A classification and construction of congenital lateral facial clefts

Rare craniofacial clefts: Surgical management protocols

BACKGROUND

Standardization of surgical protocols is an evolving issue owing to the low incidence of rare craniofacial clefts. In this article, we present our surgical management technique for repair of rare craniofacial clefts and evaluate the postoperative results.

METHODS

This study was conducted from 2013 to 2022 and included patients who presented with craniofacial clefts. The results were assessed based on parents' satisfaction and objective evaluations by two independent observers.

RESULTS

A total of 3679 patients presented with cleft anomalies; of these, 61 patients with 89 rare craniofacial clefts were observed with a prevalence of 2.42/100. The male to female ratio was 1:1.35. Craniofacial cleft "4" and "5" were the most common, with 17 (19.1%) and 16 (17.98%) patients, respectively. Multiple craniofacial clefts were observed in 37.7% of the patients. Associated craniofacial anomalies were found in 39.34% of the patients. The parents of 71.6% of the patients were very satisfied with the results. Based on the scores of two independent observers, 70.27% of the patients showed good results.

CONCLUSION

The rare nature of craniofacial clefts and involvement of various structures make the standardization of surgical procedures very challenging. Our experience with these clefts will help new surgeons both in didactics and in technical aspects of patient management.

KEY POINTS

1. We share our experience with rare craniofacial clefts. 2. Each cleft presents with its own unique reconstructive challenges. The literature describes many techniques for each type of cleft, all with multiple permutations. We present a simplified technique that has worked for us over the years for all Tessier clefts.

Bilateral Maxillary Duplication in Tessier No. 7 Cleft: An Uncommon Congenital Deformity with a Challenging Radiological Diagnosis

Tessier No. 7 cleft, known as lateral facial cleft, is a rare and understudied entity with an incidence of 1/80,000-1/300,000 live births. Besides perioral tissue abnormalities manifesting as macrostomia, Tessier 7 cleft also involves anomalies of the underlying bony structures. It can appear as part of a syndrome, such as Treacher-Collins syndrome or Goldenhar/Orbito-Auriculo-Vestibular Spectrum, or as an isolated form (unilateral or bilateral) with variable expressions. Bilateral maxillary duplication in Tessier 7 cleft is considered extremely rare, accounting for only two previously presented cases. Given that the cases presented in the literature mainly focus on clinical appearance and surgical treatment, without providing sufficient imaging, we aim to present key radiological features of Tessier 7 cleft in terms of evaluating the involved structures, which is essential for the therapeutic approach and final outcome. A 17-year-old male with incompetent lips and orthodontic abnormalities was referred to our Radiology Department for orthopantomography (OPG) and CT examinations. Hetero-anamnestic data revealed a history of surgical treatment of the commissural cleft conducted 2 months after the birth to enable feeding. Intraoral examination showed a maxillary cleft and supernumerary teeth. Since the given clinical presentation was inconclusive, radiological diagnostics took precedence in elucidating this complex entity.

Single-stage Repair of Bilateral Cleft Lip and Bilateral Transverse Facial Cleft in Goldenhar Syndrome: A Case Report

Goldenhar syndrome (GS) is a rare congenital disorder characterized by multiple facial anomalies. This case report describes a GS presenting with bilateral cleft lip and palate and bilateral transverse facial cleft. We performed a single-stage surgery to repair the bilateral cleft lip and bilateral transverse facial cleft when the patient was 4-months-old. Bilateral cleft lip repair using the Mulliken method was performed first, and then the bilateral transverse facial cleft was corrected. Orbicularis oris muscle repair was done at each clefts. Anatomical approximation technique was used and the final oral commissure was determined considering symmetry. Satisfactory outcomes were achieved without complications.

Surgical correction of Tessier cleft no. 7: A single center 18-year experience

INTRODUCTION

Tessier cleft 7 are rare craniofacial clefts. Live-birth incidence varies from 1/80,000 to 1/300,000, with the incidence of 1 in 120 craniofacial clefts among Asians. Its clinical presentation varies widely in severity, thus, complicating diagnosis and contributing to the lack of consensus regarding its surgical management. The aim of this study is to describe clinical findings, types of Tessier cleft 7 soft tissue repair, and its outcomes in Kuala Lumpur Hospital.

METHODS

This retrospective study reviewed records of children operated from January 2001 to July 2019. Data regarding concurrent congenital anomalies, complications, type of surgery, etc., were collected from outpatient records, operative notes, and clinical photographs.

RESULTS

Twenty-eight children were treated, and 33 clefts (5 bilateral) were repaired. The male-to-female ratio was 1.3:1 (16 males and 12 females). Twenty-three patients had unilateral clefts (82.14%), with 14 right (60.86%) and 8 left (34.78%). Bilateral clefts were less common (17.86%). Twenty-three patients (82.14%) were Malay, 3 (10.71%) Chinese, 1 (3.57%) Indian, and 1 (3.57%) Cambodian. Eleven medical records were untraceable (discontinued due to duration of inactivity). There were 10 straight-line repairs, 5 Z-plasties, and 1 W-plasty performed; 3 cases did not detail the type of repair. One child required scar revision, and 1 had hypertrophic scarring requiring corticosteroid injection-no disturbances in speech or oral incompetency while eating were reported. Duration of follow-up ranged from 3 to 14 years.

CONCLUSION

Our center has a higher rate of Tessier cleft 7 attendance. Straight-line cutaneous repairs combined with inferior vermilion mucosal flap can be used with low rates of complication and revision surgery.

Morphological Presentation of Orofacial Clefts: An Epidemiological Study of 5004 Patients in a Tertiary Care Hospital of Central India

To analyse the morphological presentation of orofacial clefts, gender, syndromes and systemic anomalies associated with them.

This was an epidemiological study performed in the patients who were registered for cleft lip and palate surgeries in our centre. The data was evaluated both retrospectively as well as prospectively.

The patients registered from November 2006 to April 2021 were studied. Out of 5276 patients, data of 5004 cases were analysed, rest 272 patients were excluded due to lack of information. Statistical analysis and Chi square test were applied.

Cleft deformities were more common in males than females. Cleft lip with palate was the commonest phenotype (52.2%). It was followed by isolated cleft lip (22.9%), isolated cleft palate (22.1%), rare clefts (1.62%) and syndromic clefts (1.18%). Unilateral variants were more frequent than bilateral. In unilateral, left side was more common than the right side. Among bilateral, most of the cases had premaxillary protrusion. In the present study, 3.46% of all the patients had associated anomalies affecting their other organs. Less common cleft phenotypes like microform cleft lip and submucous cleft palate ± bifid uvula showed frequency of 0.62% and 0.64% respectively.

Thorough examination of cleft deformity should be done as it may appear as an isolated deformity or part of a syndrome and have associated systemic anomalies. This may help us to deliver comprehensive care to the patients and can prevent potential operative complications.

Correction of congenital macrostomia by double reversing Z-plasty: A technical note

Congenital macrostomia is a rare congenital deformity that consists of an enlargement of the commissure of the mouth. The malformation may be unilateral or bilateral and has a polymorphic presentation. Various surgical techniques have been described to correct macrostomia, with only a few cases illustrating the expected results. The surgical repair must consider both esthetic as well as functional impacts for the patient. We here propose a technical note to refine and provide additional information for good achievement of "Double Reversing Z-Plasty" for correction of macrostomia. Our case series also reports good long-term functional and esthetic results obtained with this technique, especially in case of a minor cleft.

Congenital macrostomia management in children in a country with limited resources: A case series

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Congenital macrostomia is an uncommon facial malformation in children.

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The choice of the surgical procedure should be based on functional, aesthetic results and the surgeon's experience.

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Even in underdeveloped countries, Z-commissuroplasty could be performed with good results.

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Further research should focus on long-term follow-up of large series, regardless of the type of surgical procedure.

Unilateral Tessier 7 cleft: Case report of Z-plasty with geometric broken line repair and literature review

Tessier 7 clefts are a rare congenital anomaly, usually surgically repaired with Z-plasty or other reconstructive methods, although undesirable scars may result. We present a review of the literature and a case of unilateral Tessier 7 cleft repaired with a novel reconstruction technique using a combined Z-plasty and geometric broken line closure (GBLC) to camouflage and irregularize the otherwise linear scar. We present this case to expand the armamentarium of surgical options to address Tessier 7 clefts and to review techniques for repair.

Distribution, side involvement, phenotype and associated anomalies of Korean patients with craniofacial clefts from single university hospitalbased data obtained during 1998-2018

Objective

To investigate the distribution, side involvement, phenotype, and associated anomalies of Korean patients with craniofacial clefts (CFC).

Methods

The samples consisted of 38 CFC patients, who were treated at Seoul National University Dental Hospital during 1998-2018. The Tessier cleft type, sex, side involvement, phenotype, and associated anomalies were investigated using nonparametric statistical analysis.

Results

The three most common types were #7 cleft, followed by #0 cleft and #14 cleft. There was no difference between the frequency of male and female. Patients with #0 cleft exhibited nasal deformity, bony defect, and missing teeth in the premaxilla, midline cleft lip, and eye problems. A patient with #3 cleft (unilateral type) exhibited bilateral cleft lip and alveolus. All patients with #4 cleft were the bilateral type, including a combination of #3 and #4 clefts, and had multiple missing teeth. A patient with #5 cleft (unilateral type) had a posterior openbite. In patients with #7 cleft, the unilateral type was more prevalent than the bilateral type (87.0% vs. 13.0%, p < 0.001). Sixteen patients showed hemifacial microsomia (HFM), Goldenhar syndrome, and unilateral cleft lip and palate (UCLP). There was a significant match in the side involvement of #7 cleft and HFM (87.5%, p < 0.01). Patients with #14 cleft had plagiocephaly, UCLP, or hyperterorbitism. A patient with #30 cleft exhibited tongue tie and missing tooth.

Conclusions

Due to the diverse associated craniofacial anomalies in patients with CFC, a multidisciplinary approach involving a well-experienced cooperative team is mandatory for these patients.

Distribution, side involvement, phenotype and associated anomalies of Korean patients with craniofacial clefts from single university hospitalbased data obtained during 1998-2018

OBJECTIVE

To investigate the distribution, side involvement, phenotype, and associated anomalies of Korean patients with craniofacial clefts (CFC).

METHODS

The samples consisted of 38 CFC patients, who were treated at Seoul National University Dental Hospital during 1998-2018. The Tessier cleft type, sex, side involvement, phenotype, and associated anomalies were investigated using nonparametric statistical analysis.

RESULTS

The three most common types were #7 cleft, followed by #0 cleft and #14 cleft. There was no difference between the frequency of male and female. Patients with #0 cleft exhibited nasal deformity, bony defect, and missing teeth in the premaxilla, midline cleft lip, and eye problems. A patient with #3 cleft (unilateral type) exhibited bilateral cleft lip and alveolus. All patients with #4 cleft were the bilateral type, including a combination of #3 and #4 clefts, and had multiple missing teeth. A patient with #5 cleft (unilateral type) had a posterior openbite. In patients with #7 cleft, the unilateral type was more prevalent than the bilateral type (87.0% vs. 13.0%, p < 0.001). Sixteen patients showed hemifacial microsomia (HFM), Goldenhar syndrome, and unilateral cleft lip and palate (UCLP). There was a significant match in the side involvement of #7 cleft and HFM (87.5%, p < 0.01). Patients with #14 cleft had plagiocephaly, UCLP, or hyperterorbitism. A patient with #30 cleft exhibited tongue tie and missing tooth.

CONCLUSIONS

Due to the diverse associated craniofacial anomalies in patients with CFC, a multidisciplinary approach involving a well-experienced cooperative team is mandatory for these patients.

Orbicularis oris muscle reconstruction and cheiloplasty with Z-plasty in a patient with a transverse facial cleft

Background

Transverse facial clefts are Tessier’s number 7 facial cleft among numbers 1–15 in Tessier’s classification of craniofacial malformations, which varies from a simple widening oral commissure to a complete fissure extending towards the external ear.

Case presentation

In a patient with a transverse facial cleft, to functionally arrange the orbicularis oris muscle and form the oral commissure naturally, we performed a surgical procedure including orbicularis oris muscle reconstruction and cheiloplasty with Z-plasty.

Conclusion

We achieved good results functionally and esthetically by orbicularis oris muscle reconstruction and cheiloplasty with Z-plasty. The surgical modality of our anatomical repair and 3 months follow-up results are presented.

Surgical management of the Tessier 7 cleft: A review and presentation of 5 cases

INTRODUCTION

Several variations on the surgical technique for macrostomia repair have been described in the literature. There has been controversy regarding the preferred method for commissuroplasty and skin closure for optimal functional and aesthetic results. The aim of this study is to present these techniques and the most described methods up to date.Further, five patients operated with a combination of techniques are presented.

MATERIAL AND METHODS

PRISMA guidelines were followed for literature review.Five consecutive patients with unilateral macrostomia operated during a period of one and a half years at our craniofacial department were included in this study.

RESULTS

31 studies on macrostomia repair were obtained. The layered closure technique is widely described with several variations on closure of the inner mucosa, orbicularis muscle, commissure and skin. The inner mucosal layer is in most cases sutured with a straight line closure technique. The muscle is most often duplicated and sutured with upper branches overlapping lower branches. The skin is in most cases sutured with either a z- or a w-plasty with variations.The five presented patients all had satisfactory functional and aesthetic results at follow-up.

CONCLUSION

Many variations of surgical techniques for macrostomia repair have been presented in the past. We believe that each case of macrostomia needs to be assessed with a tailored surgical plan in order to create the best results. A combination of different techniques with Bütow and Botha's and Kaplan's technique as a starting point, is believed to give satisfactory functional and aesthetic results.

Surgical repair for transverse facial cleft: two flaps with a superiorly rotated single Z-plasty lateral to the commissure

Various techniques have been performed for repairing transverse facial clefts. This study aimed to investigate an optimal method for repairing transverse facial clefts. Twenty-seven patients from 2008 to 2017 were evaluated. Their mean age at repair was 6.7 months with a follow-up period of 6 months to 10 years. A method using an inferior lip-based triangular mucosa flap and a superior lip-based rectangular vermilion-mucosa flap was designed for transposition. The orbicularis oris was reconstructed by using everting mattress suture. The skin was sutured using linear cutaneous closure with a single superiorly rotated Z-plasty lateral to the commissure. A postoperative symmetrical commissure was obtained owing to complete contraction with the new commissure directed 2 or 3 mm medial to the symmetrical point on the lips individually for the 27 patients. Lateral displacement of the reconstructed commissure was not observed. The patients showed a plump and symmetrical cheek on the cleft side. Twenty-one patients with hemifacial microsomia achieved a prominent improvement compared with their preoperative appearance, although the postoperative cheeks still did not show fullness because of the lesser facial tissue on the cleft side. In the early follow-up period, most patients showed a minimal scar during movement. However, the scar became thinner and symmetrical oral movement was achieved over time. This method obtained a natural oral movement without a conspicuous scar and was reliable and remarkable for the postoperative appearance of commissural symmetry. We conclude that this is an optimal method to repair transverse facial clefts.

Surgical Alternative for Repair of Bilateral Macrostomia

The transverse or lateral cleft is the second most common type of craniofacial cleft. The authors report a case of bilateral macrostomia in a male newborn and the authors present a refined method of Kaplan technique for correcting macrostomia. The authors' method is characterized by the creation of a single Z-plasty with the transposed central limb placed in the nasogenian crease.

Isolated Bilateral Macrostomia

Macrostomia (Tessier's 7 cleft) is a rare congenital lip deformity. Macrostomia can occur unilateral or bilateral, isolated or associated with other syndromes. Isolated bilateral macrostomia is exceedingly rare with only a few cases reported to date. The authors report 6 cases of isolated bilateral macrostomia surgically repaired in 4-layered approaches. The traditional method was improved and the result obtained was satisfactory after longest follow-up of 3 years. The technique is easy to imitate, simple in design, aesthetically and functionally corrects the deformity.

MR Imaging of the Fetal Face: Comprehensive Review

The human face is a complex anatomic structure with an equally complex embryologic development. Derangement of the developmental process can result in various structural anomalies, which range from a mainly cosmetic deformity, such as cleft lip, to potentially life-threatening conditions such as arhinia. These anomalies (a) can occur as isolated anomalies; (b) can be associated with intracranial, spinal, or dental anomalies; or (c) can be a part of various syndromes, thus serving as diagnostic clues in such cases. Proper evaluation of fetal facial deformities can help in prognostication, family counseling, and prenatal or early postnatal intervention. Ultrasonography (US) is the first line of investigation in these cases. However, when US does not allow complete evaluation of these anomalies owing to its inherent limitations, magnetic resonance (MR) imaging allows comprehensive evaluation of the anomaly itself and also evaluation of various associations and the treatment approach. The embryology of the fetal facial structures is considered with regard to the MR imaging technique and the MR imaging anatomy. The MR imaging features of various structural anomalies are described and classified into six groups, namely, orofacial clefts, orbital anomalies, nasal anomalies, facial masses, external ear anomalies, and abnormal face shape or profile. Also, the key associations and relevant treatment implications are reviewed. The article provides a "one-stop shop" review of these unique disorders-from basic understanding of the embryology to applying the knowledge in clinical practice, helping the interprofessional team and the patients alike. ^©RSNA, 2018.

The "Double" Tessier 7 Cleft: An Unusual Presentation of a Transverse Facial Cleft

Congenital macrostomia, or Tessier number 7 cleft, is a rare craniofacial anomaly. We present a unique patient with bilateral macrostomia that consisted of a "double" transverse cleft on the left side and a single transverse cleft on the right side. A staged reconstructive approach was used to repair the "double" left-sided clefts. This staged technique produced a satisfactory aesthetic and functional outcome.

Prenatal ultrasound diagnosis of Tessier number 7 cleft: Case report and review of the literature

Lateral or transverse facial clefts are the most frequent of the atypical facial clefts, classified by Tessier as no. 7 clefts. Most of the cases are diagnosed at birth, while few cases are diagnosed prenatally. We report a case of prenatal ultrasound detection and three-dimensional characterisation of a lateral facial cleft at 21 weeks of gestation, which was terminated at 22 weeks. It was a transverse cleft, running through the left cheek towards the ear, along with micrognathia and mild polyhydramnios. We also present a review on classification, anatomical features and prenatal diagnosis of Tessier no. 7 cleft.

Unilateral macrostomia in the newborn: a rare congenital anomaly of the oral commissure

Macrostomia is a rare medical condition, defined as an enlargement of the mouth at the oral commissure. The incidence varies between 1 in 60 000 to 1 in 300 000 live births. Macrostomia is a form of a facial cleft. Macrostomia can present as a unilateral or bilateral anomaly with a partial or complete cleft. Associated anomalies of the surrounding bone, muscle and soft tissue can also be present with or without the presence of a syndrome. Macrostomia results in aesthetic disharmony and also in functional problems. In both cases surgery is the treatment of choice. In cases of macrostomia, additional investigations should be performed to rule out accompanying cardiac and renal anomalies and associated syndromes. A multidisciplinary approach and good collaboration between healthcare providers is essential for optimal care of these patients.

Macrostomia: a review of evolution of surgical techniques

Macrostomia is a congenital deformity resulting from failure of fusion of maxillary and mandibular process. It is a rare congenital deformity with an incidence of 1 in 60,000 to 1 in 300,000 live births. Transverse facial clefts are more common on right side of face in unilateral cases. Males are more affected than females. Various surgical techniques have been described in the literature for the correction of these defects. We report a case of macrostomia corrected with Z-plasty closure for skin, overlapping muscle closure, and triangular mucosal flap for commissure, with a review on existing techniques.

Lateral cleft lip and macrostomia: Case report and review of the literature

Lateral clefts are rare in occurrence. The lateral cleft is cause by failure of fusion of the maxillary and mandibular dermatomes. It is also associated with preaurical tags. We present a case of a lateral cleft of the lip with multiple bilateral preauricular tags that was repaired using triangular flaps.

Unusual case of concomitant occurrence of Tessier's number 7 cleft and dentigerous cyst

Dentigerous cysts are commonly encountered associated with impacted teeth; however the exact histogenesis of these cysts is not known even though numerous theories have been proposed. Majority of the maxillary cysts arise as a result of defect in the embryonal development, which can be either abnormal fusion of facial processes or as a result of abnormality in the development of dental follicle. Congenital Tessier's number 7 unilateral facial cleft is a rare anomaly, which arises as a result of defect in the fusion of facial processes. We report an unusual case of concomitant occurrence of Tesssier's number 7 cleft and maxillary dentigerous cyst in 11-year-old child.

Severe bilateral Tessier 3 clefts in a Uighur girl: the significance and surgical repair

The Tessier 3 cleft is one of the rarest congenital craniofacial clefts, which often extends through the upper lip, the alar groove and the medial canthus. Only a few cases have been reported. There is no standardized method for the surgical treatment for this condition in the literature, and to obtain an acceptable outcome is difficult. A Uighur girl with severe bilateral Tessier 3 clefts and associated orofacial deformities is described here, and a novel protocol for clefts of this severity and rarity is presented. This study focuses particularly on describing the surgical procedures and techniques. Further treatments required for the cleft-associated deformities during later growth and developmental stages are also discussed in detail.

Treacher Collins syndrome: clinical implications for the paediatrician--a new mutation in a severely affected newborn and comparison with three further patients with the same mutation, and review of the literature

Treacher Collins syndrome (TCS) is the most common and well-known mandibulofacial dysostosis caused by mutations in at least three genes involved in pre-rRNA transcription, the TCOF1, POLR1D and POLR1C genes. We present a severely affected male individual with TCS with a heterozygous de novo frameshift mutation within the TCOF1 gene (c.790_791delAG,p.Ser264GlnfsX7) and compare the clinical findings with three previously unpublished, milder affected individuals from two families with the same mutation. We elucidate typical clinical features of TCS and its clinical implications for the paediatrician and mandibulofacial surgeon, especially in severely affected individuals and give a short review of the literature.

CONCLUSION

The clinical data of these three families illustrate that the phenotype associated with this specific mutation has a wide intra- and interfamilial variability, which confirms that variable expressivity in carriers of TCOF1 mutations is not a simple consequence of the mutation but might be modified by the combination of genetic, environmental and stochastic factors. Being such a highly complex disease treatment of individuals with TCS should be tailored to the specific needs of each individual, preferably by a multidisciplinary team consisting of paediatricians, craniofacial surgeons and geneticists.

Tessier 3 cleft with bilateral anophthalmia: case report and surgical treatment

Tessier clefts type 3 and 4 are rare. In this paper the authors report on the management of a wide Tessier 3 cleft. There is no standardized protocol or timing of the surgical procedures in this rare disfiguring condition. Generally speaking, the aim is to preserve the function of important anatomical structures (e.g., a seeing eye.) and reconstruct, as best as possible, harmonic facial features. The authors present a "step by step" solution of the malformation pointing out the limitations of the surgical procedures they used and the goals they wanted to obtain. Despite of the uniqueness and the complexity of the pathology, the authors think they obtained reasonable results both in term of function and aesthetics, permitting the patient to be accepted in the social environment.

Commissural symmetry in unilateral transverse facial cleft patients: an anthropometric study

PURPOSE

To evaluate the commissural symmetry and commissural migration among patients with unilateral transverse facial cleft.

PATIENTS AND METHODS

From 2006 to 2009, 31 patients with unilateral transverse facial cleft were repaired with superiorly based vermillion-mucosal flap and orbicularis oris reconstruction. Linear closure and superiorly rotated and inferiorly rotated Z-plasty were randomly chosen for skin closure. An anthropometric method was used immediately after the repair and at the follow-up examination to evaluate the commissural symmetry in both horizontal and vertical directions.

RESULTS

A total of 21 patients was followed-up for 19 months on average. Satisfactory horizontal symmetry was obtained right after surgery; however, the new commissure was generally lower than the unaffected commissure. At the follow-up examination, no significant lateral commissural displacement was observed; however, the commissural droop on the cleft side became more noticeable.

CONCLUSIONS

The anthropometric method used was convenient and reliable for facial symmetry analysis. Rectangular vermillion-mucosal flap and proper muscle reconstruction could prevent the lateral commissural migration caused by skin scar contracture. Both horizontal and vertical symmetry should be considered for macrostomia repair.