Craniofrontonasal dysplasia: a surgical treatment algorithm. Plast Reconstr Surg. 2007;120:1943-1956. [PMID: 18090758 DOI: 10.1097/01.prs.0000287286.12944.9f]

Structural Rhinoplasty as an Effective Surgical Approach for Frontonasal Dysplasia

Frontonasal dysplasia (FND), a rare congenital craniofacial disorder, primarily influences the development of midline craniofacial structures. A notable manifestation of this condition is nasal hypoplasia. This report details the treatment of a 19-year-old male patient diagnosed with FND accompanied by a severe case of nasal hypoplasia. The authors used structural rhinoplasty to achieve total nasal reconstruction. Albeit with some minor sequelae, the outcome of this surgery was markedly positive, enhancing both the cosmetic appearance and functional capacity of the nose. This case underscores the effectiveness of structural rhinoplasty as a feasible therapeutic approach for individuals suffering from FND and its associated nasal hypoplasia.

A Unique Appliance for Median Facial Cleft Management With Sleep Apnea due to Undeveloped Nasal Septum: A Rare Case Report

The role of a prosthodontist in the management of facial cleft patients is the restoration of feeding, respiration, facial harmony, dental harmony and phonation. This case report presents the fabrication of an appliance for a pediatric patient with congenital median facial cleft who had sleep apnea due to the absence of nasal septum, which is a rare condition, with a unique method that fulfilled the patient's needs and improved quality of life. The patient also had median cleft lip and premaxilla along with hypertelorism.

Rhinoplasty in a 3 Week Old: Surgical Challenges in the Setting of Severe Congenital Frontonasal Dysplasia

OBJECTIVES

Congenital frontonasal dysplasia (CFND) is a rare heterogeneous collection of facial deformities. Due to the range of complexity, surgical management is not standardized.

METHODS

We present a severe case of CFND and approach to managing multiple defects with a focus on rhinoplasty.

RESULTS

This infant was born full term with a large mass instead of a nose, a bilateral cleft lip and palate, and hypertelorbitism. Our primary concerns initially were to address communication with the intracranial cavity, preserve a nasal lining, and improve nasal appearance and airway function in the short term without interfering with subsequent rhinoplasty and adult nasal appearance.

CONCLUSIONS

This complex case of CFND is more severe than anything we encountered in our literature review and demonstrates the necessity for multidisciplinary approach to multiple craniofacial defects. Future plans for this patient include rhinoplasty with auricular graft, scar revision, and addressing tip support.

Craniofrontonasal dysplasia: hypertelorism correction in late presenting patients

BACKGROUND

Craniofrontonasal dysplasia (CFND) is a rare congenital craniofacial syndrome characterized by single suture synostosis, hypertelorism, other clinical facial features, and abnormalities in the upper extremities. There are only a few studies in the applicable literature that address hypertelorism management for CFND patients and outcomes and complication rates.

METHODS

A retrospective study was performed on consecutive late presenting CFND patients referred to our hospital with substantially completed craniofacial skeleton growth, who underwent hypertelorism correction between 2007 and 2019 following intracranial pressure screening, and who received at least 1 year of follow-up care. None of the patients in this study underwent prior craniofacial surgery. Only those patients with a confirmed mutation of the EFNB1 gene were included in this study. All patients in this study underwent hypertelorism correction by facial bipartition or box osteotomy.

RESULTS

A total of ten late presenting CFND patients (all female) were treated at our hospital during the study period. None of the patients presented signs of elevated intracranial pressure. The average patient age at hypertelorism correction was 13.4 ± 7.68 years of age. Major complications, defined as complications requiring a return to the operating room, were limited to infection of the frontal bone, which required partial bone removal, and cerebrospinal fluid (CSF) leak, which was completely resolved by insertion of a lumbar shunt for a 7-day period.

CONCLUSION

The absence of elevated intracranial pressure enables hypertelorism correction in late presenting CFND patients via facial bipartition or box osteotomy without the need for additional operations that provide for cranial expansion.

Nasal Reconstruction of a Frontonasal Dysplasia via Septal L-Strut Reconstruction Using Costal Cartilage

OBJECTIVE

Frontonasal dysplasia (FND) is a rare congenital condition. Its major features include hypertelorism, a large and bifid nasal tip, and a broad nasal root. We present our technique of septal L-strut reconstruction using costal cartilage.

DESIGN

Retrospective review from June 2008 and August 2017.

METHODS

Under general anesthesia, 6 patients with FND underwent septal reconstruction using costal cartilage via open rhinoplasty. We reconstructed the nasal and septal cartilaginous framework by placing columellar struts and cantilever-type grafts.

RESULTS

The patients ranged in age from 6 to 13 years old. All were female. The follow-up period ranged from 8 months to 2 years; we encountered no postoperative complications (infection, nasal obstruction, or recurrence). All patients were satisfied with their nasal appearance.

CONCLUSIONS

Although the results were not entirely satisfactory from an esthetic point of view, we found that FND can be treated via septal reconstruction with costal cartilage and that the clinical outcomes are reliable and satisfactory. Our approach is a useful option for FND patients.

Long-Term Photogrammetric- and Panel Assessment-Based Outcome Study of Staged Reconstructive Approach for Hypertelorism Correction

BACKGROUND

The surgical management of hypertelorism is challenging for plastic surgeons, and limited long-term outcome data are available. The purpose of this long-term study was to report a single-surgeon experience with a staged reconstructive protocol for hypertelorism correction.

METHODS

This retrospective study reviewed the records of patients with hypertelorism who were surgically managed by a single surgeon between 1978 and 2000. Bone (orbital box osteotomy and orthognathic surgery) and soft tissue (rhinoplasty and epicanthoplasty) surgeries were performed based on a patient-specific surgical protocol. Included patients were divided into a childhood group and an adolescence or adulthood group according to their age at orbital repositioning (≤12 and >12 years, respectively). Patients were invited for clinical interviews in February 2020 to evaluate whether requests for revision surgery had been made. The photogrammetric analysis-based hypertelorism index was calculated at preoperative and long-term postoperative times. Satisfaction with the long-term outcome was judged by both surgical professionals and laypeople.

RESULTS

In total, 14 patients with hypertelorism of different etiologies were included, with no request for revision surgery during an average follow-up of 29 years. The preoperative hypertelorism index was higher than the long-term postoperative evaluation (all, P < 0.05) for both childhood and adolescence or adulthood groups. Intergroup comparison revealed no significant difference for the hypertelorism index and panel assessment-based satisfaction with long-term outcome analysis (all, P > 0.05).

CONCLUSIONS

Considering the complexity and wide spectrum of clinical presentation of soft tissue and bone deformities in hypertelorism and current outcomes, the surgical approach to these patients should be staged and individualized for achievement of a balanced result between functional (orbital, occlusion, and psychosocial) and aesthetic parameters.

Case Report and Review of the Literature: Congenital Diaphragmatic Hernia and Craniosynostosis, a Coincidence or Common Cause?

Congenital diaphragmatic hernia (CDH) is a life-threatening birth defect that presents as either an isolated diaphragm defect or as part of a complex disorder with a wide array of anomalies (complex CDH). Some patients with complex CDH display distinct craniofacial anomalies such as craniofrontonasal dysplasia or craniosynostosis, defined by the premature closure of cranial sutures. Using clinical whole exome sequencing (WES), we found a BCL11B missense variant in a patient with a left-sided congenital diaphragmatic hernia as well as sagittal suture craniosynostosis. We applied targeted sequencing of BCL11B in patients with craniosynostosis or with a combination of craniosynostosis and CDH. This resulted in three additional BCL11B missense mutations in patients with craniosynostosis. The phenotype of the patient with both CDH as well as craniosynostosis was similar to the phenotype of previously reported patients with BCL11B missense mutations. Although these findings imply that both craniosynostosis as well as CDH may be associated with BCL11B mutations, further studies are required to establish whether BCL11B variants are causative mutations for both conditions or if our finding was coincidental.

Extracranial midline defects in a patient with craniofrontonasal syndrome with a novel EFNB1 mutation

We report a female patient with craniofrontonasal syndrome (CFNS) who in addition showed other cranial and extracranial midline defects including partial corpus callosum agenesis, ocular melanocytosis, pigmentary glaucoma, duplex collecting system, uterus didelphys, and septate vagina. She was found to have a novel pathogenic variant in exon 5 of EFNB1, c.646G>T (p.Glu216*) predicted to cause premature protein truncation. From our review, we found at least 39 published CFNS patients with extracranial midline defects, comprising congenital diaphragmatic hernia, congenital heart defects, umbilical hernia, hypospadias, and less frequently, sacrococcygeal teratomas, and internal genital anomalies in females. These findings support that the EFNB1 mutations have systemic consequences disrupting morphogenetic events at the extracranial midline. Though these are not rigorously included as midline defects, we found at least 10 CFNS patients with congenital anomalies of the kidney and urinary tract, all females. Additionally, uterus didelphys and ocular melanocytosis observed in our patient are proposed also as a previously unreported EFNB1-related midline defects. In addition, this case may be useful for considering the intentional search for genitourinary anomalies in future patients with CFNS, which will be helpful to define their frequency in this entity.

Frontonasal dysplasia: A case report

Frontonasal dysplasia is an uncommon congenital anomaly with diverse clinical phenotypes and highly variable clinical characteristics, including hypertelorism, a broad nasal root, median facial cleft, a missing or underdeveloped nasal tip, and a widow’s peak hairline. Frontonasal dysplasia is mostly inherited and caused by the ALX genes (ALX1, ALX3, and ALX4). We report a rare case of a frontonasal dysplasia patient with mild hypertelorism, a broad nasal root, an underdeveloped nasal tip, an accessory nasal tag, and a widow’s peak. We used soft tissue re-draping to achieve aesthetic improvements.

Costochondral Grafting for Nasal Airway Reconstruction in an Infant With Frontonasal Dysplasia

Frontonasal dysplasia (FND) is a congenital malformation of the central portion of the face, including the eyes, nose, and forehead. Owing to its rarity and wide spectrum of phenotypes, the optimal timing and technique of surgery remain controversial. Here, we report a case of a patient with FND, who presented with respiratory distress. The deformed nostrils were so small that the patient could not normally breathe through the nose immediately after birth. Rhinoplasty using a costochondral graft was performed at 16 months of age. After surgery, the nostrils enlarged and the appearance of the nose improved. Although congenital nasal deformity is frequently corrected during adolescence, surgery at an early stage can be considered when important issues are noted, such as inability to breathe through the nose.

Syndromic Craniosynostosis: Complexities of Clinical Care

Patients with syndromic craniosynostosis have a molecularly identified genetic cause for the premature closure of their cranial sutures and associated facial and extra-cranial features. Their clinical complexity demands comprehensive management by an extensive multidisciplinary team. This review aims to marry genotypic and phenotypic knowledge with clinical presentation and management of the craniofacial syndromes presenting most frequently to the craniofacial unit at Great Ormond Street Hospital for Children NHS Foundation Trust.

Surgical approach of hypertelorbitism in craniofrontonasal dysplasia

OBJECTIVE

to present our experience in the hypertelorbitism surgical treatment in craniofrontonasal dysplasia.

METHODS

retrospective analysis of craniofrontonasal dysplasia patients operated through orbital box osteotomy or facial bipartition between 1997 and 2015. Surgical data was obtained from medical records, complementary tests, photographs, and clinical interviews. Surgical results were classified based on the need for additional surgery and orbital relapse was calculated.

RESULTS

seven female patients were included, of whom three (42.86%) underwent orbital box osteotomy and four (57.14%) underwent facial bipartition. There was orbital relapse in average of 3.71±3,73mm. Surgical result according to the need for further surgery was 2.43±0.53.

CONCLUSION

surgical approach to hypertelorbitism in craniofrontonasal dysplasia should be individualized, respecting the age at surgery and preferences of patients, parents, and surgeons.

Using Photovoice to Explore Quality of Life Factors of Adults With Crouzon Syndrome

In the United States, one in 60,000 adults live with Crouzon Syndrome (CS) and facial malformations. Phenomenological studies about their lived experiences and quality of life are lacking. The purpose of this participatory action research study was to gain a richer understanding of the perceived biopsychosocial and socioecological factors that impact quality of life for adults living with CS using Photovoice. Another aim was to develop a conceptual framework of quality of life for those experiencing CS to enhance tailored health education and services. A purposeful sample of nine adults with CS were recruited from U.S. national surgery centers and support groups. Participants used photography to represent their experiences and participated in individual interviews and focus groups. Data were analyzed with the participants using thematic analysis, and 44 themes emerged which informed the development of a quality of life conceptual framework and action plan described in this article.

Indications for Computer-Aided Design and Manufacturing in Congenital Craniofacial Reconstruction

The complex three-dimensional relationships in congenital craniofacial reconstruction uniquely lend themselves to the ability to accurately plan and model the result provided by computer-aided design and manufacturing (CAD/CAM). The goal of this study was to illustrate indications where CAD/CAM would be helpful in the treatment of congenital craniofacial anomalies reconstruction and to discuss the application of this technology and its outcomes. A retrospective review was performed of all congenital craniofacial cases performed by the senior author between 2010 and 2014. Cases where CAD/CAM was used were identified, and illustrative cases to demonstrate the benefits of CAD/CAM were selected. Preoperative appearance, computerized plan, intraoperative course, and final outcome were analyzed. Preoperative planning enabled efficient execution of the operative plan with predictable results. Risk factors which made these patients good candidates for CAD/CAM were identified and compiled. Several indications, including multisuture and revisional craniosynostosis, facial bipartition, four-wall box osteotomy, reduction cranioplasty, and distraction osteogenesis could benefit most from this technology. We illustrate the use of CAD/CAM for these applications and describe the decision-making process both before and during surgery. We explore why we believe that CAD/CAM is indicated in these scenarios as well as the disadvantages and risks.

Parry-Romberg reconstruction: beneficial results despite poorer fat take

OBJECTIVE

For the treatment of Parry-Romberg syndrome or progressive hemifacial atrophy, we studied the volume retention and skin changes after autologous fat grafts within diseased regions.

SUMMARY BACKGROUND DATA

The long-term survival and volume retention of fat grafts used in soft tissue reconstruction of Parry-Romberg syndrome is still unknown, as are skin changes after fat grafting.

METHODS

Sex, age, severity of deformity, number of procedures, operative times, and augmentation volumes were recorded. Preoperative/postoperative 3-dimensional computed tomographic scans were also reviewed. A digital 3-dimensional photogrammetry system was used to determine "final fat take" and symmetry. Romberg fat grafting volumes were compared to nonaffected, cosmetic fat-grafted patients. For skin changes, a spectrophotometer was used to quantify percent improvement in melanin index. Physician and patient satisfaction surveys (5-point scale) were elicited, including overall outcome and skin color/texture.

RESULTS

The mean number of procedures correlated to the severity of deformity: mild, 1.8 procedures; moderate, 3.4; and severe, 5.2. With Romberg patients, fat grafting injected: per case, 48 mL; total, 188 mL; and final measured volume, 101 mL. Romberg patients had less "fat take" than nonaffected grafted patients (final take, 41% vs 81%). Skin color/texture showed 3-fold improvement after fat grafting procedures. The mean melanin index improvement seen in the diseased regions of Romberg patients after fat grafting was 42% (+3%). Skin color and texture improvement was also shown in patient surveys (preoperative = 2.4 + 0.06 to follow-up = 3.4 + 0.09) and physician (preoperatively = 2.1 + 0.1 to follow-up = 3.6 + 0.1).

CONCLUSIONS

Despite poorer fat graft take within the disease region of Romberg patients, fat grafting resulted in long-term improvement in hypoplasia and skin hyperpigmentation.

Hypertelorism and micro-orbit simultaneous correction in a patient with paramedian bilateral facial clefts

The aim of this paper is to report a case of a patient with paramedian bilateral facial clefts and hypertelorism associated with a severe encephalocele and micro-orbit. The patient required a facial bipartition to correct a transsphenoidal encephalocele, and a modified medialization surgery of the orbits to simultaneously expand the micro-orbit and correct the hypertelorism. These procedures achieved hypertelorbitism correction, orbital expansion which allowed symmetrical facial growth, and a functional orbit that permitted the use of an ocular prosthesis. We present this unique case to highlight the predictable results of a procedure that combines 2 surgical reproducible techniques of craniofacial surgery.

Application of computer techniques in repair of oblique facial clefts with outer-table calvarial bone grafts

OBJECTIVE

This study focused on the application of computer-aided and rapid prototyping techniques in the repair of oblique facial clefts with outer-table calvarial bone.

METHODS

Five patients with oblique facial clefts underwent repair with outer-table calvarial bone. A mirror technique and rapid prototyping techniques were applied to design and prefabricate the individualized template for the preoperative repair of orbital inferior wall and maxillary anterior wall defects. Using computer software, the ideal region from which to take outer-table calvarial bone was located according to the size and surface curvature of the individualized template. During the operation, outer-table calvarial bone was fixed according to the shape of the individualized template, and bone onlay grafting was carried out after appropriate trimming. Surgical accuracy was evaluated by comparing the preoperative and postoperative 3-dimensional reconstructed images.

RESULTS

With computer-aided and rapid prototyping techniques, all 5 patients had an ideal clinical outcome with few complications. The 3-dimensional preoperative design images and postoperative images fit well. Six-month to 8-year postoperative follow-up demonstrated that 4 patients had good aesthetic facial appearances and 1 had developed recurrence of lower eyelid shortage.

CONCLUSIONS

Computer-aided and rapid prototyping techniques can offer surgeons the ability to accurately design individualized templates for craniofacial deformity and perform a simulated operation for greatly improved surgical accuracy. These techniques are useful treatment modalities in the surgical management of oblique facial clefts.

Bilateral squamosal suture synostosis: A rare form of isolated craniosynostosis in Crouzon syndrome

Craniosynostosis is a pathologic condition which is characterized by the premature fusion of cranial sutures. It may occur alone or in association with other anomalies making up various syndromes. Crouzon syndrome is the most common craniosynostosis syndrome. Bicoronal sutures fusion is most commonly involved in Crouzon syndrome. There have only been a handful of cases of squamosal suture synostosis described in the surgery literature with the few ones described in Crouzon syndrome associated with other types of craniosynostosis. To the best of our knowledge, we are presenting the first case of isolated bilateral squamosal suture synostosis in a patient with Crouzon syndrome in a radiology journal with emphasis on its radiological appearance.

Phenotypes of craniofrontonasal syndrome in patients with a pathogenic mutation in EFNB1

Craniofrontonasal syndrome (CFNS) is an X-linked developmental malformation, caused by mutations in the EFNB1 gene, which have only been described since 2004. A genotype-phenotype correlation seems not to be present. As it is of major importance to adequately counsel patients with EFNB1 mutations and their parents, and to improve diagnosis of new patients, more information about the phenotypic features is needed. This study included 23 patients (2 male, 21 female) with confirmed EFNB1 mutations. All patients underwent a thorough physical examination and photographs were taken. If available, radiological images were also consulted. Hypertelorism, longitudinal ridging and/or splitting of nails, a (mild) webbed neck and a clinodactyly of one or more toes were the only consistent features observed in all patients. Frequently observed phenotypic features were bifid tip of the nose (91%), columellar indentation (91%) and low implantation of breasts (90%). In comparison with anthropometric data of facial proportions, patients with CFNS had a significantly different face in multiple respects. An overview of all phenotypic features is shown. Patients with EFNB1 mutations have a clear phenotype. This study will facilitate genetic counseling of parents and patients, and contribute to the diagnostic and screening process of patients with suspected CFNS.

Salvage of calvarial bone graft using acellular dermal matrix in nasal reconstruction and secondary rhinoplasty for frontonasal dysplasia

Frontonasal dysplasia is a severe malformation composed of cranial, ophthalmic, nasal, upper lip, and palatal deformities. Reconstruction in these patients requires complex craniofacial efforts. A 19-year-old woman with frontonasal dysplasia was treated at our institution where she had undergone multiple prior reconstructive surgeries including facial bipartition and cantilevered calvarial bone graft for nasal reconstruction. She later presented with a palpable bone graft prominence, associated contour deformity, and an area of overlying paper-thin skin at the nasal tip. Although there was no ulceration, the threat of graft extrusion required immediate attention. The prominent bone graft tip was debrided, and the overlying soft tissue envelope was augmented using acellular dermal matrix. No surgical complication was encountered. The patient had successful salvage of the bone graft and a pleasing aesthetic outcome at 9 months of follow-up. The use of acellular dermal matrix has proven to be beneficial in the correction of nasal contour deformities given its soft, natural appearance, availability, affordability, and safety. Its use also avoids further donor site morbidity. We suggest acellular dermal matrix as a graft material in revision rhinoplasties for cases of acquired nasal contour deformity and threatened bone graft extrusion. This is the first report known to the authors using acellular dermal matrix during staged nasal reconstruction in a patient experiencing frontonasal dysplasia.

Craniosynostosis genetics: The mystery unfolds

Craniosynsostosis syndromes exhibit considerable phenotypic and genetic heterogeneity. Sagittal synostosis is common form of isolated craniosynostosis. The sutures involved, the shape of the skull and associated malformations give a clue to the specific diagnosis. Crouzon syndrome is one of the most common of the craniosynostosis syndromes. Apert syndrome accounts for 4.5% of all craniosynostoses and is one of the most serious of these syndromes. Most syndromic craniosynostosis require multidisciplinary management. The following review provides a brief appraisal of the various genes involved in craniosynostosis syndromes, and an approach to diagnosis and genetic counseling.