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Khan M, Hidayatullah, Hayat W, Khattak DA, Khan A, Hayat N, Amjad Q, Khan R. Rare craniofacial clefts: Surgical management protocols. J Plast Reconstr Aesthet Surg 2024; 97:41-49. [PMID: 39137523 DOI: 10.1016/j.bjps.2024.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 07/21/2024] [Accepted: 07/22/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Standardization of surgical protocols is an evolving issue owing to the low incidence of rare craniofacial clefts. In this article, we present our surgical management technique for repair of rare craniofacial clefts and evaluate the postoperative results. METHODS This study was conducted from 2013 to 2022 and included patients who presented with craniofacial clefts. The results were assessed based on parents' satisfaction and objective evaluations by two independent observers. RESULTS A total of 3679 patients presented with cleft anomalies; of these, 61 patients with 89 rare craniofacial clefts were observed with a prevalence of 2.42/100. The male to female ratio was 1:1.35. Craniofacial cleft "4" and "5" were the most common, with 17 (19.1%) and 16 (17.98%) patients, respectively. Multiple craniofacial clefts were observed in 37.7% of the patients. Associated craniofacial anomalies were found in 39.34% of the patients. The parents of 71.6% of the patients were very satisfied with the results. Based on the scores of two independent observers, 70.27% of the patients showed good results. CONCLUSION The rare nature of craniofacial clefts and involvement of various structures make the standardization of surgical procedures very challenging. Our experience with these clefts will help new surgeons both in didactics and in technical aspects of patient management. KEY POINTS 1. We share our experience with rare craniofacial clefts. 2. Each cleft presents with its own unique reconstructive challenges. The literature describes many techniques for each type of cleft, all with multiple permutations. We present a simplified technique that has worked for us over the years for all Tessier clefts.
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Affiliation(s)
- Mansoor Khan
- Burns & Plastic Surgery Center, Hayatabad Medical Complex, Peshawar, Pakistan
| | - Hidayatullah
- Burns & Plastic Surgery Center, Hayatabad Medical Complex, Peshawar, Pakistan
| | - Waqas Hayat
- Burns & Plastic Surgery Center, Hayatabad Medical Complex, Peshawar, Pakistan.
| | | | - Alamzeb Khan
- Saidu Hospital, Saidu Medical College, Swat, Pakistan
| | - Nasir Hayat
- Burns & Plastic Surgery Center, Hayatabad Medical Complex, Peshawar, Pakistan
| | - Qazi Amjad
- Burns & Plastic Surgery Center, Hayatabad Medical Complex, Peshawar, Pakistan
| | - Rashid Khan
- Burns & Plastic Surgery Center, Hayatabad Medical Complex, Peshawar, Pakistan
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Antic S, Bracanovic D, Janovic A, Krstic G, Plavsic D, Markovic Vasiljkovic B. Bilateral Maxillary Duplication in Tessier No. 7 Cleft: An Uncommon Congenital Deformity with a Challenging Radiological Diagnosis. Diagnostics (Basel) 2024; 14:714. [PMID: 38611628 PMCID: PMC11011745 DOI: 10.3390/diagnostics14070714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 03/22/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
Tessier No. 7 cleft, known as lateral facial cleft, is a rare and understudied entity with an incidence of 1/80,000-1/300,000 live births. Besides perioral tissue abnormalities manifesting as macrostomia, Tessier 7 cleft also involves anomalies of the underlying bony structures. It can appear as part of a syndrome, such as Treacher-Collins syndrome or Goldenhar/Orbito-Auriculo-Vestibular Spectrum, or as an isolated form (unilateral or bilateral) with variable expressions. Bilateral maxillary duplication in Tessier 7 cleft is considered extremely rare, accounting for only two previously presented cases. Given that the cases presented in the literature mainly focus on clinical appearance and surgical treatment, without providing sufficient imaging, we aim to present key radiological features of Tessier 7 cleft in terms of evaluating the involved structures, which is essential for the therapeutic approach and final outcome. A 17-year-old male with incompetent lips and orthodontic abnormalities was referred to our Radiology Department for orthopantomography (OPG) and CT examinations. Hetero-anamnestic data revealed a history of surgical treatment of the commissural cleft conducted 2 months after the birth to enable feeding. Intraoral examination showed a maxillary cleft and supernumerary teeth. Since the given clinical presentation was inconclusive, radiological diagnostics took precedence in elucidating this complex entity.
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Affiliation(s)
- Svetlana Antic
- Center for Radiological Diagnostics, School of Dental Medicine, University of Belgrade, 11000 Belgrade, Serbia; (D.B.); (A.J.); (G.K.); (D.P.)
| | | | | | | | | | - Biljana Markovic Vasiljkovic
- Center for Radiological Diagnostics, School of Dental Medicine, University of Belgrade, 11000 Belgrade, Serbia; (D.B.); (A.J.); (G.K.); (D.P.)
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Sundoro A, Hilmanto D, Soedjana H, Lesmana R, Septrina R, Hasibuan LY, Pramono GNTW. Refining macrostomia correction: Case series applying square flap technique and Z/W-plasty skin closure for enhanced aesthetic and functional outcome. Int J Surg Case Rep 2023; 113:109023. [PMID: 37956496 PMCID: PMC10661592 DOI: 10.1016/j.ijscr.2023.109023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 11/02/2023] [Accepted: 11/04/2023] [Indexed: 11/15/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Macrostomia is a congenital deformity found in Tessier no. 7 facial clefts defined as an enlargement of the mouth at the oral commissure. Several techniques are described in literature to achieve optimal functional and aesthetic results, with varying results and surgeon preferences. In this case series we report surgical repair of macrostomia with a vermillion square flap method for the oral commissure combined with either Z-plasty or W-plasty closure for the skin. CASES PRESENTATION A retrospective case analysis of 12 patients with macrostomia operated over the past 7 years at our plastic surgery division was performed (by two different operators; 11 cases by A.S. and 1 case by R.S.). Clinical features of the patients were analyzed through photography documentation, and patient description such as age of operation, operation technique, and complications were obtained through patient records. Macrostomia was corrected with a vermillion square flap method for commissure, overlapping muscle closure, along with either Z-plasty or W-plasty closure for the skin. Quality of lip commissure position, symmetry, thickness of vermillion, and scar result were recorded. CLINICAL DISCUSSION In all twelve patients repaired with the overlapping muscle closure and square flap, the lip commissures were formed with satisfactory shape, position, and thickness with no commissure contracture during the follow up period. The Z-plasty was a simpler method compared to the W-plasty, and resulted in comparable scars. One patient (adult with hemifacial macrostomia and W-plasty skin closure) underwent revision surgery for more accurate symmetry and position of the oral commissure. CONCLUSION There are many varieties of surgical repair for macrostomia, and each method should be adjusted and combined according to each patient. Overall, macrostomia repair with this technique combination produced satisfactory aesthetic and functional results in all twelve patients. Z-plasty for skin closure after muscle and vermillion closure was a simpler technique and resulted in comparable scars than W-pasty closure in this case series.
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Affiliation(s)
- Ali Sundoro
- Division of Plastic Reconstructive and Aesthetic Surgery, Department of Surgery, Faculty of Medicine Universitas Padjadjaran - Dr. Hasan Sadikin General Hospital, Bandung, Indonesia.
| | - Dany Hilmanto
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Hardisiswo Soedjana
- Division of Plastic Reconstructive and Aesthetic Surgery, Department of Surgery, Faculty of Medicine Universitas Padjadjaran - Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Ronny Lesmana
- Department of Basic Medical Science, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Rani Septrina
- Division of Plastic Reconstructive and Aesthetic Surgery, Department of Surgery, Faculty of Medicine Universitas Padjadjaran - Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Lisa Y Hasibuan
- Division of Plastic Reconstructive and Aesthetic Surgery, Department of Surgery, Faculty of Medicine Universitas Padjadjaran - Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Graciella Novian Triana Wahjoe Pramono
- Division of Plastic Reconstructive and Aesthetic Surgery, Department of Surgery, Faculty of Medicine Universitas Padjadjaran - Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
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Adhikari M, Jha K, Aryal S, Adhikari G. Comprehensive surgical reconstruction of Tessier number 7 congenital craniofacial cleft. A rare case report. Int J Surg Case Rep 2023; 111:108826. [PMID: 37716065 PMCID: PMC10509715 DOI: 10.1016/j.ijscr.2023.108826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/07/2023] [Accepted: 09/09/2023] [Indexed: 09/18/2023] Open
Abstract
Introduction and importance Tessier 7 craniofacial congenital cleft is a rare anomaly, occurring in about 1 in 80,000 to 1 in 300,000 live births, comprising 0.3% to 1.0% of total cleft cases. A total of 24 cases have been reported since 2000. This case is the 25th instance and possibly the first reported in Nepal. PRESENTATION OF THE CASE A 3-year-old child, accompanied by parents, presented at the Department of Oral and Maxillofacial Surgery with complaints of feeding difficulties, speech impediment, and aesthetic concerns. Diagnosis revealed Tessier number 7 congenital cleft. Surgical intervention successfully repaired the cleft, involving straight-line closure of mucosa and skin, suturing of perioral muscles to establish a new modiolus and formation of a new commissure. Postoperative follow-up over 6 months demonstrated excellent functional and aesthetic results without any complications. CLINICAL DISCUSSION Tessier 7 congenital cleft arises from anomalous fetal development, stemming from incomplete fusion of the maxillary and mandibular processes of the first pharyngeal arch. Surgical correction poses challenges due to atypical anatomical positioning and cleft appearance. The repair involves layered closure, linear mucosal closure, perioral muscle reorganization to establish a new modiolus, skin closure via straight-line or z-plasty techniques, culminating in the creation of a new commissure. CONCLUSION Given its rarity, surgeons must be well-versed in the intricate surgical protocol for Tessier 7 cleft treatment. Early intervention is crucial for optimal functional and cosmetic results. Key steps encompass establishing a new modiolus, forming a new commissure, and achieving effective skin closure.
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Affiliation(s)
- Manoj Adhikari
- Nepalese Army Institute of Health Sciences, College of Medicine, Affiliated to Tribhuvan University, Bhandarkhal, Sanobharyang, Kathmandu, Nepal.
| | - Kanistika Jha
- College of Medical Sciences, Affiliated to Kathmandu University, Bharatpur, Chitwan, Nepal
| | - Sameer Aryal
- Nepalese Army Institute of Health Sciences, College of Medicine, Affiliated to Tribhuvan University, Bhandarkhal, Sanobharyang, Kathmandu, Nepal
| | - Galav Adhikari
- Nepalese Army Institute of Health Sciences, College of Medicine, Affiliated to Tribhuvan University, Bhandarkhal, Sanobharyang, Kathmandu, Nepal
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Pellerin P, Tonello C, da Silva Freitas R, Tang XJ, Alonso N. Tessier's Cleft Number 6 Revisited: A Series of 26 new Cases and Literature Review of 44. Cleft Palate Craniofac J 2022:10556656221086459. [PMID: 35285292 DOI: 10.1177/10556656221086459] [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: 11/17/2022] Open
Abstract
OBJECTIVE To fix a gray zone left in Tessier's classification of rare clefts with cleft 6 and to give a more comprehensive description of cleft 6 anatomy. DESIGN The material used for the research was a series of 26 clinical cases of patients with assessed cleft 6 and 44 cases found out of a literature review with enough data to be useful. The 70 cases were cross-examined by the authors. STUDY SETTING The authors are senior craniofacial surgeons working in high-case load department from university centers where the patients are documented and receive primary as well as secondary treatment and follow-up. PATIENTS The patients were selected out of the series of craniofacial deformities taken care of by the authors' department as rare clefts. MAIN OUTCOME We describe the full spectrum of cleft 6 as an autonomous entity that could present itself in three subtypes: 6a is the most proximal and could be associated with cleft 8. The subtype 6b is medial toward the zygomatic arch and frequently associated with a bone and teeth appendage (frequently described as a "maxillary duplication"). The subtype 6C goes toward the external ear between the helix crus and the auditory meatus. CONCLUSIONS The Tessier's opinion is that Treacher Collins syndrome was the association of clefts 6, 7, and 8 and is no longer sustainable in the light of modern genetics. Most of the cleft 6 are misdiagnosed in the literature.
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Affiliation(s)
| | - Cristiano Tonello
- Cirurgia Craniofacial HRAC-USP, Curso de Medicina, da Universidade de São Paulo, Bauru, Brazil
| | | | - Xiao Jun Tang
- 74698Plastic Surgery Hospital of Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Nivaldo Alonso
- Cirurgia Craniofacial HRAC-USP, Curso de Medicina, da Universidade de São Paulo, Bauru, Brazil
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Song WL, Ma HO, Nan Y, Li YJ, Qi N, Zhang LY, Xu X, Wang YY. Prenatal diagnosis of isolated lateral facial cleft by ultrasonography and three-dimensional printing: A case report. World J Clin Cases 2021; 9:7196-7204. [PMID: 34540978 PMCID: PMC8409206 DOI: 10.12998/wjcc.v9.i24.7196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/17/2021] [Accepted: 07/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Lateral facial clefts are atypical with a low incidence in the facial cleft spectrum. With the development of ultrasonography (US) prenatal screening, such facial malformations can be detected and diagnosed prenatally rather than at birth. Although three-dimensional US (3DUS) can render the fetus' face via 3D reconstruction, the 3D images are displayed on two-dimensional screens without field depth, which impedes the understanding of untrained individuals. In contrast, a 3D-printed model of the fetus' face helps both parents and doctors develop a more comprehensive understanding of the facial malformation by creating more interactive aspects. Herein, we present an isolated lateral facial cleft case that was diagnosed via US combined with a 3D-printed model.
CASE SUMMARY A 31-year-old G2P1 patient presented for routine prenatal screening at the 22nd wk of gestation. The coronal nostril-lip section of two-dimensional US (2DUS) demonstrated that the fetus' bilateral oral commissures were asymmetrical, and left oral commissure was abnormally wide. The left oblique-coronal section showed a cleft at the left oral commissure which extended to the left cheek. The results of 3DUS confirmed the cleft. Furthermore, we created a model of the fetal face using 3D printing technology, which clearly presented facial malformations. The fetus was diagnosed with a left lateral facial cleft, which was categorized as a No. 7 facial cleft according to the Tessier facial cleft classification. The parents terminated the pregnancy at the 24th wk of gestation after parental counseling.
CONCLUSION In the diagnostic course of the current case, in addition to the traditional application of 2D and 3DUS, we created a 3D-printed model of the fetus, which enhanced diagnostic evidence, benefited the education of junior doctors, improved parental counseling, and had the potential to guide surgical planning.
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Affiliation(s)
- Wen-Ling Song
- Department of Obstetrics, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Hai-Ou Ma
- Prenatal Diagnosis Center, The Second Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Yu Nan
- Prenatal Diagnosis Center, The Second Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Yu-Jia Li
- Prenatal Diagnosis Center, The Second Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Na Qi
- Prenatal Diagnosis Center, The Second Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Li-Ying Zhang
- Prenatal Diagnosis Center, The Second Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Xin Xu
- Prenatal Diagnosis Center, The Second Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Yuan-Yi Wang
- Department of Spine Surgery, The First Hospital of Jilin University, Jilin Engineering Research Center for Spine and Spinal Cord, Changchun 130021, Jilin Province, China
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Eshete M, Banko MA, Hailu A, Brhanu A, Mossey P, Butali A. Amniotic band syndrome associated with extremely severe atypical clefts of the orofacial region. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01860-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AbstractAmniotic band syndrome (ABS) is not a commonly seen birth defect; however, it may have the potential to be severe and life-threatening requiring adequate attention. We present a severe case of amniotic band syndrome which encircled the head of the neonate tightly causing severe deformity. In this case report, the amniotic band encircled the head causing a severe bilateral Tessier 7 cleft. To our knowledge, this is the most severe type of ABS reported in the literature thus far.Level of evidence: Level V, risk / therapeutic study.
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Schwartz C, Philip S, Idicula W, Demke J. Unilateral Tessier 7 cleft: Case report of Z-plasty with geometric broken line repair and literature review. Int J Pediatr Otorhinolaryngol 2021; 140:110546. [PMID: 33310448 DOI: 10.1016/j.ijporl.2020.110546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 11/26/2022]
Abstract
Tessier 7 clefts are a rare congenital anomaly, usually surgically repaired with Z-plasty or other reconstructive methods, although undesirable scars may result. We present a review of the literature and a case of unilateral Tessier 7 cleft repaired with a novel reconstruction technique using a combined Z-plasty and geometric broken line closure (GBLC) to camouflage and irregularize the otherwise linear scar. We present this case to expand the armamentarium of surgical options to address Tessier 7 clefts and to review techniques for repair.
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Affiliation(s)
- Cynthia Schwartz
- Department of Otolaryngology-Head and Neck Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, 79430-8312, USA.
| | - Stacy Philip
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, 79430-8312, USA
| | - Winslo Idicula
- Department of Otolaryngology-Head and Neck Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, 79430-8312, USA; Division of Pediatric Otolaryngology.
| | - Joshua Demke
- Department of Otolaryngology-Head and Neck Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, 79430-8312, USA; Division of Facial Plastics Reconstruction.
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