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Surgical Strategy for the Treatment of Facial Clefts. SURGICAL TECHNIQUES DEVELOPMENT 2023. [DOI: 10.3390/std12010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Craniofacial clefts have an incidence of 1/700 [...]
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Rüegg EM, Bartoli A, Rilliet B, Scolozzi P, Montandon D, Pittet-Cuénod B. Management of median and paramedian craniofacial clefts. J Plast Reconstr Aesthet Surg 2019; 72:676-684. [PMID: 30691993 DOI: 10.1016/j.bjps.2019.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 01/06/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Median and paramedian craniofacial clefts are associated with hypertelorism, anterior encephalocele, positional abnormalities of the maxilla, and nasal deformity. Cleft lip and palate, eyelid coloboma, and widow's peak are frequently present. METHODS The authors collected data from 30 patients (mean age, 5.8 years; range, 4 months to 18 years) operated between 1986 and 2017 with median or paramedian craniofacial clefts of differing degrees of severity. Malformations of the different anatomic units and their surgical treatment were assessed, as well as complication rates. RESULTS All patients presented nasal malformations and either telecanthus (n = 16) or hypertelorism (n = 14). Most patients (n = 23) had anterior encephalocele. All patients underwent nasal corrections, and most of them had medial canthopexy (n = 24). Excision of encephalocele was associated with fronto-orbital remodeling. Medialization of the orbits was performed in 11 patients, mainly by box shift (n = 9). Patients from outside Switzerland (n = 23) were operated at an older age than those in the native patient group. Because of staged reconstruction, 13 patients had more than one operation. Surgical complications included three infections and one expander exposition. One patient had bone resorption of a frontal bone flap. Nasal correction needed more than one procedure in 5 patients, and medial canthopexy had to be repeated in 7 patients. Esthetic results were satisfactory, permitting social integration. CONCLUSION Median and paramedian craniofacial clefts need adapted and carefully planned corrections respecting the growth of anatomic units. The quality of the medial canthal and nasal reconstruction is to a large extent responsible for the overall result.
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Affiliation(s)
- Eva Meia Rüegg
- Division of Plastic, Reconstructive and Esthetic Surgery, Department of Surgery, Geneva University Hospitals and Faculty of Medicine, 4 Rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland.
| | - Andrea Bartoli
- Division of Neurosurgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Bénédict Rilliet
- Division of Neurosurgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Paolo Scolozzi
- Division of Maxillofacial Surgery, Department of Surgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Denys Montandon
- Division of Plastic, Reconstructive and Esthetic Surgery, Department of Surgery, Geneva University Hospitals and Faculty of Medicine, 4 Rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland
| | - Brigitte Pittet-Cuénod
- Division of Plastic, Reconstructive and Esthetic Surgery, Department of Surgery, Geneva University Hospitals and Faculty of Medicine, 4 Rue Gabrielle Perret-Gentil, 1211 Geneva 14, Switzerland
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Esenlik E, Aydın MA, Spolyar JL. Serial Presurgical Orthopedics for Eye Repositioning and Optimization of Soft-Tissue Repair in an Infant With Tessier No. 4 Cleft. Cleft Palate Craniofac J 2015; 53:481-90. [PMID: 26120884 DOI: 10.1597/15-031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE A male patient with Tessier No. 4 cleft (unilateral left) presented at 20 days of age. The cleft defect beginning between the cupid bow and oral commissure extended to the ipsilateral orbital floor, skirting the nose and lacrimal duct while passing through the cheek medial to the infraorbital nerve. With the lesser segment disposed 16 mm transversely, the wide gap included an absence of orbital floor and lower eyelid. A deficient midfacial platform caused a severe inferior globe dystopia, superiorly displaced left ala base, and severe vertical shortening between ala-canthus and ala-globe. INTERVENTION A modified Latham device applied directional orthopedics to contract the cleft gap and with an eye part added to elevate the dystopic globe. Two different Latham devices used in succession were each applied for 4 weeks. Lastly, a removable plate further repositioned the eye. Each appliance was designed to differentially move the noncleft and cleft segments of the maxilla. Presurgical orthopedics began at 3 weeks lasted 14 weeks. Intraoperatively at 17 weeks, the inferior globe dystopia was effectively reduced, and the cleft gaps were nearly closed and aligned at the orbital floor, cheek, and the alveolus. Respecting the aesthetic units of face became possible with the soft-tissue repair yet were tight enough in the malar region to retract the lower lid. CONCLUSION The presurgical directional orthopedic and eye-globe mechanics were sufficient to enable medial canthal repositioning, sustainable correction of orbital distopia, and optimized primary soft-tissue repair. Early result suggests that surgery with presurgical orthopedics is superior to surgery alone.
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Mathijssen IM, Versnel SL. Craniofacial clefts. Plast Reconstr Surg 2015. [DOI: 10.1002/9781118655412.ch20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Sesenna E, Anghinoni ML, Modugno AC, Magri AS. Tessier 3 cleft with bilateral anophthalmia: case report and surgical treatment. J Craniomaxillofac Surg 2012; 40:690-3. [PMID: 22266226 DOI: 10.1016/j.jcms.2011.12.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 12/22/2011] [Accepted: 12/22/2011] [Indexed: 11/17/2022] Open
Abstract
Tessier clefts type 3 and 4 are rare. In this paper the authors report on the management of a wide Tessier 3 cleft. There is no standardized protocol or timing of the surgical procedures in this rare disfiguring condition. Generally speaking, the aim is to preserve the function of important anatomical structures (e.g., a seeing eye.) and reconstruct, as best as possible, harmonic facial features. The authors present a "step by step" solution of the malformation pointing out the limitations of the surgical procedures they used and the goals they wanted to obtain. Despite of the uniqueness and the complexity of the pathology, the authors think they obtained reasonable results both in term of function and aesthetics, permitting the patient to be accepted in the social environment.
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Affiliation(s)
- Enrico Sesenna
- Maxillo-Facial Surgery Division, Head and Neck Department, University and Hospital of Parma, Parma, Italy
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Abenavoli FM. Letters to the editor. Cleft Palate Craniofac J 2011; 49:122. [PMID: 21942730 DOI: 10.1597/11-192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Fabio Massimo Abenavoli
- "San Pietro" Hospital, Fatebenefratelli, Via Cassia 600, Rome, Italy, President, Smile Train Onlus Italia
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van den Elzen MEP, Versnel SL, Wolvius EB, van Veelen MLC, Vaandrager JM, van der Meulen JC, Mathijssen IMJ. Long-term results after 40 years experience with treatment of rare facial clefts: Part 2--Symmetrical median clefts. J Plast Reconstr Aesthet Surg 2011; 64:1344-52. [PMID: 21616735 DOI: 10.1016/j.bjps.2011.04.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 04/19/2011] [Accepted: 04/22/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND Median facial clefts are reconstructive challenges, requiring multiple operations throughout life. Long-term results are often still far from ideal and could be improved. Due to surgical intervention and diminished intrinsic growth potential, surgical results may change from initially good into a progressively disappointing outcome. If, however, the ideal timing and type of surgery are known, in combination with the intrinsic growth potential, the results can be ameliorated. A guideline for surgical treatment is given. METHODS Twenty patients with a pure symmetrical median cleft were evaluated on intermediate and long-term surgical results. The final result was scored based on severity of the initial and the remaining facial deformities, and the need for revisional surgery. RESULTS The long-term surgical outcome was initially good for each of the affected facial parts and the face in general, but worsened over time, especially in the zone of the nose. An adequate and stable result of hypertelorism correction was observed for both the orbital box osteotomy and medial faciotomy, even when performed at a young age. CONCLUSIONS The intrinsic growth restriction is mainly localised in the central midface. This leads to a complex and often unpredictable growth of the maturing face. It makes it difficult to achieve perfect reconstructions. Caution with surgical interventions of the nose at a young age is required. Once the face has matured, a midface advancement and secondary nose correction should be considered for satisfactory projection. Early referral to a specialised centre is essential.
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Affiliation(s)
- Marijke E P van den Elzen
- Department of Plastic and Reconstructive Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands.
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Twigg SR, Versnel SL, Nürnberg G, Lees MM, Bhat M, Hammond P, Hennekam RC, Hoogeboom AJM, Hurst JA, Johnson D, Robinson AA, Scambler PJ, Gerrelli D, Nürnberg P, Mathijssen IM, Wilkie AO. Frontorhiny, a distinctive presentation of frontonasal dysplasia caused by recessive mutations in the ALX3 homeobox gene. Am J Hum Genet 2009; 84:698-705. [PMID: 19409524 PMCID: PMC2681074 DOI: 10.1016/j.ajhg.2009.04.009] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Revised: 04/03/2009] [Accepted: 04/14/2009] [Indexed: 01/06/2023] Open
Abstract
We describe a recessively inherited frontonasal malformation characterized by a distinctive facial appearance, with hypertelorism, wide nasal bridge, short nasal ridge, bifid nasal tip, broad columella, widely separated slit-like nares, long philtrum with prominent bilateral swellings, and midline notch in the upper lip and alveolus. Additional recurrent features present in a minority of individuals have been upper eyelid ptosis and midline dermoid cysts of craniofacial structures. Assuming recessive inheritance, we mapped the locus in three families to chromosome 1 and identified mutations in ALX3, which is located at band 1p13.3 and encodes the aristaless-related ALX homeobox 3 transcription factor. In total, we identified seven different homozygous pathogenic mutations in seven families. These mutations comprise missense substitutions at critical positions within the conserved homeodomain as well as nonsense, frameshift, and splice-site mutations, all predicting severe or complete loss of function. Our findings contrast with previous studies of the orthologous murine gene, which showed no phenotype in Alx3(-/-) homozygotes, apparently as a result of functional redundancy with the paralogous Alx4 gene. We conclude that ALX3 is essential for normal facial development in humans and that deficiency causes a clinically recognizable phenotype, which we term frontorhiny.
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Affiliation(s)
- Stephen R.F. Twigg
- Weatherall Institute of Molecular Medicine, University of Oxford, Oxford OX3 9DS, UK
| | - Sarah L. Versnel
- Department of Plastic and Reconstructive Surgery, Erasmus Medical Center, 3000 CB Rotterdam, The Netherlands
| | - Gudrun Nürnberg
- Cologne Center for Genomics and Institute for Genetics, University of Cologne, D-50674 Cologne, Germany
| | - Melissa M. Lees
- Department of Clinical Genetics, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
- North Thames Cleft Centre, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
| | | | - Peter Hammond
- Molecular Medicine Unit, Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Raoul C.M. Hennekam
- Department of Clinical Genetics, Great Ormond Street Hospital for Children, London WC1N 3JH, UK
- Clinical and Molecular Genetics Unit, Institute of Child Health, University College London, London WC1N 1EH, UK
- Department of Pediatrics, Academic Medical Centre, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | | | - Jane A. Hurst
- Department of Clinical Genetics, Oxford Radcliffe Hospitals NHS Trust, Oxford OX3 9DU, UK
- Department of Plastic and Reconstructive Surgery, Oxford Radcliffe Hospitals NHS Trust, Oxford OX3 9DU, UK
| | - David Johnson
- Department of Plastic and Reconstructive Surgery, Oxford Radcliffe Hospitals NHS Trust, Oxford OX3 9DU, UK
| | - Alexis A. Robinson
- Neural Development Unit, Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Peter J. Scambler
- Molecular Medicine Unit, Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Dianne Gerrelli
- Human Developmental Biology Resource, Institute of Child Health, University College London, London WC1N 1EH, UK
| | - Peter Nürnberg
- Cologne Center for Genomics and Institute for Genetics, University of Cologne, D-50674 Cologne, Germany
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, D-50674 Cologne, Germany
- Center for Molecular Medicine Cologne, University of Cologne, D-50931 Cologne, Germany
| | - Irene M.J. Mathijssen
- Department of Plastic and Reconstructive Surgery, Erasmus Medical Center, 3000 CB Rotterdam, The Netherlands
| | - Andrew O.M. Wilkie
- Weatherall Institute of Molecular Medicine, University of Oxford, Oxford OX3 9DS, UK
- Department of Clinical Genetics, Oxford Radcliffe Hospitals NHS Trust, Oxford OX3 9DU, UK
- Department of Plastic and Reconstructive Surgery, Oxford Radcliffe Hospitals NHS Trust, Oxford OX3 9DU, UK
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Sieg P, Hakim SG, Jacobsen HC, Saka B, Hermes D. Rare facial clefts: treatment during charity missions in developing countries. Plast Reconstr Surg 2005; 114:640-7. [PMID: 15318038 DOI: 10.1097/01.prs.0000130934.26961.29] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
During 10 charity missions in developing countries, 14 patients of a total of 374 children with cleft lip and palate deformities were treated for rare facial clefts. There were three midline clefts (Tessier no. 0 cleft, n = 1; Tessier no. 14 cleft, n = 2), four oblique facial clefts (Tessier no. 3 cleft, n = 2; Tessier no. 5 cleft, n = 2), and seven lateral facial clefts (Tessier no. 7 cleft). Surgical treatment focused on cleft repair by soft-tissue reconstruction apart from two Tessier no. 14 clefts, in which the bony gap was also closed using bone grafts from the iliac crest. The postoperative course was uneventful except for one local wound infection that was treated successfully using oral antibiotics. This article summarizes the authors' experience with the surgical management of these malformations and considers the limitations under conditions of charity missions in developing countries. Furthermore, some rare forms of cleft formation are added to the existing literature.
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Affiliation(s)
- Peter Sieg
- Department of Maxillofacial Surgery, University Hospital Schleswig-Holstein, Campus Luebeck, Germany.
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Sari A, Yavuzer R, Ozmen S, Tuncer S, Latifoglu O. Early bone grafting in Tessier number 4 cleft: a case report. J Craniofac Surg 2003; 14:406-10; discussion 411-2. [PMID: 12826812 DOI: 10.1097/00001665-200305000-00021] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Rare craniofacial clefts have an incidence of at least 1 per 100,000 live births. A Tessier number 4 cleft is one of the most rare craniofacial clefts, with less than 50 cases being reported in the literature. Both soft and bony tissue abnormalities take place in the cleft morphology, so not only clinical examination of the maxillofacial region but a detailed radiological workup is needed to assess clearly the nature of the clefts. A patient with a Tessier number 4 cleft is presented, whose bony defect was obliterated with autogenous iliac bone graft chips and soft tissue reconstruction was performed with multiple Z-plasty flaps. Postoperative clinical and radiological results demonstrate fine healing and good cosmesis. Although controversy still exists about the treatment of facial clefts with early bone grafts, advantages of performing both bony and soft tissue reconstructions in a single session make this treatment a good alternative with satisfactory clinical and radiological results.
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Affiliation(s)
- Alper Sari
- Department of Plastic and Reconstructive Surgery, Medical Faculty, Gazi University, Ankara, Turkey
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Abstract
Congenital craniofacial abnormalities frequently require ophthalmic evaluation and surgical management. Called upon to perform as part of the craniofacial team managing the often severely deformed craniofacial patient, the ophthalmologist must bring a basic knowledge of craniofacial syndromes and developmental anatomy, as well as clinical acumen to help preserve or improve ocular and adnexal function. As an introduction to this area of ophthalmology, the clinical features, classification, appropriate facial embryology, assessment and surgical considerations of the various congenital craniofacial abnormalities are reviewed. The expanding availability of craniofacial surgeons and surgical teams along with improved surgical results will ultimately require an increasing involvement by many more ophthalmologists in the evaluation and management of these congenital abnormalities.
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Affiliation(s)
- P D Fries
- Division of Ophthalmology, Children's Hospital of Philadelphia, Pennsylvania
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