Median cleft of the upper lip: A new classification to guide treatment decisions

Distribution of Specialties Providing Surgical Management of Cleft-Related Speech Disorders in Children 3 years of Age and Older: 2004 to 2021

Given the overlap in specialties performing secondary correction of velopharyngeal incompetence (VPI), the present study investigated the specialty distribution for surgical providers of cleft care from 2004 to 2021. Data were obtained from 45 hospitals from 2004 to 2021 through the Pediatric Health Information System database. Cases of secondary surgical management of VPI were retrieved, identifying the year of surgery and specialty of the providing surgeon. A total of 7090 procedures were included in this study, of which 36.0% were secondary palatoplasty/lengthening, 34.1% were sphincter pharyngoplasty, and 29.8% were pharyngeal flap. Secondary management of VPI was performed by plastic surgeons (67%), otolaryngologists (31%), and oral and maxillofacial surgeons (OMFS, 12%). Palatal revision and/or lengthening procedures were the most common secondary procedure performed by plastic surgeons (42%) and OMFS (64%), whereas sphincter pharyngoplasty was the most common procedure performed by otolaryngologists (55%; P <0.001). The proportion of sphincter pharyngoplasty performed by plastic surgeons significantly decreased from 2017-2021 ( P <0.05). Plastic surgeons performed most procedures for secondary management of VPI from 2004 to 2021, followed by otolaryngologists and OMFS. The type of procedure selected for secondary management of VPI differed significantly between the provider's specialty, with otolaryngologists more likely to perform sphincter pharyngoplasty.

Cleft Lip and/or Palate Repair in Children With Hypopituitarism: Analysis of the Kids' Inpatient Database

OBJECTIVE

Children with hypopituitarism (CwHP) can present with orofacial clefting, frequently in the setting of multiple midline anomalies. Hypopituitarism (HP) can complicate medical and surgical care; the perioperative risk in CwHP during the traditionally lower risk cleft lip and/or palate (CL/P) repair is not well described. The objective of this study is to examine the differences in complications and mortality of CL/P repair in CwHP compared to children without hypopituitarism (CwoHP).

DESIGN

A retrospective cross-sectional analysis.

SETTING

The 1997 to 2019 Kids' Inpatient Databases (KID).

PATIENTS

Children 3 years old and younger who underwent CL/P repair.

MAIN OUTCOME MEASURE(S)

Complications and mortality.

RESULTS

A total of 34 106 weighted cases were analyzed, with 86 having HP. CwHP had a longer length of stay (3.0 days [IQR 2.0-10.0] vs 1.0 day [IQR 1.0-2.0], P < .001) and higher rates of complications and mortality (12.8% vs 2.9%, P < .001) compared to CwoHP. Controlling for demographic factors, CwHP had 6.61 higher odds of complications and mortality than CwoHP (95% CI 3.38-12.94, P < .001).

CONCLUSIONS

CwHP can present with a CL/P and other midline defects that can increase the complexity of their care. These data show a significant increase in length of stay, complications, and mortality in CwHP undergoing CL/P repair. Increased multidisciplinary attention and monitoring may be needed for these children peri- and postoperatively, especially if additional comorbidities are present. Further studies on perioperative management in this population are warranted to reduce morbidity and mortality.

Midline cleft of the upper lip associated with a microform unilateral cleft and a proboscis-like structure: a case report

A midline or median cleft lip is rare, and a midline cleft associated with a unilateral cleft and a proboscis-like structure is rarer still. We present a case managed at our center in which a 5-year-old male had a median cleft of the upper lip with an associated 'proboscis' and a microform unilateral cleft lip.

Msx1 is essential for proper rostral tip formation of the mouse mandible

The right and left mandibular processes derived from the first branchial arch grow toward the midline and fuse to create the rostral tip region of the mandible during mandibular development. Severe and mild cases of failure in this process results in rare median cleft of the lower lip and cleft chin, respectively. The detailed molecular mechanisms of mandibular tip formation are unknown. We hypothesize that the Msx1 gene is involved in mandibular tip development, because Msx1 has a central role in other craniofacial morphogenesis processes, such as teeth and the secondary palate development. Normal Msx1 expression was observed in the rostral end of the developing mandible; however, a reduced expression of Msx1 was observed in the soft tissue of the mandibular tip than in the lower incisor bud region. The rostral tip of the right and left mandibular processes was unfused in both control and Msx1-null (Msx1^-/-) mice at embryonic day (E) 12.5; however, a complete fusion of these processes was observed at E13.5 in the control. The fused processes exhibited a conical shape in the control, whereas the same region remained bifurcated in Msx1^-/-. This phenotype occurred with 100% penetrance and was not restored at subsequent stages of development. Furthermore, Meckel's cartilage in addition to the outline surface soft tissues was also unfused and bifurcated in Msx1^-/- from E14.5 onward. The expression of phosho-Smad1/5, which is a mediator of bone morphogenetic protein (Bmp) signaling, was downregulated in the mandibular tip of Msx1^-/- at E12.5 and E13.5, probably due to the downregulated Bmp4 expression in the neighboring lower incisor bud. Cell proliferation was significantly reduced in the midline region of the mandibular tip in Msx1^-/- at the same developmental stages in which downregulation of pSmad was observed. Our results indicate that Msx1 is indispensable for proper mandibular tip development.

Toward clinical and molecular dissection of frontonasal dysplasia with facial skin polyps: From Pai syndrome to differential diagnosis through a series of 27 patients

Unique or multiple congenital facial skin polyps are features of several rare syndromes, from the most well-known Pai syndrome (PS), to the less recognized oculoauriculofrontonasal syndrome (OAFNS), encephalocraniocutaneous lipomatosis (ECCL), or Sakoda complex (SC). We set up a research project aiming to identify the molecular bases of PS. We reviewed 27 individuals presenting with a syndromic frontonasal polyp and initially referred for PS. Based on strict clinical classification criteria, we could confirm only nine (33%) typical and two (7%) atypical PS individuals. The remaining ones were either OAFNS (11/27-41%) or presenting with an overlapping syndrome (5/27-19%). Because of the phenotypic overlap between these entities, OAFNS, ECCL, and SC can be either considered as differential diagnosis of PS or part of the same spectrum. Exome and/or genome sequencing from blood DNA in 12 patients and from affected tissue in one patient failed to identify any replication in candidate genes. Taken together, our data suggest that conventional approaches routinely utilized for the identification of molecular etiologies responsible for Mendelian disorders are inconclusive. Future studies on affected tissues and multiomics studies will thus be required in order to address either the contribution of mosaic or noncoding variation in these diseases.

Holoprosencephaly with Clefts: Data of 85 Patients, Treatment and Outcome: Part 1: History, Subdivisions, and Data on 85 Holoprosencephalic Cleft Patients

CONTEXT

Cleft patients with Holoprosencephaly (HPE) constitute a controversy due to a variable facial appearance. HPE appearance varies from only a columella to a prolabium-premaxilla complex agenesis up to a common unilateral or bilateral cleft lip and palate with a single central incisor, various brain deformities, and/or even normal brain development. It is challenging to designate such various appearances, to understand their etiopathogenesis, and to choose the most appropriate management. Literature was reviewed for diagnostic criteria, pregnancy history, clinical findings, brain development, survival rate, initial perioperative management, and postsurgical midfacial growth in cleft patients with HPE. The findings were compared with a clinical database of 85 cleft patients with HPE at the Department of Maxillofacial and Oral Surgery, University of Pretoria.

AIMS OF PART 1

The aim of the study is to overcome disparities widely existing among clinicians regarding definitive diagnostic criteria, especially in cases with a common appearance of a uni- or bilateral cleft lip alveolus or cleft lip, alveolus and palate deformity, and cases presenting facial structural agenesis.

MATERIALS AND METHODS

A literature search related to diagnostic criteria was compared to results of a cleft HPE database from a single tertiary institution.

RESULTS

HPE cleft cases can be allocated to one of the following subdivisions: (1) columella complex agenesis (Ag-Colum), (2) prolabium-premaxilla-columella complex agenesis in cleft lip-alveolus deformities (Ag-CLA), (3) prolabium-premaxilla-columella agenesis in cases with complete cleft lip alveolus palate (Ag-CLAP), and (4) standard type (holoprosencephaly in patients with a standard cleft) with uni- or bilateral CLA or CLAP, hard and soft palate cleft (hPsP), and atrophic premaxillae, with or without single central incisor. Further, incidence, variation in brain development, and appearances in HPE cleft patients of different races and gender, epilepsy, and early death are discussed. Conclusion: This paper adds new data and facts to the existing literature related to cleft lip and palate patients suffering from HPE.

Bilateral Cleft Lip and Palate, With Facial Dysplasia: Interdisciplinary Treatment and Long-Term Follow-Up

Bilateral complete clefts represent the result of an incomplete fusion with all the morphologic components present. It is well known that patients with bilateral cleft lip and palate have typical characteristics such as insufficient medial face development with an orthodontic class III tendency, flat nose and short columella with abnormal nasolabial angle, bilateral oronasal fistulas, alterations in the number and position of the lateral incisors, and agenesis or supernumerary teeth. Successfully solving these cases, results in a difficult challenge and studies showing extended follow-up are not frequent. Bilateral complete clefts, including medial facial dysplasia, are a rare condition, not only difficult to be included in any classification but also of complex solution. These patients require multiple surgical procedures throughout life, and long-term results are often still far from ideal. Due to surgical intervention and diminished intrinsic growth potential, surgical results may change from initially good into a progressively disappointing outcome. However, if the ideal timing and type of surgery are known, in combination with the intrinsic growth potential, these results could be ameliorated. A patient with complete bilateral cleft, presenting hypoplasia of philtrum and premaxilla, flat nose with rudimentary columella and septum, is reported. A description of her interdisciplinary treatment and long-term outcome with an adequate and stable result was observed. Being the intrinsic growth restriction mainly localized in the central mid-face, a protocol oriented to stimulate facial development during growth period could be essential to reduce the number of surgical procedures and prevent sequels. Early referral to a specialized center is mandatory to achieve a correct treatment and result.

Prevalence of True Median Cleft of Upper Lip as Reflected from a Small Central Indian Population: Attempt to Report and Review the True Median Cleft of Upper Lip

Aims and Objectives

The median clefts of the facial skeleton and soft tissue are least in occurrence. Here we have attempted to analyze and review the prevalence of median clefts in our center.

Materials and Methods

All the patients who reported with congenital deformities from January 2013 to June 2016 were included in the study. A detailed list of patients was then re-evaluated to preclude duplication of the record which could have occurred during the admission process. All the characteristics which can be evaluated epidemiologically were individually tabulated and evaluated in detail.

Results

Out of the 1184 patients included in the study only 2 were affected with median cleft. The prevalence of true median cleft was hence determined to be 0.17% among the cleft population.

Conclusion

The prevalence of the true median cleft lip is rare and hence makes it difficult to classify these clefts, and also the treatment protocol needs to be fabricated for the treatment of such clefts.

Congenital Midline Upper Lip Sinuses

Congenital sinuses of the upper lip are rare congenital malformations. There have been only 40 cases described in the literature. We report 3 cases of congenital midline upper lip sinus in Caucasian children. Two of those lesions were associated with other anomalies (complete cleft palate and hemifacial macrosomia or submucous cleft palate with bifid uvula). The pathophysiology remains unexplained yet. Congenital upper lip sinuses can be considered as possible microforms of cleft-lips. Associated anomalies are frequent and must be sought. The treatment is a full excision of the sinus tract and of the skin around the punctum in order to avoid risks of recurrence.

Comparing Plastic Surgery and Otolaryngology Management in Cleft Care: An Analysis of 4,999 Cases

Care for patients with cleft lip and palate is best managed by a craniofacial team consisting of a variety of specialists, including surgeons, who are generally plastic surgeons or otolaryngologists trained in the United States. The goal of this study was to compare the surgical approaches and management algorithms of cleft lip, cleft palate, and nasal reconstruction between plastic surgeons and otolaryngologists. We performed a retrospective analysis of the American College of Surgeons' National Surgical Quality Improvement Program Pediatric database between 2012 and 2014 to identify patients undergoing primary repair of cleft lip, cleft palate, and associated rhinoplasty. Two cohorts based on primary specialty, plastic surgeons and otolaryngologists, were compared in relation to patient characteristics, 30-day postoperative outcomes, procedure type, and intraoperative variables. Plastic surgeons performed the majority of surgical repairs, with 85.5% ( n  = 1,472) of cleft lip, 79.3% ( n  = 2,179) of cleft palate, and 87.9% ( n  = 465) of rhinoplasty procedures. There was no difference in the age of primary cleft lip repair or rhinoplasty. However, plastic surgeons performed primary cleft palate repair earlier than otolaryngologists ( p  = 0.03). Procedure type varied between the specialties. In rhinoplasty, otolaryngologists were more likely to use septal or ear cartilage, whereas plastic surgeons preferred rib cartilage. Results were similar, with no statistically significant difference in terms of mortality, reoperation, readmission, or complications. Significant variation exists in the treatment of cleft lip and palate based on specialty service with regard to procedure timing and type. However, short-term rates of mortality, wound occurrence, reoperation, readmission, and surgical or medical complications remain similar.