and reprint requests to Wencan Wu, Department of Ophthalmology, Eye Hospital of Wenzhou Medical University, 270 Xue-Yuan West Road, Wen Zhou, Zhe Jiang 325000, China. E-mail: wuwencan118@163.com The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001864 Brief Clinical Studies The Journal of Craniofacial Surgery � Volume 26, Number 5, July 2015 should be kept in mind that frontal sinolith can show nonspecific findings of calcifications, and the diagnosis of frontal sinolith requires a high index of suspicion. The sinolith can be found along with chronic inflammatory changes within the paranasal sinuses, and occasionally it may be an incidental finding, as in this patient. The sinolith should be differentiated from fungal infection, ossify- ing fibroma, osteoma, osteoblastoma, benign odontoma, cemen- toma, primary or metastatic carcinoma, osteogenic sarcoma, fibrous dysplasia, calcified mucous, and retention cyst.2 MRI findings of sinolith show low signal intensity or signal void on all sequences and variable signal intensity in the surrounding of the sinolith on T1- and T2-weighted images according to secretion or inflamed mucosa in the sinus. A mycetoma, dessicated secretions, an intra- sinus tooth, or osteoma have similar findings on MRI.9 The treatment of choice for a sinolith is surgical drainage.1–7 Surgical removal of the sinolith is usually performed along with appropriate treatment of the coexisting sinus disease.1,2 The endo- scopic approach is preferable and it offers advantages such as easy access to the lesion, perfect visualization, low morbidity, and low complications,1 and external surgery is attempted if a sinolith cannot be removed with endoscopic surgery. In conclusion, sinolith in the paranasal sinus is still a rare entity and the frontal sinus is a very unusual location of a sinolith. Despite its rarity, frontal sinolith should be considered in the differential diagnosis of radiodensities in the frontal sinus. REFERENCES 1. Almaši M, Andrašovská M, Koval J. Sinolith in the ethmoid sinus: report of two cases and review of the literature. Eur Arch Otorhinolaryngol 2010;267:1649–1652 2. Özcan C, Vaysoğlu Y, Görür K. Sinolith: a rare isolated sphenoid sinus lesion. J Craniofacial Surg 2013;24:e104–e106 3. Nayak DR, Bhandarkar AM, Valiathan M, et al. Incidental ‘ethmoid sinolith’: an unusual cause of frontal recess obstruction. BMJ Case Rep 2014 doi: 10.1136/bcr-2014-204157 4. Grant DG, Hussain A, Burgel R. Frontal sinolith. J Laryngol Otol 1998;112:570–572 5. Mori S, Lee K, Fujieda S, et al. Antrolithiasis in the frontal sinus. ORL J Otorhinolaryngol Relat Spec 2000;62:335–337 6. Kanzaki S, Sakamoto M. Sinolith in the ethmoid sinus. J Laryngol Otol 2006;120:e11 7. Wyllie JW 3rd, Kern EB, Djalilian M. Isolated sphenoid sinus lesions. Laryngoscope 1973;83:1252–1265 8. Manjaly G, Pahor AL. Antral rhinolithiasis and tooth filling. Ear Nose Throat J 1994;73:676–679 9. Burgener FA, Meyers SP, Tan RK, Zaunbauer W. Paranasal sinus and nasal cavity. In: Differential Diagnosis in Magnetic Resonance Imaging. Stuttgart, Germany/New York: Georg Thieme Verlag; 2002;224–231. A Lacrimal Sump Syndrome With a Large Intranasal Ostium Zhenbin Qian, MD, Yunhai Tu, MD, Tianlin Xiao, MD, and Wencan Wu, MD Abstract: Lacrimal sump syndrome is an uncommon cause of failed dacryocystorhinostomy. Small osteotomy was reported as the major cause of this syndrome. Here, the authors described the first case of a lacrimal sump syndrome with a large intranasal ostium following endoscopic endonasal dacryocystorhinostomy (EE-DCR). A 51-year-old women patient suffered recurrence of Copyright © 2015 Mutaz B. Habal, MD. Unautho e386 epiphora and dacryocystitis for 8 months following an EE-DCR. Examination showed a large intranasal ostium with a lot of purulent discharge and patent lacrimal irrigation. Lacrimal sump syndrome was diagnosed after passing a probe into the residual lacrimal sac under the aid of an endoscope. The residual sac was reopened and merogel was packed around the wound. The clinical symptoms disappeared after the surgery. It is indicated that lacrimal sump syndrome does happen not only in a small intranasal ostium, but also in a large intranasal ostium. Existing residual sac with bacterial infection may be related to this particular case. Key Words: Endonasal dacryocystorhinostomy, lacrimal sump syndrome, large intranasal ostium ndoscopic endonasal dacryocystorhinostomy (EE-DCR) is now Ewidely considered a successful treatment for nasolacrimal duct obstruction. It has shown a number of advantages over external DCR (EX-DCR), including preservation of medial canthal tendon and pump function, direct visualization of nasal anatomy, and avoidance of cutaneous scar.1–3 Lacrimal sump syndrome is an uncommon cause of failed dacryocystorhinostomy. It was early described in 1993 in a case report by Jordan and McDonald.4 The occurrence of lacrimal sump syndrome was reported from 0.3% to 4.8% of endonasal or external DCR patients.2,4–6 The distinctive feature of the syndrome is the residual lacrimal sac formed after DCR, mostly present epiphora with or without mucopurulent discharge; however, lacrimal irriga- tion and dye disappearance may seem normal. It has been reported that the small osteotomy is the main cause of lacrimal sump syndrome.2,4–5 Here, we reported a case of lacrimal sump syndrome unusually with a large intranasal ostium and a patent lacrimal irrigation, which has been successfully treated after reopening the residual sac and packing the wound with merogel. As our knowledge, this is the first report about lacrimal sump syndrome having a large ostium following EE-DCR. CLINICAL REPORT A 51-year-old woman was referred with a 5-year history of epiphora in both eyes and 1-year history of purulent discharge in right eye. Since no significant improvement after 3 times of probing, a bilateral EEDCR was performed by a skilled surgeon. All the symptoms disappeared and lacrimal irrigation test easily passed after the surgery. But 8 months later, epiphora with purulent discharge in her left side recurred (Fig. 1A), especially in the morning. No remarkable change in her CT scan was found (Fig. 1B). Endoscopic examination showed a large intranasal ostium in a size around 5� 3 mm,wildly opened but with a lot of purulent discharge (Fig. 1C-D); however, lacrimal irrigation was easily passed. Postoperative infection was first considered and then intravenous lavofloxacin lactate was recommended to apply after positive bacterial culture showing growth of Klebsiella rized reproduction of this article is prohibited. # 2015 Mutaz B. Habal, MD mailto:wuwencan118@163.com http://dx.doi.org/10.1097/SCS.0000000000001936 FIGURE 1. Recurrent dacrocysitis after EE-DCR. A 51-year-old women had recurrent epiphora with discharge after 8 months of EE-DCR. A, Shows purulent discharge covering her left eyelid; B, shows no remarkable finding with her CT scanning; and C and D, display a widely opened ostium with a lot of purulent discharge. FIGURE 3. Photographs at 12 months of postoperation. A, Shows the discharge around her left eyelid disappeared; B, shows a 5 mm � 8 mm of intranasal ostium widely opened, which is measured by a marked tweezer. No discharge is noted around it. The Journal of Craniofacial Surgery � Volume 26, Number 5, July 2015 Brief Clinical Studies pneumoniae and Streptococcus pneumonia, which were sensitive to lavofloxacin lactate. The discharge around the eyelid decreased after 5 days of treatment, but it remained surrounding the ostium. Then, an endoscopic-guided probing was conducted, and a residual sac formed by the proliferated nasal mucosa was detected (Fig. 2A), which suggested a diagnosis of lacrimal sump syndrome. The residual sac was reopened under local anesthesia with the aid of an endoscope, and then merogel coverage was followed around the reopened wound (Fig. 2B-C). All symptom disappeared (Fig. 3A-B) and no recurrence after 1 year of follow-up. DISCUSSION Several reports have explained how is the lacrimal sump syndrome formed. Migliori and coworkers suggested inadequate bone removal or failure to completely open the lacrimal sac into the nose is the main cause of the lacrimal sump syndrome.7 They illustrated that the residual sac was reformed either by nasal mucosa or adhesion between middle turbinate and lateral nasal wall, in which the residual sac was identified by passing a Bowman probe into the sac and tenting it away from common internal punctum. Fayet et al2 demon- strated too small oseteotomy, or insufficient downward extension of the osteotomy may be related to lacrimal sump syndrome. Welham and Wulc6 displayed the development of this syndrome was attrib- uted to placing the nasal ostium too high, thus creating a blind pouch that retains tears and is vulnerable to infection. In our case, the EE-DCR was performed by a skilled surgeon who made a large osteotomy with totally opened sac that maintained the lacrimal drainage system working anatomically and function- ally for 8 months. If we defined a large intranasal ostium as 5 mm or more in any dimension, the ostium of 5� 3 mm in our case belongs to the large one (Figs. 1A, 3B). However, the symptoms recurred after 8 months of postoperation when we thought it would never block the tears flow causing excess tearing again. We primarily thought those recurrent symptoms were induced by the postopera- tive infection since a lot of purulent discharge presented around the eyelid and intranasal ostium (Fig. 1A-C), especially when the bacterial culture showing positive result. Having not good response to antibacterial treatment, we finally realized it was lacrimal sump syndrome after we passed a probe into the residual sac under the guidance of an endoscope (Fig. 2A). Examination showed that the proliferated nasal mucosa formed the lower portion of residual sac. Copyright © 2015 Mutaz B. Habal, MD. Unautho FIGURE 2. Residual sac detection and resection. A, Shows a probe is used to detect the bottom of residual sac which reformed by proliferated nasal mucosa. Black arrow shows the large ostium opened. B, Shows the sac was reopened; C, shows merogel was covered around the wound. # 2015 Mutaz B. Habal, MD As mentioned before, lacrimal sump syndrome mostly was related to a small osteotomy. Literature search has not found any case of lacrimal sump syndrome with a large ostium. We speculate the large ostium in our case drained the tears freely at first few months of postoperation; however, with the deposit of more and more bacteria to the bottom of residual sac, those bacteria quickly proliferated and produced a lot of purulent discharge that eventually blocked the whole lacrimal system and induced epi- phora with discharge. It demonstrated not only a residual sac from the proliferated nasal mucosa contributed to this syndrome, but a lot of discharge from bacterial infection also participated in its blockage. Yazici and coworkers thought that the occurrence of lacrimal sump syndrome was underestimated; furthermore, not all of residual sac will induce lacrimal sump syndrome. They found 3 (7%) of residual lacrimal sac in 41 cases of successful Ex-DCR, but none of them having lacrimal sump syndrome. Thus, they specu- lated a lacrimal sump syndrome will not happen if the osteotomy is big and functional, even lower lacrimal sac existed.8 Our obser- vation is agreed with Yazici’ finding, which means, excepting the residual sac, other factors may involve in the happen of lacrimal sump syndrome. Since lacrimal sump syndrome is an uncommon complication of failed Ex- or EE-DCR, there are only few reporters described this syndrome. The detail description, for example, the relationship of the size of an ostium with lacrimal sump syndrome is still unclear. Linberg et al9 observed mean final ostium diameter after Ex-DCR was only 1.8 mm under endoscopic study, and excellent functional results were obtained even when the intranasal ostium was quite small. Ben Simon et al10 reported the mean (SD) postoperative ostium size was 9.6 mm2, and the intraoperative osteotomy size correlated positively with the postoperative intranasal ostium size; however, there was no difference in either the intraoperative osteotomy size or the postoperative ostium size between failed and successful cases. Yazici et al used digital subtraction macrodacryocystography to assess the healed nasolacrimal ostium after ex-DCR. The average height of the healed ostium was 3.5 mm (range, 1.2–6.5 mm) for all 41 patients. Among 3 of nasolacrimal ostium located at the middle part of the regenerated sac, the height of ostium is 3.0, 2.1, and 1.6 mm, respectively, but none of them having lacrimal sump syn- drome.8 Comparing with our case, the postoperative ostium is larger than those reports, so it is truly a lacrimal sump syndrome with a large intranasal ostium. Treatment for the lacrimal sump syndrome is not difficult. Jordan and McDonald4 suggested that making a large osteotomy and opening the bottom of the lacrimal sac are considered can reduce the chance of the sump syndrome. Expand osteotomy and resect the lacrimal sac flaps and the surrounding nasal mucosa can be done in endoscopic revision surgery. Migliori7 demonstrated that using contact Nd:YAG laser and implanting silicone stent is an effective method for treating lacrimal sump syndrome. In our case, the residual lacrimal sac was reopened under local anesthesia, and the wound was covered by the merogel. Merogel coverage helps early re-epithelialization of the ostium and inhibition of the fibrotic tissues, which may enhance the success rate of the surgery.11 We consider that our method is minor invasive and highly efficient for the management of lacrimal sump syndrome with a large ostium. rized reproduction of this article is prohibited. e387 From the �Service de Chirurgie Maxillo-faciale et Stomatologie de l’Hôpital Roger Salengro du Centre Hospitalier Universitaire de Lille, Lille; yService de Médecine Interne et Maladies Infectieuses du Centre Hospitalier Universitaire de Poitiers, Poitiers; and zUnité d’Infectiologie du Service de gestion du risque infectieux et des vigilances et infectio- logie de l’Hôpital Huriez du Centre Hospitalier Universitaire de Lille, Lille, France. Received February 15, 2015. Accepted for publication March 16, 2015. Address correspondence and reprint requests to Dr Farah