The Journal of Craniofacial Surgery Volume 28, Number 5, July 2017 Brief Clinical Studies

3. Atan D, O¨ zcan KM, Ikinciog˘ullari A, et al. The effect of obstructive included, and Tessier craniofacial clefting classification was used sleep apnea syndrome and continuous positive airway pressure for classifying the clefts. treatment on voice performance. Sleep Breath 2015;19:777–782 Results: Of 964 patients with craniofacial clefts, 80 (8.29%) 4. Kilic¸ MA. Evaluation of the patient with voice problem by objective and subjective methods. Curr Pract ORL 2010;6:257–265 patients were identified with rare craniofacial clefts. There were 5. Fujita S, Conway WA, Zorick F, et al. Surgical correction of anatomical 39 (48.7%) males and 41 (51.3%) females. Family history was abnormalities in obstructive sleep apnea syndrome: determined positive in 30 (37.5%) patients. Tessier number 0 uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 1981;89: (58.7%) was the most common cleft in the authors’ study. Tessier 923–934 6. Pang KP, Terris DJ. Modified-cautery assisted palatal stiffening numbers 8, 13, and 30 were the rarest clefts. There was no patient operation: new method for treating snoring and mild obstructive with Clefts numbers 5, 6, or 9. Maternal smoking during pregnancy sleep apnea. Otolaryngol Head Neck Surg 2007;136:823–826 was observed in 1 (1.3%) of the women and 3 of the women had 7. Pang KP, Woodson BT. Expansion sphincter pharyngoplasty: a new used drugs, 1 of them used the dexamethasone tablets and 2 of them technique for the treatment of obstructive sleep apnea. Otolaryngol could not remember name of the used drug. Head Neck Surg 2007;137:110–114 8. Atan D, Apaydin E, O¨ zcan KM, et al. Does tonsillectomy affect voice Conclusions: Tessier number 0 was the most common cleft and in early or late postoperative periods in adults? J Voice 2017;31: Tessier numbers 8, 13, and 30 were the rarest types. The precise 131.e5–131.e8 etiology of rare craniofacial clefts remained undetermined in this 9. Van Lierde KM, Van Borsel J, Moerman M, et al. Nasalance, nasality, study. Women should be educated about the risk factors and voice, and articulation after uvulopalatopharyngoplasty. Laryngoscope 2001;112:873–878 subsequent ways of preventing from these risk factors. 10. Greene JS, Zipfel TE, Harlor M. The effect of uvulopalatopharyngoplasty on the nasality of voice. J Voice Key Words: Cleft, craniofacial, facial cleft, rare clefts 2004;18:423–430 11. Eun YG, Shin SY, Kim SW. Effects of uvulopalatopharyngoplasty with or without radiofrequency tongue base reduction on voice in patients n comparison with the cleft lip/palate, craniofacial clefts are with obstructive sleep apnea. Laryngoscope 2013;123:1806–1810 I extremely rare congenital malformations. Nevertheless, a con- 12. Akpinar ME, Kocak I, Gurpinar B, et al. Effects of soft palate implants siderable portion of congenital facial deformities is related to the on acoustic characteristics of voice and articulation. J Voice craniofacial malformations.1,2 To date, the precise etiology is 2011;25:381–386 unknown, but presumably, it appears to be as a result of the genetic predisposition, related abnormalities, mutations during craniofacial embryogenesis, and the impact of environmental risk factors, including radiation, infection, metabolic abnormalities, and drug use during pregnancy.3–9 Owing to the low incidence of the craniofacial clefts, its incidence remains unclear but is estimated Prevalence of Rare Craniofacial between 1.4 and 4.9 per 100,000 live births.10 Once an infant with the craniofacial cleft is born, a significant Clefts impairment of facial aesthetic which affects both individual’s Abdoljalil Kalantar-Hormozi, MD, and his or her family’s quality of life is unavoidable.11–13 In Ali Abbaszadeh-Kasbi, MD,y Farhood Goravanchi, MD,z consequence, a huge magnitude financial burden of treatment is 13,14 and Nazanin Rita Davai, MD§ imposed on the patient’s family along with the insurance. In this study, due to the importance of the issue and also paucity of literature regarding the craniofacial clefts and lack of locally Background: Craniofacial clefts are extremely rare congenital relative article in the Iran, and help to improve global registry as malformations that have adverse functional, psychosocial, and well as data base on clefts, a retrospective study was conducted in aesthetic effects on patients’ life. Although the exact incidence the 15-Khordad hospital to provide high insights into the prevalence is unclear, it is estimated between 1.4 and 4.9 per 100,000 live of rare craniofacial clefts among the craniofacial clefts as well as the births. Prevalence of the rare craniofacial clefts is imprecise due to etiologies involved. the paucity of literature as well as their etiologies. Methods: All the patients with rare craniofacial clefts during METHODS 10 years in a plastic surgery tertiary referral hospital were This retrospective study was carried out at the 15-Khordad Hospital which is the major referral hospital for plastic surgery among the From the Department of Plastic and Craniofacial Surgery, Medical Iranian counterparts. The current study was approved by the ethical College of Shahid Beheshti University of Medical Science (SBMU), 15 committee of the Shahid Beheshti University of Medical Science. y z Khordad Hospital; Tehran University of Medical Science; Medical All the patients who presented with craniofacial clefts as well as College of Shahid Beheshti University of Medical Science (SBMU), 15 Khordad Hospital; and §Private Practice, Tehran, Iran. those who had craniofacial clefts and were hospitalized in NICU of Received December 10, 2016. the Mofid Children Hospital because of the medical illness from Accepted for publication March 2, 2017. June 2006 to April 2016 were included. Medical files with insuffi- Address correspondence and reprint requests to Abdoljalil Kalantar- cient data were completed by calling patients or their parents. The Hormozi, MD, Professor of Plastic Surgery, Department of Plastic and variables for each patient include: gender, age, maternal drug Craniofacial Surgery, Medical College of Shahid Beheshti University of use and smoking during pregnancy, cleft and other associated Medical Science (SBMU), 15 Khordad Hospital, Azodi Street, Karim conditions (syndrome or anomaly), and the cleft type. The cleft Khan Building, Tehran, Iran 19117-94797; type for all patients was identified according to Tessier craniofacial E-mail: [email protected] clefting classification1 which provides an insight for making prac- The authors report no conflicts of interest. Copyright # 2017 by Mutaz B. Habal, MD tical and definite decisions regarding patients’ conditions and ISSN: 1049-2275 related treatment. All statistical analyses were performed with DOI: 10.1097/SCS.0000000000003771 statistical package for social science (SPSS 16, SPSS Inc, Chicago,

# 2017 Mutaz B. Habal, MD e467 Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Brief Clinical Studies The Journal of Craniofacial Surgery Volume 28, Number 5, July 2017

total numbers males females 1000 50 884 47 900 800 45 700 40 600

35 500 400 30 300 24 25 23 200 80 100 47 222 20 18 0 Number of patients Unaffected Paents with Tessier no. 0 (TheTessier no. 8 (The Tessier no. 13 Tessier no. 30 15 paents by rare rare craniofacial most common rarest type) (The rarest type) (The rarest type) 10 10 craniofacial cle s cle s type) 10 8 66 Number of paents 5 5 4 4 5 3333 3 3 2 222 2 222 1 1 1 1 1 1 0 000000 000 00 0 0 0 FIGURE 3. Illustrates the number of unaffected patients by rare craniofacial 0 No. 0 No. 1 No. 2 No. 3 No. 4 No. 5 No. 6 No. 7 No. 8 No. 9 No. 10 No. 11 No. 12 No. 13 No. 14 No. 30 clefts, rare, and common craniofacial clefts among affected patients. Tessier Classification

FIGURE 1. Distribution of clefts. Twenty-four (11 males and 13 females) of the mentioned patients were from a village in which most of its inhabitants IL). x2 and Fisher exact tests were used in analyzing the correlations suffer from the craniofacial clefts, more commonly Tessier numbers in this study. A P value <0.05 is considered statistically significant. 0, 1, and 14. After ignoring these patients’ information from the database, the most common clefts would be Tessier numbers 0 and 14, while the rarest clefts would be Tessier numbers 8, 13, and 30 RESULTS (Fig. 4). Among the 964 presented patients with craniofacial clefts, 80 Familial background was positive in 30 (37.5%) patients, (8.29%) of them including 39 (48.7%) males and 41 (51.3%) including 13 males and 17 females. Of all the 30 patients with females had rare craniofacial clefts (Fig. 1). Overall, 80 patients positive familial history, 24 (30%) individuals were from the with 105 clefts (Fig. 2) were studied: a number of the patients had mentioned village. Ultrasonographic assessments detected clefts several types of clefts concurrently. Forty-nine (61.25%) patients in 4 (5%) of the patients. Ten (12%) patients including 6 males and 4 were 10 years and above, whereas 5 (6.25%) of them were 6 females had syndromic disease. Four of them had the Hemifacial months or less. Preterm delivery was noticed in 4 (5%) patients, Microsomia, whereas 1 of them had . while 76 (95%) were term infants. According to the Fisher exact test, there was a significant difference in the types of clefts between term and preterm infants. Four (6%) women were 35 DISCUSSION years and above, while 22 (37%) women were between 20 and 25 Craniofacial clefts are situations caused by the disruption of normal embryonic processes of which majority of these clefts years. Tessier number 0 was the most common cleft among both 3,15,16 males and females, while Tessier numbers 8, 13, and 30 were the occur during the first 12 weeks of gestation. Although the rarest types (Fig. 3). Tessier numbers 5, 6, and 9 have not been incidence of rare craniofacial clefts is unknown due to dearth of observed among the patients. There was a significant difference in literature, it has been estimated to be approximately between 1.4 and 4.9 per 100,000 live births by Ozaki and Kawamoto10 and also the types of the cleft between boys and girls (P < 0.001). Maternal 9 smoking during pregnancy was observed in 1 (1.3%) women and in Moore et al study was reported between 1.5 and 6.0 per 100,000 none of the women used illicit drug during pregnancy. Three of live births. mothers used nonillicit drugs, 1 of them had used the dexametha- Both girls and boys are being affected by rare craniofacial clefts, sone tablets whereas 2 of them could not remember the name of but girls are more commonly affected. The cause of enormous the used drug that they used. number of patients belonging to the age group of 10 years and above is that most of them are from rural and remote areas that were referred to our hospital as a result of the inadequate medical facilities.

total males females

16 14 14 14

12 10 10 9

8 7 7

6 5 5 5 4 4 Number of patients 4 3 3 3 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 No. 0 No. 1 No. 2 No. 3 No.4 No. 5 No. 6 No. 7 No. 8 No. 9 No. No. No. No. No. No. 10 11 12 13 14 30 Tessier Classification FIGURE 2. A patient with multiple rare craniofacial clefts (Tessier numbers 0, 14, bilateral 2, left 12, orbital , left orbital dystopia, and etc.). FIGURE 4. Distribution of clefts after ignoring the village’s inhabitants. e468 # 2017 Mutaz B. Habal, MD Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. The Journal of Craniofacial Surgery Volume 28, Number 5, July 2017 Brief Clinical Studies

Forty-seven (59.5%) of eligible patients had Tessier number 0 4. Fantel AG, Shepard TH, Newell-Morris LL, et al. Teratogenic effects of cleft that was the most common type of rare craniofacial clefts in retinoic acid in pigtail monkeys (Macaca nemestrina). I. General the current study, as mentioned by da Silva Freitas et al17 in features. 1977;15:65–71 2008. Tessier numbers 8, 13, and 30 were the rarest (each of 5. Lecanda F, Warlow PM, Sheikh S, et al. Connexin43 deficiency causes them represented in 1 patient [1.25%]) types of rare craniofacial delayed ossification, craniofacial abnormalities, and osteoblast clefts in our study. In van der Meulen et al18 study Tessier dysfunction. J Cell Biol 2000;151:931–944 19 6. Dixon J, Jones NC, Sandell LL, et al. Tcof1/Treacle is required for number 9 was the rarest craniofacial cleft. Morian found that cell formation and proliferation deficiencies that cause Tessier number 3 is the most common cleft among rare cranio- craniofacial abnormalities. Proc Natl Acad Sci USA 2006;103: facial clefts. In another study that has been carried out by Mishra 13403–13408 20 and Purwar, Tessier numbers 3 and 4 were the rarest types. 7. Marcano A, Doudney K, Braybrook C, et al. TBX22 mutations are a Tessier number 7 was described as an uncommon condition by frequent cause of cleft palate. J Med Genet 2004;41:68–74 Woods et al21 in their retrospective case review. Portier-Marret 8. Mintz-Hittner HA, Semina EV, Frishman LJ, et al. VSX1 (RINX) et al and Alonso et al22 reported Tessier number 4 as the rarest mutation with craniofacial anomalies, empty sella, corneal craniofacial cleft in their patient series study.23 da Silva Freitas endothelial changes, and abnormal retinal and auditory bipolar cells. et al24 detected Tessier number 5 as an extremely rare cranio- Ophthalmology 2004;111:828–836 9. Moore MH. Rare craniofacial clefts. J Craniofac Surg 1996;7:408–411 facial cleft. 10. Ozaki W, Kawamoto HK Jr. Craniofacial clefting. In: Lin KY, Ogle Due to the antiquated ultrasound systems, lack of 3-dimensional RC, Jane JA, eds. Craniofacial Surgery: Science and Surgical ultrasound in some centers, and screening evaluations by a non- Technique. Philadelphia, PA: Saunders; 2002:309–331 expert sonographer, ultrasonographic assessments during preg- 11. Tobiasen JM. Social judgments of facial deformity. Cleft Palate J nancy, could only detect rare craniofacial clefts in 4 (5%) patients. 1987;24:323–327 Genetic and nongenetic causes for developing rare craniofacial 12. Tobiasen JM, Levy J, Carpenter MA, et al. Type of facial cleft, clefts have been described by Anderson.25 Despite the current associated congenital malformations, and parents’ ratings of school study, the definite role of maternal smoking and drug use during and conduct problems. Cleft Palate J 1987;24:209–215 pregnancy in rare craniofacial clefts remained undetermined due to 13. Wehby GL, Cassell CH. The impact of orofacial clefts on quality of life and healthcare use and costs. Oral Dis 2010;16:3–10 the low prevalence of maternal smoking and drug use (eg, illicit or 26 14. Boulet SL, Grosse SD, Honein MA, et al. Children with orofacial clefts: nonillicit) among women during pregnancy. Kallen described a health-care use and costs among a privately insured population. Public relationship between maternal smoking and craniosynostosis and Health Rep 2009;124:447–453 27 also Gardner et al demonstrated an association between exposure 15. Sperber GH. Craniofacial Embryology. 4th ed. London, UK: Wright; to drugs during pregnancy and craniosynostosis. Moreover, large 1989 doses of radiation, infection, vitamin deficiencies, metabolic syn- 16. Johnston MC. Embryology of head and neck. In: McCarthy JG, ed. dromes, as well as Vitamin A toxicity during pregnancy contributed Plastic Surgery. Philadelphia, PA: Saunders; 1990:2451–2495 to the development of rare craniofacial clefts.28–30 Hence, edu- 17. da Silva Freitas R, Alonso N, Shin JH, et al. Surgical correction of cation for women of child-bearing age regarding the risk factors and Tessier number 0 cleft. J Craniofac Surg 2008;19:1348–1352 18. van der Meulen JC, Mazzola R, Vermey-Keers C, et al. A a genetic counseling for high-risk individuals have a key role in the morphogenetic classification of craniofacial malformations. Plast prevention of rare craniofacial clefts. Reconstr Surg 1983;71:560–572 According to the present study, the prevalence of rare cranio- 19. Morian R. About oblique facial clefts [in German]. Arch Klin Chir facial clefts in Iran is higher than global trends, but still infrequently 1887;35:245 affects individuals. Indeed, it confirms the impact of environmental, 20. Mishra RK, Purwar R. Formatting the surgical management of Tessier racial, and ethnic factors on the prevalence of clefts. cleft types 3 and 4. Indian J Plast Surg 2009;42 (suppl):S174–S183 Given that rare craniofacial clefts may be concurrent with 21. Woods RH, Varma S, David DJ. Tessier no. 7 cleft: a new extremities, respiratory system, neurological, teeth, and ophthalmic subclassification and management protocol. Plast Reconstr Surg involvement, the proper treatment can be provided by a multi- 2008;122:898–905 22. Alonso N, Freitas Rda S, de Oliveira e Cruz GA, et al. Tessier no. 4 disciplinary and cooperative team including plastic surgeon, neu- facial cleft: evolution of surgical treatment in a large series of patients. rosurgeon, ophthalmologist, orthodontics, otolaryngologist, and Plast Reconstr Surg 2008;122:1505–1513 orthopedics as well as psychiatrist for social and aesthetics-related 23. Portier-Marret N, Hohlfeld J, Hamedani M, et al. Complete bilateral 31–33 issues. facial cleft (Tessier 4) with corneal staphyloma: a rare association. J Pediatr Surg 2008;43:e15–e18 CONCLUSION 24. da Silva Freitas R, Alonso N, Shin JH, et al. The Tessier number 5 facial cleft: surgical strategies and outcomes in six patients. Cleft Palate As regards the importance of rare craniofacial clefts due to con- Craniofac J 2009;46:179–186 current involvement of other organs, psychosocial troubles, and 25. Fogh-Andersen P. Genetic and non-genetic factors in the etlology of treatment-related financial burden, more efforts should be made to facial clefts. Scand J Plast Reconstr Surg 1967;1:22–29 prevent pregnant women from exposure to risk factors during 26. Kallen K. Maternal smoking and craniosynostosis. Teratology pregnancy and also high-risk women of child-bearing age should 1999;60:146–150 be referred for genetic counseling. 27. Gardner JS, Guyard-Boileau B, Alderman BW, et al. Maternal exposure to prescription and non-prescription pharmaceuticals or drugs of abuse and risk of craniosynostosis. Int J Epidemiol 1998;27:64–67 28. Hunt JA, Hobar PC. Common craniofacial anomalies: facial clefts and REFERENCES . Plast Reconstr Surg 2003;112:606–615 1. Tessier P. Anatomical classification facial, cranio-facial and latero- 29. Murray JC. facts: genes, environment, and clefts. Am J Hum Genet facial clefts. J Maxillofac Surg 1976;4:69–92 1995;57:227–232 2. Kara IG, Ocsel H. The Tessier number 5 cleft with associated extremity 30. Moore LL, Singer MR, Bradlee ML, et al. A prospective study of the anomalies. Cleft Palate Craniofac J 2001;38:529–532 risk of congenital defects associated with maternal obesity and diabetes 3. Bradley JP, Hurwitz DJ, Carstens MH. Embryology, classifications, and mellitus. Epidemiology 2000;11:689–694 descriptions of craniofacial clefts. In: Mathes SJ, Hentz V, eds. Plastic 31. Forbes BJ. Congenital craniofacial anomalies. Curr Opin Ophthalmol Surgery. 2nd ed, Vol 4 Philadelphia, PA: Saunders Elsevier; 2006:15 2010;21:367–374

# 2017 Mutaz B. Habal, MD e469 Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Brief Clinical Studies The Journal of Craniofacial Surgery Volume 28, Number 5, July 2017

32. Speltz ML, Richman L. Progress and limitations in the psychological face width was significantly greater in the Colombian males and study of craniofacial anomalies. J Pediatr Psychol 1997;22:433–438 females. 33. Pope AW, Speltz ML. Research of psychosocial issues of children with Conclusions: Sexual dimorphism for facial features was presented craniofacial anomalies: progress and challenges. Cleft Palate Craniofac J 1997;34:371–373 in both the Colombian and Mexican-American populations. In addition, there were significant differences in facial morphology between these 2 populations.

Key Words: 3dMDface system, Colombian population, Mexican- Three-Dimensional American population Anthropometric Evaluation of nhancement of the facial appearance is one of the most import- E ant factors for patient seeking orthodontic treatment. Three- Facial Morphology dimensional (3D) imaging in orthodontics has been developing at a fast pace over the past 3 decades.1,2 Traditionally, for obtaining 3D Ahmet Arif Celebi, DDS, PhD, records, study models have been used by orthodontists, allowing Chung How Kau, DDS, PhD, y them to examine malocclusions from many viewpoints. At the time and Bunyamin Ozaydin, BS, PhD of this writing, digitization of 3D models by virtual technologies has been preferred by many clinicians.3 Two-dimensional diagnostic Objectives: The objectives of this study were to evaluate sexual methods, such as lateral cephalometric radiographs and profile dimorphism for facial features within Colombian and Mexican- photographs, have been replaced by 3D images used to diagnose American populations and to compare the facial morphology by sex malocclusions. Facial soft tissues obtained from 3D technology between these 2 populations. have the advantage of being able to provide an orthodontist with a more accurate representation of facial morphologies4 and can be Materials and Methods: Three-dimensional facial images were 5 acquired by using the portable 3dMDface system, which captured beneficial to better understand, compare, and predict outcomes before and after treatment.6 223 subjects from 2 population groups of Colombians (n ¼ 131) and The paradigm shift in treatment philosophies has been existing Mexican-Americans (n ¼ 92). Each population was categorized into for nearly 3 decades. This shift means that many orthodontists have male and female groups for evaluation. All subjects in the groups startedtoplanfromsofttissuesofthefacetoevaluatethe were aged between 18 and 30 years and had no apparent facial limitations of orthodontic treatment. The key determinant in anomalies. A total of 21 anthropometric landmarks were identified orthodontic diagnosis and treatment success now lies behind on the 3-dimensional of each subject. The independent t test patient’s limits of soft tissue adaptation and contours.7 Orthodon- was used to analyze each data set obtained within each subgroup. tists as well as maxillofacial and plastic surgeons may not be able to Results: The Colombian males showed significantly greater width make decisions for the treatment of racially diverse individuals on of the outercanthal width, eye fissure length, and orbitale than the the same basis of facial morphological standards. Therefore, in Colombian females. The Colombian females had significantly order to obtain an esthetic outcome, knowledge of the facial features and distinctive properties of populations with various smaller lip and mouth measurements for all distances except upper racial and ethnic backgrounds is essential information for a vermillion height than Colombian males. The Mexican-American clinician. females had significantly smaller measurements with regard to the The purpose of this study is to compare the facial morphologies nose than Mexican-American males. Meanwhile, the heights of the of an adult Mexican-American population with the facial face, the upper face, the lower face, and the were all morphologies of an adult Colombian population using a 3D surface significantly less in the Mexican-American females. The inter- imaging device. canthal and outercanthal widths were significantly greater in the Mexican-American males and females. Meanwhile, the orbitale MATERIALS AND METHODS distance of Mexican-American sexes was significantly smaller than Subjects were selected from 2 different study sites. One group of those of the Colombian males and females. The Mexican-American subjects consisting of 63 males and 68 females was selected from group had significantly larger nose width and length of alare than Cali, Colombia, and the other group of the subjects composed of 44 the Colombian group regarding both sexes. With respect to the nasal males and 48 females was from Houston, TX. Inclusion criteria tip protrusion and nose height, they were significantly smaller in the were as follows: an identifiable ethnic descent, no history of Colombian females than in the Mexican-American females. The previous orthodontic treatment, between 18 and 30 years of age, present with no adverse skeletal deviations (a basic orofacial From the Department of Orthodontics, University of Alabama School of examination was performed to exclude them), with a normal body Dentistry; and yHealth Informatics Program, University of Alabama at mass index value of 18.5 to 25, and no craniofacial or neuromus- Birmingham, Birmingham, AL. cular deformities. Ethical approval and informed consent for this Received December 21, 2016. study were obtained from the relevant institutional review boards Accepted for publication March 2, 2017. and the participants in the study. Address correspondence and reprint requests to Dr Chung How Kau, DDS, The imaging system used in this study was the portable PhD, Department of Orthodontics, University of Alabama School of 3dMDface system (3dMD LLC, Atlanta, GA), a structured light Dentistry, University of Alabama at Birmingham, 1919 Seventh Ave S, system combining stereophotogrammetry and the structured light Birmingham 35294, AL; E-mail: [email protected] technique.8 This system uses a multicamera configuration, with 3 The authors report no conflicts of interest. Copyright # 2017 by Mutaz B. Habal, MD cameras on each side (1 color and 2 infrared), that captures ISSN: 1049-2275 photorealistic quality pictures. A random light pattern is projected DOI: 10.1097/SCS.0000000000003773 onto a subject, and an image is captured with multiple synchronized e470 # 2017 Mutaz B. Habal, MD Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.