Microform cleft lip associated with a complete cleft palate

History of Eugenics in Otorhinolaryngology: Ernst Rüdin and the International Eugenics Network

Introduction  The early geneticist and psychiatrist Ernst Rüdin (1874-1952) became one of the key figures in the eugenics movement and in the German health system of the Nazi era. His connections in the international eugenics network have played an important role in the history of eugenics. Objective  To discuss the connections between Ernst Rüdin's scientific group in Munich and Otmar von Verschuer's group in Frankfurt during the Nazi era. Methods  Otorhinolaryngological materials from Ernst Rüdin's former private library are presented, and they show Rüdin's deep involvement in the international eugenics network. These materials provide insights into early medical genetics in otorhinolaryngology. Results  One result of the present study is that eugenics groups from Munich, Frankfurt, and New York certainly influenced one another in the field of otorhinolaryngology. Karlheinz Idelberger and Josef Mengele were two scientists who performed hereditary research on orofacial clefts. Later, Mengele became deeply involved in Nazi medical crimes. His former work on orofacial clefts clearly had, to some extent, an influence on subsequent studies. Conclusion  An international eugenics network already existed before 1933. However, it becomes clear that the weaknesses of many early genetic studies did not enable its authors to draw firm scientific conclusions, suggesting that scientists lacked an accurate concept of the genetic causes of most illnesses.

Comparison of Cleft Lip Nasal Deformities Between Lesser-Form and Incomplete Cleft Lips: Implication for Primary Rhinoplasty

OBJECTIVE

This study investigated various manifestations of nasal deformities in lesser-form cleft lips, including the minor-form, microform, and mini-microform, by photogrammetric comparison with incomplete cleft lips.

DESIGN

Retrospective study.

SETTING

Tertiary university-affiliated hospital.

PARTICIPANTS

A total of 160 patients with unrepaired unilateral incomplete cleft lips ranging from lesser-form to two-thirds way clefts.

MAIN OUTCOME MEASURES

The severity of nasal deformities was assessed by photogrammetric measurements of linear and angular variables. The symmetry ratio between the cleft and non-cleft sides was obtained by measuring various nasal parameters and comparing them among the different labial cleft groups.

RESULTS

The degree of nasal deformities increased with the extent of labial clefts among the 3 labial cleft groups (lesser-form, halfway, and two-thirds way clefts) in terms of alar base width ratio (1.102, 1.197, 1.309; P < .05), nostril width ratio (1.287, 1.387, 1.551; P < .05), and columellar angle (11.5, 14.45, 18.197; P < .05). Each parameter indicated lesser-form, halfway, and two-thirds way clefts, respectively. However, only the lateral lip height ratio (0.942, 0.851, 0.87; P < .05) and nostril width ratio (1.207, 1.35, 1.29; P < .05) significantly differed among the 3 subgroups. Each parameter indicated mini-microform, microform, and minor-form, respectively.

CONCLUSIONS

The cleft nasal deformities in lesser-form cleft lip present comparable severities among its subtypes, which implies that the extent of the labial cleft is not correlated with nasal deformities. Each nose in the lesser form cleft should be individually assessed for primary rhinoplasty and requires tailored correction.

Working in Peru: A 25-Year Experience With Voluntary Cleft Missions, and a Technique for the Primary Repair of the Unilateral Cleft Lip and Nasal Deformity

BACKGROUND

CIRPLAST is a nonprofit volunteer plastic surgery program that has provided free surgery for patients with cleft lip and palate deformities in different parts of Peru since 1995. In 2015, the author reported 6,108 patients that had been successfully operated on by the CIRPLAST team over a 20-year period. A technique, developed by the author, for the straight-line vertical cleft lip closure without skin flaps of the unilateral cleft lip, was mentioned in that publication but it was not described. 1 The purpose of this article is to present the technique, which has been successfully employed in all the CIRPLAST cleft missions in Peru, for the past 25 years.

METHODS

The straight-line vertical cleft closure does not rely on measurements or skin flaps, and it can be used to close any degree of unilateral cleft lip cleft. The procedure is simple and dependable. After incising the cleft borders on both sides of the cleft, the orbicularis oris muscle is liberated from the surrounding tissues, segmented, and then moved down toward the free border of the lip, so that the cupid's bows can be placed in its normal horizontal position, together with the philtrum on the medial lip, providing normal fullness and pouting of the lower part of the upper lip. Lip length results from the orbicularis oris muscle repair and not from skin flaps. The associated nasal deformity is addressed at the same time as the lip repair, by freeing on the cleft side, the lower lateral cartilage (alar cartilage) from the external nasal skin through a rim incision, and then elevating the cartilage together with its vestibular skin, to place it in its normal position at the tip of the nose, and fixing it there with sutures.

RESULTS

The anatomic, functional, and esthetic results of the lip closure together with the correction of the associated nasal deformity have been satisfactory, when comparing the repaired cleft side with the normal side, for symmetry.

CONCLUSIONS

The straight-line vertical cleft lip closure, based on the orbicularis oris muscle repair, can be used to close any degree of lip clefting, including very wide clefts, without skin flaps. The associated cleft nasal deformity is corrected before the lip closure. The procedure has been used in all the CIRPLAST cleft missions in Peru for the past 25 years, and the outcomes of the repair over time have been satisfactory and stable.

Long-Term Outcomes of the Minimal Skin Incision Technique for Correcting Severe Microform and Minor-Form Cleft Lip With Philtrum Reconstruction Through the Intraoral Incision

BACKGROUND

Because the traditional technique is known to cause visible scarring, it is challenging to yield optimal outcomes while treating a severe type of microform and minor-form cleft lip. The authors present a new refined technique with minimal skin incision and philtrum formation through an intraoral incision.

METHODS

The surgical technique involves single Z-plasty or double or triple unilimb Z-plasty to restore an elevated cupid's bow peak and overlapping of an orbicularis oris muscle flap to create the philtrum through an intraoral incision. Cleft lip nasal deformity was corrected with reverse-U incision and V-Y plasty.

RESULTS

Eighteen patients were operated between September 2008 and June 2017. Patient age at the time of surgery ranged from 3 to 12 months. The duration of follow-up ranged from 12 months to 7 years (mean, 36 months). The elevated cupid's bow was corrected by performing single Z-plasty in 6 patients, double unilimb Z-plasty in 7 patients, and triple unilimb Z-plasty in 5 patients. In all cases, the notch or elevated cupid's bow was corrected, the surgical scar was minimal, and philtrum reconstruction was satisfactory. Minor scar revision was performed in 4 patients. Cleft lip nasal deformity was corrected in fifteen patients.

CONCLUSIONS

The technique adopted here causes minimal scarring, facilitates the formation of an anatomical philtrum, preserves the continuity and function of the muscle, and presents sufficient elevation of the philtral column.

Correction of Minor-Form and Microform Cleft Lip Using Modified Muscle Overlapping with a Minimal Skin Incision

Background

In treating minor-form or microform cleft lip, obtaining an optimal result is a challenge because of the visible scarring caused by traditional surgery. We present a refined method using muscle overlapping with a minimal skin incision in patients younger than 3 years, a group characterized by thin muscle.

Methods

The surgical technique involves restoration of the notched vermillion using Z-plasty, formation of the philtral column using overlapping of an orbicularis oris muscle flap through an intraoral incision, and correction of the cleft lip nasal deformity using a reverse-U incision and V-Y plasty. A single radiologist evaluated ultrasonographic images of the upper lip.

Results

Sixty patients were treated between September 2008 and June 2014. The age at the time of operation ranged from 6 to 36 months (mean, 26 months). The follow-up period ranged from 8 to 38 months (mean, 20 months) in minor-form cases and from 14 to 64 months (mean, 37 months) in microform cases. A notched cupid's bow was corrected in 10 minor-form cases and 50 microform cases. Ultrasonographic images were obtained from 3 patients with minor-form cleft lip and 9 patients with microform cleft lip 12 months after surgery. The average muscle thickness was 4.5 mm on the affected side and 4.1 mm on the unaffected side.

Conclusions

The advantages of the proposed procedure include the creation of an anatomically natural philtrum with minimal scarring. This method also preserves the continuity and function of the muscle and provides sufficient augmentation of the philtral column and nostril sill.

IRF6 Sequencing in Interrupted Clefting

In a retrospective review of patients seen at the University of Alabama at Birmingham Cleft and Craniofacial Center, four patients with rare interrupted clefting were identified who had undergone genetic testing. Each of these patients had a typical cleft lip, with intact hard palate and cleft of the soft palate. Given this picture of mixed clefting, IRF6 sequencing was done and was negative for mutations in all four patients. As genetic testing for single-gene mutations and exome sequencing become clinically available, it may be possible to identify novel mutations responsible for this previously unreported type of interrupted clefting.

Clinical Features of the Microform Cleft Lip and the Ultrastructural Characteristics of the Orbicularis Oris Muscle

Objective

To clarify the clinical features of the microform cleft lip and to establish the ultrastructural characteristics of the orbicularis muscle.

Design

Clinical observations of the characteristic deformities and associated anomalies were made. Muscle biopsies were harvested for histologic and ultrastructural analyses.

Patients

Seventy-one consecutive patients with microform cleft lip were included in the study. Muscle biopsies were investigated in 11 patients among them.

Results

Nasal deformity, a ridge or a groove from the vermilion to the nostril sill, and interruption of the “white roll” were present in all patients. Lack of a philtral column and a free border notch was observed in over 97% of patients. The orbicularis muscle demonstrated hypoplastic myofibers with nonneurogenic atrophy and focal accumulation of subsarcolemmal mitochondria.

Conclusion

The typical gross morphology of the microform cleft lip is a surface manifestation of muscular defect, and the disruption of the muscle further extends down to the ultrastructural level. The clinical features, taken together with the ultrastructural defects of the musculature, might help with a more precise delineation of the microform cleft lip, and provide better understanding of cleft lip in general.

The Parental Dentocraniofacial Phenotype—An Orofacial Clefting Microform

Objective

Using the systematic review method, (1) to identify the investigations of the parental dentocraniofacial phenotype in orofacial clefting, (2) synthesize the data to derive a model of the phenotypic features that will assist in the identification of cleft morphogenes, and (3) make recommendations for the future global strategy for researching the parental craniofacial phenotype in orofacial clefting.

Search Strategy

The Cochrane, Medline (via PubMed and OVID platforms [1966 to December 2006]), Embase, CINAHL, and ASKSAM Orthodontic Reference Database (1950–1997) databases were searched using a combination of the following keywords: microform, parent, craniofacial, dental, and cleft. All published articles were reviewed. There were no exclusions of non-English reports. Of the 36 studies identified using this strategy, 26 met the inclusion criteria.

Data Abstraction/Synthesis

The statistically significant data were abstracted using a pro forma, and the methodological quality of the selected studies was evaluated using a checklist. There was considerable heterogeneity among the studies, and therefore it was not possible to synthesize the data. We were, however, able to collate the data.

Results/Conclusions

(1) The craniofacial phenotype possessed by parents of children with orofacial clefting is distinctive when compared with that of the noncleft population. (2) There is insufficient evidence to produce a model of the phenotypic features to assist in the search for orofacial clefting morphogenes. (3) The pattern of expression of the phenotypic features identified to date supports the contention that there are differences in the inheritance of cleft lip with or without cleft palate and isolated cleft palate. Progress in this field is affected by extreme heterogeneity in etiology of cleft lip with or without cleft palate, as well as heterogeneity in study design. (4) Subphenotyping using features such as microforms should be employed to reduce the heterogeneity and to improve the power of future genetic investigations and will also assist in clinical management and genetic counseling for families.

Rethinking isolated cleft palate: evidence of occult lip defects in a subset of cases

Emerging research suggests that subepithelial defects of the upper lip musculature are part of the phenotypic spectrum of cleft lip and/or palate (CL/P) and may represent an occult, subclinical manifestation of the anomaly. The present study investigates whether similar occult lip defects are present in individuals affected with isolated cleft palate (CP). To this end, upper lip ultrasounds of 33 CP cases (12 males, 21 females) were evaluated retrospectively for the presence of discontinuities (i.e., breaks) within the orbicularis oris muscle (OOM). In four CP cases (2 males, 2 females), distinct discontinuities of the OOM were identified. Of the remaining CP individuals, 23 demonstrated normal lip morphology on ultrasound (7 males, 16 females), while, in 6 cases (3 males, 3 females), a definitive evaluation was not possible. As CP and CL/P are traditionally thought to be etiologically distinct, these findings raise the possibility that some CP cases may be misclassified. Such diagnostic errors could have important implications for recurrence risk estimation and studies aimed at discovering etiology. (c) 2008 Wiley-Liss, Inc.

Double Unilimb Z-Plastic Repair of Microform Cleft Lip

BACKGROUND

Microform unilateral cleft lip is characterized by 1) notched mucosal margin; 2) thin medial vermilion; 3) elevated medial peak of Cupid's bow; 4) furrowed philtral column; 5) hypoplastic orbicularis oris; and 6) minor nasal deformity.

METHODS

The author's registry of unilateral incomplete cleft lip was culled for patients with microform cleft lip. Operative correction included: double-limb Z-plasty at the vermilion-cutaneous and vermilion-mucosal junctions; eversion of orbicularis oris; augmentation of philtral ridge with a dermal graft; medial positioning of the alar base; and elevation of the lower lateral cartilage.

RESULTS

Microform phenotype was found in 33 of 360 infants (9.2 percent) with unilateral incomplete cleft lip. Male-to-female and left-to-right ratio were both 2:1. Median age at presentation was 11 months (range, 2 weeks to 9 years). Twenty-three patients had a double unilimb Z-plastic repair (including dermal graft and nasal correction). No revisions have been necessary at median follow-up of 5 years, however, 13 percent of children lacked prominence of the upper philtral column and one-third of children exhibited minor nostril asymmetry.

CONCLUSIONS

Double unilimb Z-plasty corrects the vertical asymmetry in a microform cleft lip while limiting the scar to the lower one-half of the lip. The philtral ridge is formed by repair of the muscular diastasis and onlay of a dermal graft. Components of this technique are applicable to secondary cleft deformities, such as elevated peak of the Cupid's bow and inadequate philtral ridge.