Craniofacial Microsomia

Surgical decision-making regarding hearing and ear reconstruction in craniofacial microsomia: Exploring caregiver narratives

Treatment decision-making is an integral but complex part of healthcare, particularly in the context of craniofacial surgeries. The aim of the current study was to explore caregiver narratives to inform future surgical care delivery and best practice. 'Life Story' narrative interviews were conducted with US English- and Spanish-speaking caregivers (n = 62) of children aged 3-17 years with craniofacial microsomia (CFM). Extracts relating to treatment decision-making were inductively coded using Reflexive Thematic Analysis. Four themes were identified: 1) 'Grappling with Difference' exemplifies how participants dealt with having a child who was different; 2) 'Seeking Authoritative Guidance' illustrates how participants proactively pursued information about treatment options over several years; 3) 'In the Driving Seat' describes participants' beliefs about whether and how much to involve their child in treatment decisions; and 4) 'Post-Treatment Reflections' depicts participants' reflections of the decision-making experience. Surgeons and other healthcare providers are encouraged to use neutral and accessible language, to ensure families and children have a thorough understanding of all treatment pathways, and to engage in effective shared decision-making practices. Content predominantly focused on surgeries for ear reconstruction and hearing amplification. Future studies would benefit from examining other treatment decisions that caregivers are required to make.

Splicing Defects and Cell Death Cause SF3B2-Linked Craniofacial Microsomia

Craniofacial microsomia (CFM) is a genetically and phenotypically heterogeneous disorder characterized by hypoplasia of facial tissue that is often asymmetric. Affected tissues typically include the ears (external and internal), mandible, and maxilla, but various extracranial anomalies have also been reported. Loss-of-function variants in the SF3B2 gene have recently been reported in 8 cases of CFM, representing one of the more common genetic causes identified to date. To better define the full phenotypic spectrum associated with variants in SF3B2, we report novel loss-of-function variants in SF3B2 in 5 new families with CFM. Furthermore, to determine the mechanism by which SF3B2 loss-of-function perturbs craniofacial development, we established sf3b2-null mutant zebrafish, which exhibited severe deficiencies in craniofacial cartilage and bone progenitors due to elevated apoptosis and reduced proliferation of cranial neural crest cells. In addition, we generated a heterozygous truncating variant of SF3B2 in human induced pluripotent stem cells using CRISPR/Cas9 gene editing. Differentiation of these cells into neural crest cells was accompanied by increased cell death and reduced proliferation. RNA sequencing of sf3b2 mutant zebrafish revealed widespread disruption of mRNA splicing, including mdm2, a key regulator of Tp53-mediated apoptosis. Genetic inhibition of tp53 in sf3b2 mutants demonstrated that tp53 inhibition reduces early cell death but does not improve proliferation or craniofacial cartilage development. Therefore, our functional studies indicate that widespread mRNA splicing disruption, in addition to Tp53-dependent cell death, contributes to the craniofacial features observed in SF3B2-related CFM.

Craniofacial Microsomia

Patients with craniofacial microsomia comprise a diverse clinical cohort that requires individualized attention and surgical consideration that benefits from multidisciplinary team management to optimize functionality and esthetics. Specific concerns regarding airway, vision, feeding, growth, hearing, speech, development, and quality of life may require intervention. The full reconstructive ladder may be utilized in the care of these patients. Ultimately, tailoring surgery to optimize final facial symmetry while minimizing the burden of surgical interventions serves these patients well.

Understanding the Psychological Impact of Medical Care Experiences on Adults With Craniofacial Conditions: A Pilot Survey of Traumatic Stress Symptoms and Resilience

Craniofacial conditions often require extensive medical care and surgeries throughout childhood and adolescence. However, there is limited research investigating the psychological effects of craniofacial care, including risks for medical traumatic stress. This cross-sectional study investigated the medical care experiences of adults with craniofacial conditions, including the frequency of potentially traumatic medical events, post-traumatic stress disorder (PTSD) symptoms, and resilience. Participants (N=34; mean age 35.2 ± 12.2 y; 71% female) were recruited at 3 US pediatric hospitals and craniofacial support organizations. Participants completed the PTSD Checklist (PCL-5), Connor-Davidson Resilience Scale, the Craniofacial Experiences Questionnaire, and open-ended questions about their medical care experiences. Most participants reported experiencing potentially traumatic medical experiences, such as prolonged and/or painful dental (79%) and medical treatments (73%) and hospitalization in the intensive care unit (70%). On the PCL-5, 21% met the criteria for PTSD, which is similar to other medical populations and higher than the 6% rate of PTSD in the general US population. Participants reported both stressors and positive aspects related to living with a craniofacial condition; however, resilience scores were lower relative to a US community sample. Qualitative analysis of open-ended responses identified themes including interactions with providers, medical treatment experiences, and psychosocial impacts. Adults with craniofacial conditions appear to be vulnerable to post-traumatic stress symptoms related to their medical care experiences, and report reduced resilience relative to community samples. Implications for clinical care and research include the integration of trauma-informed care approaches and strategies to support coping and resilience across the lifespan.

Development of a Novel Large-Animal Model for Craniofacial Microsomia: Proportional Skeletal Defects in Mandibular Ramus and Zygomatic Arch

Craniofacial microsomia (CFM) involves complex skeletal asymmetries, including mandibular and zygomatic arch deficiencies, leading to facial deformities and occlusal cant. Current animal models inadequately replicate these features, hindering the development of customized temporomandibular joint prostheses for CFM. This study aimed to develop a miniature pig model that mimics the proportional craniofacial skeletal defects observed in severe CFM, serving as a platform for future TMJ reconstruction studies. Three miniature pigs underwent preoperative CT imaging and digital surgical planning. Proportional mandibular ramus and zygomatic arch defects were created on the surgical side to reflect measurements from clinical CFM patients. Craniofacial morphology, masticatory efficiency, and maximum mouth opening (MMO) were assessed preoperatively and postoperatively at 3 and 13 weeks. At 13 weeks, craniofacial asymmetry closely resembled CFM. The ramus height and zygomatic arch surgical side to nonsurgical side ratios were reduced by 30% (P = 0.003) and 52% (P = 0.003), respectively, compared with preoperative values. Despite significant occlusal plane cant (P = 0.011), maxillary height and chin deviation showed nonsignificant changes. Functional outcomes, including MMO and masticatory efficiency, were preserved. This model successfully replicates craniofacial skeletal defects characteristic of severe CFM. It offers a quantitative framework for testing TMJ prostheses, advancing reconstructive approaches for craniofacial deformities.

Computed tomographic assessment of orbital and maxillary dysmorphology in craniofacial microsomia

INTRODUCTION

Mandibular dysmorphology is well-documented in craniofacial microsomia (CFM), but data on midface abnormalities remain limited. This study aimed to compare orbital and maxillary dimensions between the affected and unaffected sides in patients with CFM.

METHODS

The retrospective cross-sectional study conducted in South Australia comprised 31 patients with CFM and 31 age- and sex-matched control patients (median age 13.2 years; range 0.3-48.4 years; 80.6% children and 19.4% adults; 51.6% males and 48.4% females). Computed tomography reconstructions were assessed bilaterally for 4 orbital and 6 maxillary dimensions in mild, moderate, and severe subgroups, as well as in the control group. Linear mixed-effects models, adjusted for age and sex, were performed to assess whether there were significant differences in the measured dimensions between the sides and groups.

RESULTS

Midface asymmetries in patients with CFM were generally commensurate with their severity. In moderate CFM, the affected side showed hypoplastic orbits and maxillae compared with the unaffected side (orbital height: -4.9%; P = 0.018; maxillary middle height: -10.3%; P <0.001). In severe CFM, the reduced maxillary middle height on the affected side (-18.5%; P <0.001) was compensated by increases in the orbital height (+7.0%) and maxillary depth (+6.8%; P = 0.014) (all data adjusted for covariates).

CONCLUSIONS

CFM is a bilateral condition characterized by orbital and maxillary asymmetries, primarily because of hypoplasia but occasionally involving hyperplasia on the affected side. In severe CFM, compensatory increases in maxillary depth and orbital height often offset midmaxillary height deficiencies.

The novel role of foxi3 in zebrafish mandibular development

Recent studies have identified pathogenic variants in the FOXI3 gene associated with craniofacial microsomia pedigrees. In zebrafish, the foxi1 gene is considered a functional homolog of the mouse Foxi3. However, research on foxi3a and foxi3b, which display homologous genes in the naming of FOXI3 in zebrafish, has predominantly focused on their roles in epidermal ionocyte function. Our study reveals that disruption of foxi3a or foxi3b results in a reduced number of cranial neural crest cells (CNCCs) and hypoplastic mandibular cartilage in zebrafish. These findings introduce a new perspective on the functional homologs of FOXI3 and highlight an unrecognized role of foxi3 in zebrafish CNCC and mandibular development.

The Biomechanical Properties of A Modified Distraction Device Used in Mandibular Distraction Osteogenesis for Craniofacial Microsomia Patients: A Simulation Finite Element Analysis Study

OBJECTIVE

Finite element analysis (FEA) of the biomechanical properties of the modified extraoral distractor device used in the mandibular distraction of craniofacial microsomia patients.

MATERIALS AND METHODS

Finite element analysis (FEA) models of 5 patients under 2 working conditions, the instance when the distractor is activated and when the distractor participates in mastication, were included in the current study. To conduct the FEA, load boundary conditions (35.6 N on the distractor for the first working condition and 50 N on the unoperated side, 100 N and 200 N on both sides for the second working condition) were applied. Besides, constraint boundary conditions and contact conditions were also applied.

RESULTS

With 5 or 3 bioabsorbable screws fixing the upper fixing plate, the maximal displacement of the mandible was <3 mm and the maximal stress distributed on distractor and bioabsorbable screws was less than the yield strength of corresponding materials under the 2 working conditions when setting 50 N on the unoperated side and 100 N on both sides for the second working condition. However, when setting 200 N on both sides for the second working condition, the maximal displacement of the mandible slightly increased, and stress distributed on distractor and bioabsorbable screws exceeded the yield strength of corresponding materials in some patients.

CONCLUSION

In most cases, both 5 and 3 poly-L-lactic acidscrews could firmly fix the distractor on the mandible without plastic deformation, although the situation would be different when the mastication force was too powerful.

Two-step cluster analysis based on three-dimensional CT measurements of craniofacial structures in severe craniofacial microsomia

BACKGROUND

The Pruzansky-Kaban and OMENS classifications do not provide additional details on temporomandibular joint deformities. The aim of this study was to classify and quantitatively define severe forms of craniofacial microsomia based on three-dimensional maxillofacial measurements, focusing on deformities in the zygomatic, temporal, and mandibular bones.

METHODS

Maxillofacial computed tomography (CT) scans of children with severe types of craniofacial microsomia (CFM) from 2010 to 2020 were collected. Three-dimensional measurements of zygomatic arch length, height of mandibular ramus, height of maxilla, and occlusal cant were performed. A two-step cluster analysis was conducted based on zygomatic arch continuity, occlusal cant, and the ratio of the affected side to the unaffected side (A/U ratio) for zygomatic arch length, mandibular ramus height, and maxillary height.

RESULTS

Fifty patients (32 male, 18 female) were included in the study. They were classified into 2 clusters through cluster analysis. Cluster 1 comprised subjects (44% of patients) with continuous zygomatic arches. Cluster 2 comprised subjects (39% of patients) with discontinuous zygomatic arches. The zygomatic arch A/U ratio in cluster 1 was greater than that in cluster 2, with statistical significance observed. Additionally, the maxilla height A/U ratio in cluster 1 was lower than in cluster 2, also with statistical significance. There was no statistically significant difference observed in the ramus height A/U ratio and occlusal cant between clusters 1 and 2.

CONCLUSIONS

Based on craniofacial measurements, severe CFM can be categorized into two types: continuous zygomatic arch and discontinuous zygomatic arch. This cluster analysis complemented the OMENS classification and could assist in the selection and design of prosthetic joints for patients with CFM.

Overlapping Spectrum of Craniofacial Microsomia Phenotype in Cat-Eye Syndrome

This study reports three patients with Cat-eye Syndrome (CES), two of which present a previous clinical diagnosis of Craniofacial microsomia (CFM). Chromosomal microarray analysis (CMA) revealed a tetrasomy of 1,7 Mb at the 22q11.2q11.21 region, which is the typical region triplicated in the CES, in all patients. The most frequent craniofacial features found in individuals with CFM and CES are preauricular tags and/or pits and mandibular hypoplasia. We reinforce that the candidate genes for CFM features, particularly ear malformation, preauricular tags/pits, and facial asymmetry, can be in the proximal region of the 22q11.2 region.

Establishing an International Interdisciplinary Research Network in Craniofacial Microsomia: The CARE Program

OBJECTIVE

Craniofacial microsomia (CFM) is a broad clinical term used to describe a congenital condition most commonly involving the underdevelopment of the external ear, mandible, soft tissues, and facial nerve. Despite medical advances, understanding of the psychological health and healthcare experiences of individuals with CFM and their caregivers remains limited. This article describes a research program designed to address these knowledge gaps, and identify opportunities for psychosocial intervention and improved healthcare provision.

DESIGN

The Craniofacial microsomia: Accelerating Research and Education (CARE) research program aims to: 1) Conduct up to 160 narrative interviews with individuals and caregivers to validate a conceptual framework; 2) Administer an online international survey of up to 800 individuals with CFM and caregivers to identify predictors of psychological distress; 3) Perform up to 60 semi-structured interviews with healthcare providers and advocacy leaders to examine the extent to which current healthcare provisions address identified patient needs; and 4) Establish a participant registry to build a longitudinal database and develop an international community.

RESULTS

Teams in the USA and UK have been established, alongside an international, interdisciplinary Advisory Committee. Data analysis for Aim 1 is ongoing and informing the delivery of Aims 2-3. Aim 4 is also in development. A dedicated website serves as a recruitment tool, educational resource, and mechanism for engaging with the CFM community.

CONCLUSIONS

The CARE program provides a comprehensive approach to understanding the experiences of individuals with CFM and their caregivers. Challenges encountered and lessons learned are shared for the benefit of the community.

Genetic Testing in Craniofacial Care: Development of Algorithms for Testing Patients with Orofacial Clefting, Branchial Arch Anomalies, and Craniosynostosis

OBJECTIVE

To develop consensus-based algorithms for genetic testing in patients with common craniofacial conditions.

DESIGN

An online collaborative consisting of online meetings, independent work, and feedback across groups. Setting/Participants: A collaborative of genetics and pediatrics providers from three regional craniofacial centers (four institutions).

METHODS

Collaborative participants agreed upon a shared initial framework, developed algorithms independently, and presented/tested the algorithms with a national audience. Algorithms were modified based on consensus feedback.

RESULTS

The collaborative group developed final algorithms for genetic testing in patients with orofacial cleft, branchial arch conditions, and craniosynostosis.

CONCLUSIONS

Timely and accurate diagnosis of genetic conditions can support medical management recommendations that result in safer surgical interventions. Algorithms can help guide best-practices for testing, particularly in institutions without easy access to genetics providers.

Clinical Analysis and Treatment Strategies About Cartilage Scaffold Exposure After Auricular Reconstruction With the Expanded Two-Flap Method

Objectives: Soft tissue expansion is one of the main methods for autologous cartilage auricular reconstruction. The aim of this study was to analyze the risk factors for cartilage exposure after this method and to describe a surgical method for this complication. Methods: From January 2018 to December 2020, 853 patients (908 sides) underwent auricular reconstruction with an expanded two-flap method at our center. Thirty-two patients experienced cartilage exposure postoperatively. These patients were set as the case group, and 1:1 matched sampling was performed among patients who did not have cartilage exposure. The matched sample of 32 cases was set as the control group. All 64 patients were evaluated according to the Orbit, Mandible, Ear, Nerve, and Soft tissue (OMENS) classification system to analyze the correlation between cartilage exposure and hemifacial microsomia (HFM) and OMENS subtypes. The complication was repaired with superficial temporal fascial flap combined with skin graft. Results: HFM might be a risk factor for scaffold cartilage exposure, and there was a significant correlation between cartilage exposure and orbital malformation, facial nerve dysplasia, and soft tissue developmental malformation. The use of a superficial temporal fascial flap combined with a split-thickness skin graft to repair the complication achieved satisfactory outcomes. Conclusions: There is a correlation between cartilage scaffold exposure and the severity of HFM. Temporoparietal fascial flap transfer combined with skin grafting proved to be an effective method for cartilage exposure.

Fetal Head and Neck Imaging

Prenatal MRI plays an essential role in the evaluation of the head and neck. This article overviews technical considerations and both isolated and syndromic anomalies of the fetal calvarium, globes and orbits, ears, maxilla, mandible, and neck.

"I can't provide what my child needs": Early feeding experiences of caregivers of children with craniofacial microsomia

PURPOSE

Craniofacial microsomia (CFM) is a congenital condition that can be associated with feeding challenges in infants. As part of the larger 'Craniofacial microsomia: Accelerating Research and Education (CARE)' program, this study described caregivers' early feeding experiences.

DESIGN AND MATERIALS

US-based caregivers of 34 children with CFM participated in remote narrative interviews. Two authors completed inductive thematic analysis in an iterative process until consensus was reached.

RESULTS

Caregivers' narratives outlined the inherent challenges of feeding an infant with special healthcare needs. The first theme 'Navigating Challenges and Managing Expectations' describes the distress participants experienced when they were unable to breastfeed and the negative emotional effect of switching to formula. The second theme 'Making Adaptations' outlines the methods participants tried, including breast pumps and feeding tubes. The third theme 'Accessing Support' describes participants' interactions with healthcare providers and challenges accessing feeding support. The final theme 'Growing from Adversity' recounts participants' relief once their child established a feeding pattern and the personal growth gained from their experiences.

CONCLUSIONS

Caregivers reported several feeding related challenges associated with CFM, many of which negatively affected their wellbeing. Negative consequences were particularly pronounced in cases where caregivers' feeding experiences differed from their expectations. Participants identified challenges in accessing reliable feeding information and support. Despite difficult experiences, caregivers cited some positive outcomes, including increased confidence and resilience.

PRACTICE IMPLICATIONS

Holistic feeding information and support for families affected by CFM should be inclusive of several feeding methods to improve care delivery, child health, and the caregiver experience.

Soft Palate Dysplasia: Properties and Surgical Techniques

BACKGROUND

The authors aimed to report a hitherto undescribed class of patients with the obvious phenotype of a novel soft palate dysplasia (SPD) combining unilateral soft palate hypoplasia with a fully developed uvula. The authors also aimed to investigate and evaluate the corresponding surgical approaches.

METHODS

Twelve patients were clinically diagnosed with SPD. Clinical examination, including radiographic tests, was performed to characterize the congenital deformity. The effectiveness of velopharyngeal closure and speech were tested preoperatively and postoperatively.

RESULTS

SPD was featured with velopharyngeal insufficiency, food regurgitation, and speech disorders. It was commonly manifested as structural deformities of the soft palate, tongue palatine arch, pharyngeal palatine arch, and pterygomandibular fold, but with complete uvula shape. According to radiographic analysis, in five patients, the lateral pterygoid processes were poorly developed, and other malformations were present. Velopharyngoplasty based on the unilateral posterior pharyngeal flap can well restore the velopharyngeal closure and speech intelligibility without respiration obstruction.

CONCLUSIONS

SPD is characterized as congenital velopharyngeal insufficiency manifested as a primary soft palate defect. It is highly associated with other physical deformities but independent of conventionally known syndromes. The cause may be an abnormal development of the pterygoid process. Unilateral velopharyngoplasty based on the posterior pharyngeal flap is a great technique to repair SPD.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Management of unilateral craniofacial microsomia with orthopaedic functional appliances: A systematic literature review

The study aimed to summarize current knowledge regarding the use of orthopaedic functional appliances (OFA) in managing unilateral craniofacial microsomia (UCM). The eligibility criteria for the review were (1) assessing use of OFA as a stand-alone treatment and (2) using OFA in combination during or after MDO. The PICO (population, intervention, comparison and outcome) format formulated clinical questions with defined inclusion and exclusion criteria. No limitations concerning language and publication year were applied. Information sources: A literature search of Medline, Scopus, Embase, Cochrane Central Register of Controlled Trials, Web of Science databases without restrictions up to 30 September 2022. The risk of bias was assessed. According to Cochrane and PRISMA guidelines, two independent authors conducted data extraction. The level of evidence for included articles was evaluated based on the Oxford evidence-based medicine database. Due to the heterogeneity of studies and insufficient data for statistical pooling, meta-analysis was not feasible. Therefore, the results were synthesized narratively. A total of 437 articles were retrieved. Of these, nine met inclusion criteria: five assessing OFA and four assessing OFA during or after MDO. There is limited evidence to suggest that stand-alone and combination treatment with OFA is beneficial for treating mild-to-moderate UCM-related dentofacial deformities in short term. No studies assessed the burden of care. In the management of UCM, there is insufficient evidence supporting the efficacy of OFA as a stand-alone treatment or when combined with MDO. Additionally, there is a lack of evidence regarding treatment protocols and the effect on the condyles and the TMJ. The study was registered at Prospero database number CRD42020204969.

Psychosocial Experiences of Spanish-Speaking Parents of Children With Craniofacial Microsomia

Craniofacial microsomia (CFM) and microtia psychosocial research in the US is primarily with English-speaking participants. Given that 19% of the US is Latino, and there is a higher prevalence of CFM in Latino populations, this study aims to describe psychosocial experiences related to CFM among Spanish-speaking Latino caregivers to better inform health care. Narrative interviews (mean 73±17 min) were completed in Spanish with parents of children with CFM aged 3 to 17 (mean age 10.8±4.8 years). Transcripts were analyzed using quantitative linguistic analyses and reflexive thematic analysis. Participants (N=12) were mostly mothers (83%) who had immigrated to the US and had low socioeconomic status. Based upon analysis of grouped word counts, participants spent approximately half of their narratives discussing the first two years of their child's life. Themes selected based on US Latino sociodemographics and cultural values included the Impact of Language, Healthcare Challenges, Supportive Healthcare Experiences, Caregiver Coping with CFM, Family Roles, and Addressing Social Implications of CFM. Results highlighted that the first years of care are of critical importance to parents and suggest this is an optimal time to focus on education and support services for families. Additional treatment suggestions include providing interpretation and informational materials in Spanish, addressing care barriers, supporting familial and child coping, accounting for the role of extended family, and helping address social concerns. Ongoing research with Latino families can further assist in guiding culturally sensitive CFM health care.

Early Experiences of Parents of Children With Craniofacial Microsomia

OBJECTIVE

To describe the early health care experiences of parents of children with craniofacial microsomia (CFM), a congenital diagnosis often identified at birth.

DESIGN

Qualitative descriptive.

SETTING

Homes of participants.

PARTICIPANTS

Parents of 28 children with CFM from across the United States.

METHODS

We interviewed participants (27 mothers individually and one mother and father together) via telephone or teleconference and used reflexive thematic analysis to derive themes that represented early health care experiences of parents of children with CFM.

RESULTS

Participants' narratives included detailed recounting of their birth and early care experiences. We identified two overarching themes. The first overarching theme, Stressors, included four subthemes that represented difficulties related to emotional reactions and negative experiences with health care providers. The second overarching theme, Finding Strength, included four subthemes that represented participants' positive adjustment to stressors through independent information seeking about CFM, adaptive coping, positive experiences with health care providers, and drawing on external supports.

CONCLUSION

Participants often described early experiences as challenging. Findings have implications for improving early care, including increasing open and supportive communication by health care professionals, expanding access to CFM information, screening for mental health concerns among parents, strengthening coping among parents, and linking families to resources such as reliable online CFM information and early intervention programs.

A Conceptual Thematic Framework of Psychological Adjustment in Caregivers of Children with Craniofacial Microsomia

OBJECTIVE

Children with craniofacial microsomia (CFM) have complex healthcare needs, resulting in evaluations and interventions from infancy onward. Yet, little is understood about families' treatment experiences or the impact of CFM on caregivers' well-being. To address this gap, the NIH-funded 'Craniofacial microsomia: Accelerating Research and Education (CARE)' program sought to develop a conceptual thematic framework of caregiver adjustment to CFM.

DESIGN

Caregivers reported on their child's medical and surgical history. Narrative interviews were conducted with US caregivers (n = 62) of children aged 3-17 years with CFM. Transcripts were inductively coded and final themes and subthemes were identified.

RESULTS

Components of the framework included: 1) Diagnostic Experiences, including pregnancy and birth, initial emotional responses, communication about the diagnosis by healthcare providers, and information-seeking behaviors; 2) Child Health and Healthcare Experiences, including feeding, the child's physical health, burden of care, medical decision-making, surgical experiences, and the perceived quality of care; 3) Child Development, including cognition and behavior, educational provision, social experiences, and emotional well-being; and 4) Family Functioning, including parental well-being, relationships, coping strategies, and personal growth. Participants also identified a series of "high" and "low" points throughout their journey and shared their priorities for future research.

CONCLUSIONS

Narrative interviews provided rich insight into caregivers' experiences of having a child with CFM and enabled the development of a conceptual thematic framework to guide clinical care and future research. Information gathered from this study demonstrates the need to incorporate evidence-based psychological support for families into the CFM pathway from birth onward.

The TET-Sall4-BMP regulatory axis controls craniofacial cartilage development

Craniofacial microsomia (CFM) is a congenital defect that usually results from aberrant development of embryonic pharyngeal arches. However, the molecular basis of CFM pathogenesis is largely unknown. Here, we employ the zebrafish model to investigate mechanisms of CFM pathogenesis. In early embryos, tet2 and tet3 are essential for pharyngeal cartilage development. Single-cell RNA sequencing reveals that loss of Tet2/3 impairs chondrocyte differentiation due to insufficient BMP signaling. Moreover, biochemical and genetic evidence reveals that the sequence-specific 5mC/5hmC-binding protein, Sall4, binds the promoter of bmp4 to activate bmp4 expression and control pharyngeal cartilage development. Mechanistically, Sall4 directs co-phase separation of Tet2/3 with Sall4 to form condensates that mediate 5mC oxidation on the bmp4 promoter, thereby promoting bmp4 expression and enabling sufficient BMP signaling. These findings suggest the TET-BMP-Sall4 regulatory axis is critical for pharyngeal cartilage development. Collectively, our study provides insights into understanding craniofacial development and CFM pathogenesis.

3D-CT measurements of facial symmetry in severe CFM patients: A comparative study between mandibular ascending ramus distraction osteogenesis and bone grafting

This study aims to compare the effects of mandibular distraction osteogenesis (MDO) and bone grafting on the facial symmetry of children with Pruzansky-Kaban type IIB and III craniofacial microsomia (CFM). Medical records and three-dimensional computed tomography (3D-CT) data of CFM patients who had primarily undergone MDO and bone grafting were collected. A retrospective analysis of pre-and post-operative 3D imaging data was conducted to compare the improvement rate in facial symmetry between the two groups based on occlusal cant, affected/unaffected ramus height ratio and chin point deviation. The data were tested for normality using the Shapiro-Wilk test. When the data followed a normal distribution, a paired sample t-test was employed for the comparison between preoperative and postoperative data. When the data did not follow a normal distribution, the Wilcoxon signed-rank test for paired samples was used for preoperative and postoperative comparison. The study included 18 children with type IIB and III CFM, 11 in the MDO group and 7 in the bone grafting group. In the MDO group, postoperative Gn-FH and Gn-Cor distances increased significantly, whereas the postoperative Gn-Mid distance decreased significantly. Occlusal cant decreased significantly and ramus height affected/unaffected ratio increased significantly after MDO. In the bone graft group, there was no statistically significant difference in the postoperative ratios of chin deviation, occlusal cant, and ramus height affected/unaffected compared to the preoperative values. Compared to bone grafting, MDO can significantly enhance ramus height ratio, level occlusal plane, and centralize the chin point among patients with CFM. Furthermore, MDO achieves superior enhancements in facial symmetry.

Clinical report and genetic analysis of a Chinese neonate with craniofacial microsomia caused by a splicing variant of the splicing factor 3b subunit 2 gene

BACKGROUND

Craniofacial microsomia (CFM) is a common congenital malformation with unknown pathogenesis. Although few cases have been reported, it is suggested that variants of the SF3B2 gene may lead to CFM. We herein report the case of a neonate with CFM exhibiting rare features of airway obstruction.

METHODS

Trio whole-exome sequencing and Sanger validation were performed on the proband and her parents. Candidate gene mutations were analyzed using the Genome Aggregation Database (gnomAD) for normal frequency distributions. The Human Splicing Finder (HSF) and Rare Disease Data Center (RDDC) RNA splicer algorithms predicted the variant's harmfulness, verified by a Minigene assay.

RESULTS

The proband had a heterozygous SF3B2 variant, NM_006842.3:c.777+1G>A. The patient's father also carried this variant and exhibited facial abnormalities. The variant was not in gnomAD, and HSF and RDDC RNA splicers indicated donor site disruption. The minigene assay suggested that two mRNA products were produced, leading to a premature termination codon.

CONCLUSION

For this family, the pathogenesis of CFM may have been caused by an SF3B2 splicing variant. Affected family members exhibited varying degrees of malformation, indicating that CFM has phenotypic heterogeneity. This finding expands the phenotype and variant spectrum of SF3B2, enriches neonatal CFM research, and provides a possible guide to genetic counseling.

Airway management under general anesthesia for infants and young children with the first and second branchial syndrome featuring unilateral mandibular dysplasia: A case series of 8 children

OBJECTIVE

To investigate and summarize the airway management methods for infants and young children of the first and second branchial syndrome featuring mandibular dysplasia, and to evaluate the auxiliary effect of direct laryngoscope and video laryngoscope during tracheal intubation.

METHODS

From March 2017 to March 2022, 8 cases with the first and second branchial syndrome featuring absent or hypoplastic mandibular ascending ramus that underwent cleft palate repair or transverse facial cleft repair under general anesthesia were retrospectively reviewed and summarized. The information such as demographic data, preoperative airway assessment, mask ventilation effect, anesthesia method, anesthesiologist's evaluation of laryngoscope exposure and intubation, operation method, operation time, and extubation time was collected.

RESULTS

The median age of the 8 children was 12 months; none of them had limitation of mouth opening, 4 had snoring during sleep, 2 had unilateral absence of the ascending ramus of the mandible, and 6 had partial absence. Of the 8 children, 3 underwent cleft palate repair, and 5 underwent transverse facial cleft repair. During anesthesia induction, 1 case of mask ventilation was graded as Grade 2, and the other 7 cases were graded as Grade 1; the Cormack-Lehane (C-L) grade of glottic exposure by direct laryngoscope was graded as Grade 3 (3 cases) and Grade 4 (5 cases), and the C-L grade by video laryngoscope was graded as Grade 1 (4 cases) and Grade 2 (4 cases). All the children completed video laryngoscope-assisted intubation successfully in one time. The extubation was completed smoothly, without complications related to anesthesia. The median operation time was 50 minutes, and the median time from end of operation to extubation was 240 seconds.

CONCLUSION

For anesthesia of infants and children with the first and second branchial syndrome, especially those with hypoplasia of the mandible, a comprehensive preoperative assessment is needed, and direct laryngoscope may lead to difficulty in glottic exposure, and adequate planning for difficult airway management is necessary.

Conductive Hearing Loss in Children

A variety of congenital and acquired disorders result in pediatric conductive hearing loss. Malformations of the external auditory canal are invariably associated with malformations of the middle ear space and ossicles. Isolated ossicular malformations are uncommon. Syndromes associated with external and middle ear malformations are frequently associated with abnormal development of first and second pharyngeal arch derivatives. Chronic inflammatory disorders include cholesteatoma, cholesterol granuloma, and tympanosclerosis.

Focuses, Trends, and Developments in Craniofacial Microsomia From 1992 to 2022: A Bibliometric Analysis

There is a current lack of scientific bibliometric analyses in craniofacial microsomia (CFM) and relevant fields. Craniofacial microsomia is a congenital disease resulting from a series of structural malformations involving the first and second branchial arches. Craniofacial microsomia and related fields have attracted the attention of clinicians and interested researchers worldwide. This study summarizes the research status and focuses to help researchers fully grasp the current research situation of CFM and relevant fields in the past three decades and drive future research into new publications. Literature data were retrieved from the Web of Science Core Collection database. Results Analysis and Citation Report of Web of Science, and CiteSpace software were used to evaluate and visualize the results, including publication characteristics, disciplines, journals, literature, countries/regions, institutions, authors, research focuses, etc. A total of 949 original articles and reviews were included after manual screening, and the overall trend of the number of annual publications and citations was increasing. According to the analysis, the description of the clinical characteristics of CFM, the classification of CFM, and mandibular distraction osteogenesis have always been the focus of research in this field. Besides, with the continuous progress of new technologies such as gene sequencing and the expansion of researchers' understanding of diseases, research on genetics and etiology related to CFM has been a developing trend.

Quantification of Bony Depression in Mastoid Region After Expander Implantation for Microtia Reconstruction in Hemifacial Microsomia

Object: Three-stage expansion method represents the most common form of microtia reconstruction in hemifacial microsomia (HFM). Although the complication related expander has lowered owing to the current advances, bony depression in mastoid region in microtia patients with hemifacial microsomia was observed in clinical work. The aim of this study was to quantify bony depression after retroauricular expander implantation and identify associated factors. Methods: 42 patients were enrolled and studied prospectively utilizing 3-dimensional (3D) evaluation. Craniofacial computed tomography (CT) was performed before the first (pre-expansion) and the second stage (post-expansion) and 3D quantification was done to quantify bony depression in mastoid region by using CT data. Univariate analysis was performed to identify factors associated with bony depression in mastoid region. Results: The mean level of mastoid depression was 0.83 mm (range: 0.07-4.08 mm), and the max level of mastoid depression was 1.40 mm (range: 0.20-6.65 mm). In univariate analysis, capsular duration of expansion and expansion volume were associated factors with mastoid depression. Conclusion: This study showed the possibility of mastoid depression following expander implantation for microtia reconstruction in hemifacial microsomia. Plastic surgeons should be aware of the possibility and associated factors of bony depression in mastoid region following expander implantation to optimize microtia reconstruction for patients with HFM.

Morphologic Variability of Bone and Soft Tissue in Microtia With Hemifacial Microsomia

Objective: Microtia patients with hemifacial microsomia (HFM) have a host of distinct anatomical disorder of skeletal and soft tissue asymmetries. The purpose of this study was to assess soft tissue discrepancies in microtia patients with HFM and their correlation with skeletal discrepancies. Methods: A total of 42 patients were enrolled and studied prospectively using a 3-dimensional superimposition and color mapping of the soft and hard tissues. Mirroring techniques created perfectly symmetric models for comparison. Differences between affected and normal sides were evaluated in 5 areas: retroauricular mastoid, malar, maxillary frontal, mandibular frontal, and gonion areas. Pearson correlations were used to assess the relationship between skeletal and soft tissue asymmetry. Results: Hard tissue asymmetry ranged from 0.79 mm (mandibular frontal) to 1.29 mm (malar), while soft tissue asymmetry ranged from 1.34 mm (maxillary frontal) to 5.26 mm (retroauricular mastoid). Correlations between skeletal and soft tissue asymmetry varied, with the strongest correlation observed at the retroauricular mastoid area and the weakest at the maxillary frontal area. Conclusion: There was a high correlation between bone and soft tissue hypoplasia at the retroauricular mastoid area, while the other evaluated areas showed poor correlation between skeletal and soft tissue asymmetries. Clinicians should assess each component separately for optimal treatment planning in microtia patients with HFM.

Psychosocial and Health-Related Experiences of Individuals With Microtia and Craniofacial Microsomia and Their Families: Narrative Review Over 2 Decades

This paper describes 20 years of microtia and craniofacial microsomia (CFM) psychosocial and healthcare studies and suggests directions for clinical care and research.

A narrative review of papers January 2000 to July 2021 related to psychosocial and healthcare experiences of individuals with microtia and CFM and their families.

Studies (N = 64) were mainly cross-sectional (69%), included a range of standardized measures (64%), and were with European (31%), American (27%), or multinational (23%) samples. Data were generally collected from both patients and caregivers (38%) or patient self-report (35%). Sample sizes were 11 to 25 (21%), 26 to 50 (19%), 51 to 100 (22%), or over 100 (38%). Studies addressed 5 primary topics: (1) Healthcare Experiences, including Medical Care, Hearing Loss/Amplification, Diagnostic Experiences, and Information Preferences; (2) Psychosocial Experiences, including Teasing, Behavioral Adjustment, Psychosocial Support, and Public Perception; (3) Neurocognitive Functioning and Academic Assistance; (4) Pre- and Post-Operative Psychosocial Outcomes of Ear Reconstruction/Canaloplasty; and (5) Quality of Life and Patient Satisfaction.

Care involved multiple specialties and was often experienced as stressful starting at diagnosis. Psychosocial and neurocognitive functioning were generally in the average range, with possible risk for social and language concerns. Coping and resiliency were described into adulthood. Satisfaction and positive benefit of ear reconstruction/canaloplasty were high. Care recommendations include increasing: hearing amplification use, microtia and CFM knowledge among providers, efficient treatment coordination, psychosocial support, academic assistance, and advances to minimize surgical scarring. This broad literature overview informs clinical practice and research to improve psychosocial outcomes.

Evaluating International Diagnostic, Screening, and Monitoring Practices for Craniofacial Microsomia and Microtia: A Survey Study

To (1) appraise current international classification and clinical management strategies for craniofacial microsomia (CFM) and microtia, and (2) to assess agreement with the European Reference Network "European Guideline Craniofacial Microsomia" recommendations on screening and monitoring.

This was a cross-sectional online survey study. The survey consisted of 44 questions on demographics, diagnostics and classification, obstructive sleep apnea, feeding difficulties, speech and language development, hearing, ocular abnormalities, visual development, orthodontic screening, genetic counselling, psychological wellbeing, and extracraniofacial anomalies.

Respondents were participants of 3 international cleft and craniofacial conferences, members of the American Cleft Palate and Craniofacial Association and members of the International Society for Auricular Reconstruction. Respondents were requested to complete 1 questionnaire per multidisciplinary team.

Fifty-seven responses were received from 30 countries (response rate ∼3%).The International Consortium for Health Outcomes Measurement diagnostic criteria were used by 86% of respondents, though 65% considered isolated microtia a mild form of CFM. The Orbit, Mandible, Ear, Facial Nerve and Soft Tissue classification system was used by 74% of respondents. Agreement with standardized screening and monitoring recommendations was between 61% and 97%. A majority of respondents agreed with screening for extracraniofacial anomalies (63%-68%) and with genetic counselling (81%).

This survey did not reveal consistent agreement on the diagnostic criteria for CFM. Respondents mostly supported management recommendations, but frequently disagreed with the standardization of care. Future studies could focus on working towards international consensus on diagnostic criteria, and exploring internationally feasible management strategies.

Hospitalizations from Birth to 28 Years in a Population Cohort of Individuals Born with Five Rare Craniofacial Anomalies in Western Australia

OBJECTIVE

To describe trends, age-specific patterns, and factors influencing hospitalizations for 5 rare craniofacial anomalies (CFAs).

METHODS

Data on livebirths (1983-2010; n = 721 019) including rare CFA (craniofacial microsomia, mandibulofacial dysostosis, Pierre Robin sequence, Van der Woude syndrome, and frontonasal dysplasia), episodes of death, and demographic and perinatal factors were identified from the Western Australian Register of Developmental Anomalies, Death Registrations and Midwives Notification System. Information on incident craniofacial and noncraniofacial related admissions, length of hospital stay, and intensive care and emergency-related admissions were identified using principal diagnosis and procedural codes were extracted from the Hospital Morbidity Data Collection and linked to other data sources. Associations of hospitalizations by age groups as well as demographic and perinatal factors were expressed as incidence rate ratio (IRR).

RESULTS

The incident hospitalizations were 3 times as high for rare CFA (IRR 3.22-3.72) throughout childhood into adolescence than those without. Children with rare CFA had 3-4 times as many potentially preventable hospitalizations until 18 years of age than those without. Specifically, respiratory infections (IRR 2.13-2.35), ear infections (IRR 7.92-26.28), and oral health-related conditions contributed for most noncraniofacial admissions until the adolescence period. A greater incidence of noncraniofacial related hospitalizations was observed among Indigenous children, births with intrauterine growth restrictions, and families with high socioeconomic disadvantage.

CONCLUSIONS

Throughout childhood, individuals with rare CFA had greater hospital service use, specifically for potentially preventable conditions, than those without. These population-level findings can inform new preventive strategies and early disease management targeted toward reducing preventable hospitalizations.

Piezosurgery in hemifacial microsomia: a promising exemption from conventional peri-osteotomy suffering

Introduction

Mandibular distraction osteogenesis, a recommended therapy for hemifacial microsomia, has brought much agony because of its traumatic procedures and peri-osteotomy complications. Our study aims to retrospectively compare piezoelectric osteotome with conventional reciprocal bone saw for hemifacial microsomia patients and validate its meliority in operability, surgical risks and patient outcomes.

Methods

All patients included underwent osteotomies conducted by either piezosurgery or bone saw. Information of intraoperative blood loss, operation duration, postoperative pain and complications was collected from patient files, ward round inspections and follow-ups.

Results

Among all 40 patients, 13 underwent piezo-osteotomy. Piezosurgery performed better than conventional reciprocal bone saw in decreasing intraoperative blood loss (p < 0.001) and operation duration (p = 0.030). No significant difference was found in hospitalization duration, total expenses or complication rates between two groups. There were positive relations between operation duration and intraoperative blood loss (p = 0.042), and between hospitalization duration and total expenses (p = 0.0096). Postoperative pain scores of both groups declined over time while the piezosurgery group had a statistically significant tendency (p = 0.006) to suffer less than the conventional group.

Discussion

Piezosurgery diminishes intraoperative blood loss, operative duration, and postoperative pain, making an alternative to conventional osteotomes to mitigate patients' and families' peri-osteotomy sufferings, and a more humane solution to HFM.

Goldenhar syndrome complicated with subglottic airway stenosis: a case report

BACKGROUND

Goldenhar syndrome is a congenital disease that involves an absence or underdevelopment of structures that arise from the first and second pharyngeal arches and more or less severe extracranial anomalies. A variety of supraglottic malformations may be observed, including mandibular hypoplasia, mandibular asymmetry and micrognathia. Subglottic airway stenosis (SGS), which can cause difficulties in airway management during the perioperative period, is seldom emphasized in literature descriptions of Goldenhar syndrome, but can be clinically significant.

CASE PRESENTATION

An 18-year-old female with a history of Goldenhar syndrome presented for placement of a right mandibular distractor, right retroauricular dilator, and stage I transfer of a prefabricated expanded flap under general anesthesia. During tracheal intubation, the endotracheal tube (ETT) met resistance unexpectantly when attempting to pass through the glottis. Subsequently, we attempted the procedure with a smaller size ETT but again met resistance. With fiberoptic bronchoscope, we found that the whole segment of the trachea and bilateral bronchi were obvious narrow. Given the finding of unexpected severe airway stenosis and the associated risks with proceeding with the surgery, the operation was cancelled. We removed the ETT once the patient was fully awake.

CONCLUSIONS

Anesthesiologists should be aware of this clinical finding when evaluating the airway of a patient with Goldenhar syndrome. Coronal and sagittal measurements on computerized tomography (CT) and three-dimensional image reconstruction can be used to evaluate the degree of subglottic airway stenosis and measure the diameter of the trachea.

Craniofacial Microsomia: New Updates in Spinal Anomalies

INTRODUCTION

Craniofacial microsomia (CFM) involves anomalies of the first and second pharyngeal arches, mainly of the mandible, maxilla, ears, and vertebral spine. This study aimed to identify the frequency and morphology of spinal anomalies of individuals with clinical diagnoses of CFM. In addition, the correlation between spinal anomalies and craniofacial involvement was performed.

MATERIALS AND METHODS

This study was a retrospective review of individuals with a clinical diagnosis of craniofacial microsomia. The inclusion criteria were a clinical diagnosis of CFM with no overlap with any other syndromes of first and second pharyngeal arches and radiograph availability in the hospital's database. Prevalence and morphology of spinal anomalies were calculated and clinical details were recorded: types of spinal anomalies and correlations according to OMENS score.

RESULTS

The sample consisted of 46 individuals with a clinical diagnosis of CFM, 24 (52,2%) female and 22 (47,8%) male (1M:1F). Twenty-one (45,7%) had unilateral craniofacial involvement and 25 (54,3%), bilateral. Twenty-eight (60,9%) individuals presented spinal anomalies. Those with unaltered spinal morphology showed a slight preference toward OMENS scores under 5: 7 patients did, only one of which had spinal alterations (14,3%); 68,8% (22) in the group with scores 5 to 9 (n=32) and 71,4% (5) in the 10 to 15 group (n=7) did as well.

DISCUSSION AND CONCLUSIONS

Spinal anomalies in individuals with CFM are more common than usually reported in medical literature, mainly when associated with radial anomalies and correlate with statistical significance to facial features, mainly the OMENS score.

A Proposal for the Classification of Temporomandibular Joint Disc Deformity in Hemifacial Microsomia

Hemifacial microsomia (HFM) is the second most common congenital craniofacial disease and has a wide spectrum of symptoms. The classic diagnostic criterion for hemifacial microsomia is the OMENS system, which was later refined to the OMENS+ system to include more anomalies. We analyzed the data of 103 HFM patients with magnetic resonance imaging (MRI) for temporomandibular joint (TMJ) discs. The TMJ disc classification was defined into four types: D0 for normal disc size and shape; D1 for disc malformation with adequate length to cover the (reconstructed) condyle; D2 for disc malformation with inadequate length to cover the (reconstructed) condyle; and D3 for no obvious presence of a disc. Additionally, this disc classification was positively correlated with the mandible classification (correlation coefficient: 0.614, p < 0.01), ear classification (correlation coefficient: 0.242, p < 0.05), soft tissue classification (correlation coefficient: 0.291, p < 0.01), and facial cleft classification (correlation coefficient: 0.320, p < 0.01). In this study, an OMENS+D diagnostic criterion is proposed, confirming the conjecture that the development of the mandibular ramus, ear, soft tissue, and TMJ disc, as homologous and adjacent tissues, is affected to a similar degree in HFM patients.

Craniofacial microsomia - more than a structural malformation

OBJECTIVES

To analyse the prevalence and distribution of craniofacial microsomia (CFM) cases in Finland and their most frequent comorbidities. The second aim was to analyse the patients' need for specialized healthcare services.

MATERIALS AND METHODS

Data were gathered from two complementary registers: The Register of Congenital Malformations and the Care Register for Social Welfare and Health Care (Hilmo) of the Finnish Institute for Health and Welfare (THL).

RESULTS

The prevalence of CFM patients in Finland was 1:10 057. They were evenly distributed across the five university hospital districts. Their most frequently used ICD-10 diagnosis codes were F40-48 (Neurotic, stress-related and somatoform disorders), 60% of patients in adolescent and adult psychiatry; Q67.0 (Facial asymmetry), 43% in plastic surgery; Z00.4 (General psychiatric examination, not elsewhere classified), 31% in child psychiatry; Z31.5 (Genetic counselling), 28% in clinical genetics and Q67.40 (Other congenital deformities of the skull, face and jaw, Hemifacial atrophy), 18% in dental, oral and maxillofacial diseases. Of the patients, 70% had had visits in clinical genetics, 60% in plastic surgery, 41% in dental, oral and maxillofacial diseases, 28% in adolescent/adult psychiatry and 21% in child psychiatry. The majority of the patients' plastic surgery visits were concentrated in one university hospital. Other services were mainly provided by patients' own hospital districts.

CONCLUSIONS

Even though the majority of CFM patients' visits in specialized healthcare services are related to correction of facial asymmetry and ear malformations, the obvious need for psychiatric care was apparent in all age groups.

Use of a Fibula Free Flap for Mandibular Reconstruction in Severe Craniofacial Microsomia in Children with Obstructive Sleep Apnea

This is a retrospective study describing a multi-stage protocol for the management of severe mandibular hypoplasia in craniofacial microsomia (CFM) with accompanying obstructive sleep apnea (OSA). Patients with severe mandibular hypoplasia require reconstruction functionality and esthetical features. In the cohort, reconstructions based on free fibular flaps (FFF) may be the most effective way. Patients aged 4-17 years with severe mandibular hypoplasia were treated with FFF, which initially improved the respiratory function assessed on polysomnography (AHI). In the next stages of treatment of cases with respiratory deterioration, it was indicated to perform distraction osteogenesis (DO) of the mandible and the structures reconstructed with FFF. All surgeries were planned in accordance with virtual surgery planning VSP. The aim of the study was to prospectively assess the effectiveness of multi-stage mandibular reconstruction in craniofacial microsomia with the use of a free fibula flap in terms of improving respiratory failure due to obstructive sleep apnea (OSA). The FFF reconstruction method, performed with virtual surgical planning (VSP), is proving to be an effective alternative to traditional methods of mandibular reconstruction in patients with severe CFM with OSA.

Damaging variants in FOXI3 cause microtia and craniofacial microsomia

PURPOSE

Craniofacial microsomia (CFM) represents a spectrum of craniofacial malformations, ranging from isolated microtia with or without aural atresia to underdevelopment of the mandible, maxilla, orbit, facial soft tissue, and/or facial nerve. The genetic causes of CFM remain largely unknown.

METHODS

We performed genome sequencing and linkage analysis in patients and families with microtia and CFM of unknown genetic etiology. The functional consequences of damaging missense variants were evaluated through expression of wild-type and mutant proteins in vitro.

RESULTS

We studied a 5-generation kindred with microtia, identifying a missense variant in FOXI3 (p.Arg236Trp) as the cause of disease (logarithm of the odds = 3.33). We subsequently identified 6 individuals from 3 additional kindreds with microtia-CFM spectrum phenotypes harboring damaging variants in FOXI3, a regulator of ectodermal and neural crest development. Missense variants in the nuclear localization sequence were identified in cases with isolated microtia with aural atresia and found to affect subcellular localization of FOXI3. Loss of function variants were found in patients with microtia and mandibular hypoplasia (CFM), suggesting dosage sensitivity of FOXI3.

CONCLUSION

Damaging variants in FOXI3 are the second most frequent genetic cause of CFM, causing 1% of all cases, including 13% of familial cases in our cohort.

Bioinformatics Analysis of Hub Genes Involved in Alcohol-Related Hemifacial Microsomia Pathogenesis

OBJECTIVE

Alcohol is a recognized teratogen, and alcohol exposure increases the risk for hemifacial microsomia (HFM) of the fetus during maternal pregnancy. The present study aimed to explore potential mechanisms and verify hub genes of HFM associated with alcohol by bioinformatics methods.

METHODS

First, HFM and alcohol pathogenic genes were obtained. Thereafter, a protein-protein interactional (PPI) network was constructed. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway enrichment analyses and molecular complex detection were performed by Metascape. Finally, we used the cytoHubba plugin to screen the hub genes.

RESULTS

A total of 43 HFM genes and 50 optimal alcohol candidate genes were selected. The PPI networks for pathogenic genes contained 93 nodes and 503 edges. Functional enrichment analysis largely focused on tissue formation and development. Two modules were identified from the PPI network, and 10 hub genes were screened out. The genes most relevant to alcohol-induced HFM pathogenesis included CTNNB1, TP53, MYC, HDAC1, and SOX2.

CONCLUSIONS

This study identified some significant hub genes, pathways, and modules of HFM related to alcohol by bioinformatics analyses. Our results suggest that the CTNNB1, TP53, MYC, HDAC1, and SOX B1 gene subfamilies may have played a major role in alcohol-induced HFM.

Surgical Microtia Reconstruction in Hemifacial Microsomia Patients: Current State and Future Directions

Background:

Hemifacial microsomia (HFM) is one of the most common congenital craniofacial disorders. Among many other features, microtia is present in the large majority of these patients. However, mainly due to the unilateral hypoplastic anatomy, microtia reconstruction among this patient population remains a reconstructive challenge for plastic surgeons. Given that no clear standards exist, an evidence-based synthesis of the literature was devised.

Methods:

A systematic search of Pubmed, Medline, and Embase was carried out, in accordance with the PRISMA guidelines. Studies discussing surgical microtia reconstruction for HFM patients were retained. Qualitative data regarding study design, challenges addressed, specific recommendations, and their respective strengths/limitations were extracted from each. Retrieved recommendations were consolidated and assigned a level of evidence grade.

Results:

Although only 11 studies were included in this review, these provided 22 main recommendations regarding the eight HFM-specific challenges identified, which were of either grade C (n = 5) or D (n = 17). Included studies addressed construct location (n = 7), the low hairline (n = 6), soft tissue construct coverage (n = 6), earlobe reconstruction (n = 6), construct projection (n = 5), anomalies of the relevant neurovascular systems (n = 2), retroauricular construct coverage (n = 2), and sizing of the construct (n = 2).

Conclusions:

Given the many persisting reconstructive challenges regarding surgical microtia reconstruction for HFM patients, the authors present a comprehensive and evidence-based consolidation of recommendations specific to these challenges. The authors hope this systematic review can appropriately guide plastic surgeons and will ultimately improve care for this patient population.

A new treatment strategy for hemifacial microsomia: Auricular reconstruction with an expanded two-flap method and simultaneous mandibular distraction osteogenesis

BACKGROUND

Owing to the complex clinical manifestations of hemifacial microsomia (HFM), multidisciplinary cooperation is required to achieve better therapeutic effects in terms of function and aesthetics. This study aimed to explore the efficacy of the expanded two-flap auricular reconstruction combined with mandibular distraction osteogenesis in the treatment of HFM.

METHODS

This surgical strategy was performed in three stages. In the first stage, the retroauricular skin was expanded with a tissue expander and a mandibular distraction device was installed. In the second stage, the traditional expanded two-flap method for auricular reconstruction was adapted, and the framework was fabricated with costal cartilage and wrapped with the expanded skin flap, retroauricular fascia flap, and full-thickness skin graft. In the final stage, the tragus and lobule were rebuilt, the concha cavity deepened, and the mandibular distraction device removed.

RESULTS

From January 2014 to November 2018, 166 HFM patients underwent auricular reconstruction with the expanded two-flap method and simultaneous mandibular extension in our hospital. The median follow-up period was 9.3 months. Of the 166 patients, 154 patients and their families were satisfied with the results, and only 16 patients experienced complications.

CONCLUSIONS

This three-stage technique of simultaneous auricular reconstruction and mandibular distraction osteogenesis is safe and effective in achieving facial symmetry, improving occlusal contact, shortening treatment course, and relieving patient's suffering, especially for HFM patients.

Three-dimensional measurements on the mandible of patients with hemifacial microsomia

Background:

Hemifacial microsomia (HFM), which involves multiple sites with different levels of severity, is the second most common congenital craniofacial deformity after cleft lip and palate. However, three-dimensional (3D) measurements of mandibular deformities have not yet been studied in detail. The objective of this study is to investigate the method of 3D measurements of mandibular deformities in HFM patients.

Methods:

A total of 48 HFM patients were included in this study. All clinical treatment for patients was performed in the Plastic Surgery Hospital of the Chinese Academy of Medical Sciences at Peking Union Medical College from June 2006 to June 2020. The patients’ 3D computerized tomography scan data were processed using medical imaging software, following four iterative steps: 3D reconstruction, mirroring, differential analysis, and partition.

Results:

The characteristics of the mandibular bone in HFM patients are mainly presented as follows: (1) compared to the normal side, the part of the bone body that extends from the ascending ramus to the pogonion (Po-NB) is analyzed using a dynamic process: less fullness-fullness-more fullness; (2) absences were frequently observed among the angular zones, that is, the height of the ascending ramus is deficient.

Conclusions:

HFM is a complicated condition with numerous variations in clinical presentation. We employed both 3D image reconstruction and computerization image processing techniques to investigate asymmetrical mandibular deformity in HFM patients in detail and with great accuracy. This will be of great use to clinicians for disease management.

Proposed clinical approach and imaging studies in families with oculo-auriculo-vertebral spectrum to assess variable expressivity

A diagnosis of oculo-auriculo-vertebral spectrum (OAVS) is established when microtia is present in association with hemifacial hypoplasia (HH) and/or ocular, vertebral, and/or renal malformations. There is no consensus on which imaging studies should be used to rule out variable expressivity and distinguish "sporadic" from "familial" patients. This observational and descriptive study was performed in a Mexican population of 51 patients (32 males, 19 females, 0-18 years old) with microtia/OAVS, and their available parents. A clinical history, genealogy, and physical examination were obtained from all included patients, as were a computed tomography (CT) scan of the ear, audiological evaluation, orthopantomography, complete spine radiography, and renal ultrasound. The same approach was completed in their available parents (51 mothers and 40 fathers), excluding the CT scan and audiological evaluation. By genealogy, 53% of patients were classified as "sporadic"; of the "familial" patients, at least 79.1% had suggestion of a multifactorial inheritance. In the available parents, orthopantomography, complete spine X-ray, and renal ultrasound identified the following OAVS-related manifestations: HH (16.2%, n = 14/86), vertebral alterations (10.9%, n = 10/91), and renal anomalies (2.2%, n = 2/90). Our evaluation of the parents allowed three patients to be reclassified from "sporadic" to "familial" (5.8%, n = 3/51). Our proposed clinical and imaging approach allowed the identification of variable expressivity that more clearly distinguished between "sporadic" and "familial" OAVS patients, which is of utmost importance in providing proper genetic counseling to these families.

Postoperative Changes in the Upper Airway Following Mandibular Distraction Osteogenesis in Pediatric Hemifacial Microsomia

BACKGROUND

Patients with hemifacial microsomia (HFM) may undergo unilateral mandibular distraction osteogenesis (MDO) before skeletal maturity in an effort to improve facial symmetry. Mandibular distraction osteogenesis's effect on airway volumes have been studied in the past, though to our knowledge, none have accounted for the effect of head and neck posture on airway morphology. This study aimed to tackle this shortcoming, using imaging to analyze the upper airway of patients with HFM before and after surgical intervention with MDO.

METHODS/DESCRIPTION

The authors retrospectively reviewed patients with a diagnosis of unilateral HFM whom underwent unilateral MDO with an oblique vector at age 4 to 14 years at a single institution from 2004 to 2019. Patients with pre- and post-MDO three-dimensional computed tomography scans of the upper airway within 12 months of distractor placement and removal, respectively, were included. Head and neck postures were determined by craniocervical, pitch, roll, and yaw angles. Pre- and post-operative pharyngeal airway volumes, pharyngeal surface area, minimum retropalatal cross-sectional areas (RP CSA) and retroglossal (RG) CSA and associated anteroposterior distances were measured using Mimics 22.0 (Materialise; Leuven, Belgium). Comparison was done using Kruskal-Wallis tests and linear mixed-effects models controlling for head and neck postures.

RESULTS

Ten patients met inclusion criteria. Mean age at pre-distractor placement computed tomography scan was 99 ± 35 months, and mean duration between pre- and post-surgery scans was 220 ± 90 days. Head and neck posture were found to be significant predictors of all airway dimensions. After controlling for significant factors with fixed effects linear modeling, surface area was found to be significantly smaller in patients after MDO by 189.48 mm2 (F[10.8] = -3.47, P = 0.0053), compared to their preoperative measurements. Surgery was not a significant predictor of changes in airway volume (F[11.6] = 0.52, P = 0.61), minimum RP CSA (F[12.2] =  -0.64, P = 0.53), minimum RG CSA (F[12.6] =  -1.64, P = 0.13), RP anteroposterior distance (F[14.0] = 0.30, P = 0.77), or RG anteroposterior distance (F[20.0] =  -0.04, P = 0.97).

CONCLUSIONS

Oblique vector MDO in patients with HFM is associated only with statistically significant changes in the surface area of the upper airway, and is not associated with statistically significant changes in dimensions like volume, CSA, or anteroposterior dimension. This is an important finding, as it may guide discussions surrounding risk/benefit ratio for MDO in childhood.

Craniofacial microsomia: Reflections on diagnosis and severity assessment based on a series of cases

This study aims to discuss diagnostic criteria and severity assessment for craniofacial microsomia (CFM). A series of 61 patients with diverse CFM phenotypes had their clinical data collected by experienced dysmorphologists using a single protocol. Genetic abnormalities were searched through karyotype and chromosomal microarray analysis. Sex ratio, prenatal risk factors, and recurrence rate corroborated the literature. Despite the wide variability of clinical findings, ear disruption was universal. Eight patients were assigned as syndromic, four of whom had demonstrable genetic alterations. The majority of patients (67.2%) fulfilled four known diagnostic criteria, while 9.8% fulfilled one of them. Data strengthened disruptions of the ear and deafness as a semiotically valuable sign in CFM. Facial impairment should consider asymmetry as a mild expression of microsomia. Spinal and cardiac anomalies, microcephaly, and developmental delay were prevalent among extra craniofacial features and should be screened before planning treatment and follow up. The severity index was able to recognize the less and the most affected patients. However, it was not useful to support therapeutic decisions and prognosis in the clinical scenario due to syndromic and non-syndromic phenotypes overlapping. These issues make contemporary the debate on diagnostic methods and disease severity assessment for CFM. They also impact care and etiopathogenetic studies.

The need to belong: Subjective experiences of living with craniofacial conditions and undergoing appearance-altering surgery

The purpose of this study was to better understand how individuals with craniofacial conditions experience living with visible differences and make sense of appearance-altering surgery. We conducted semi-structured qualitative interviews with 11 adults with Goldenhar or Crouzon syndrome. Interviews were analysed using a hermeneutic-phenomenological approach to thematic analysis. Our analysis revealed the following overarching theme, To see myself as other people see me, which encompassed three main themes: a) Striving to fit in, b) Altering the way I look and c) Support from family and friends. The participants' sense of their own appearance seemed to be connected to how they perceived others to evaluate their appearance. All had experienced negative reactions from others. They experienced themselves as different and had a desire to belong. All participants had undergone appearance-altering surgery, hoping that by changing appearance, they would reduce negative reactions and feel more connected to and accepted by other people. The process of undergoing appearance-changing surgery was experienced as challenging, and participants wished for a dialogue with surgeons which included psychological and emotional aspects of changing appearance. A better understanding of how to strengthen positive identity processes and feelings of belongingness should be a key focus of future research.

Haploinsufficiency of SF3B2 causes craniofacial microsomia

Craniofacial microsomia (CFM) is the second most common congenital facial anomaly, yet its genetic etiology remains unknown. We perform whole-exome or genome sequencing of 146 kindreds with sporadic (n = 138) or familial (n = 8) CFM, identifying a highly significant burden of loss of function variants in SF3B2 (P = 3.8 × 10^-10), a component of the U2 small nuclear ribonucleoprotein complex, in probands. We describe twenty individuals from seven kindreds harboring de novo or transmitted haploinsufficient variants in SF3B2. Probands display mandibular hypoplasia, microtia, facial and preauricular tags, epibulbar dermoids, lateral oral clefts in addition to skeletal and cardiac abnormalities. Targeted morpholino knockdown of SF3B2 in Xenopus results in disruption of cranial neural crest precursor formation and subsequent craniofacial cartilage defects, supporting a link between spliceosome mutations and impaired neural crest development in congenital craniofacial disease. The results establish haploinsufficient variants in SF3B2 as the most prevalent genetic cause of CFM, explaining ~3% of sporadic and ~25% of familial cases.

Whole-Exome Sequencing Reveals Rare Germline Mutations in Patients With Hemifacial Microsomia

Hemifacial microsomia (HFM) is a rare congenital disease characterized by a spectrum of craniomaxillofacial malformations, including unilateral hypoplasia of the mandible and surrounding structures. Genetic predisposition for HFM is evident but the causative genes have not been fully understood. Thus, in the present study, we used whole-exome sequencing to screen 52 patients with HFM for rare germline mutations. We revealed 3,341 rare germline mutations in this patient cohort, including those in 13 genes previously shown to be associated with HFM. Among these HFM-related genes, NID2 was most frequently mutated (in 3/52 patients). PED4DIP, which has not been previously associated with HFM, exhibited rare variants most frequently (in 7/52 patients). Pathway enrichment analysis of genes that were mutated in >2 patients predicted the "laminin interactions" pathway to be most significantly disrupted, predominantly by mutations in ITGB4, NID2, or LAMA5. In summary, this study is the first to identify rare germline mutations in HFM. The likely disruptions in the signaling pathways due to the mutations reported here may be considered potential causes of HFM.