Van der Woude Syndrome and Lower Lip Pits Treatment

Rare Congenital Upper Lip Pit

Congenital lip pits are characterized by sinuses or fistulas in the lips that can occur in isolation or as part of a genetic disorder. A 6-year-old girl with a right upper lip lesion present at birth presented with recurrent swelling and occasional erythema. Examination revealed a mildly swollen punctum at the right upper wet/dry vermillion with expressible serous drainage. There were no other phenotypic or cognitive concerns. The lesion was surgically excised using vertical wedge resection. The postoperative course showed well well-healed incision. The pathology report confirmed a lip pit. The family was referred to genetics for further evaluation. Van der Woude syndrome (VWS) is a genetic disorder associated with abnormal development of the paramedian lip. Most congenital lip pits are primarily found on the lower lips, with paramedian lip pits being the most common. Upper lateral lip pits with or without accompanying lip pits are considerably rarer. Though VWS is commonly associated with mutations in the interferon regulatory factor 6 or grainyhead-like protein 3 genes, ~25% of affected individuals lack an identified genetic etiology. A high index of suspicion for VWS is warranted if lip pits are present in the absence of other phenotypic abnormalities and should prompt genetic testing for interferon regulatory factor 6 and grainyhead-like protein 3 mutations. Multidisciplinary teams should consider patient self-esteem, quality of life, and potential family planning when deciding on surgical intervention for lip pits. Surgical management of pits should entail tissue-preserving techniques such as vertical wedge resection and inverted T-lip reduction to prevent whistle-lip deformity.

Clinical Findings and Outcomes of Palatal Repair in 9 Patients With Van der Woude Syndrome

INTRODUCTION

Van der Woude syndrome (VWS), an autosomal dominant condition associated with clefts of the lip and/or palate and lower lip pits, is caused by mutations in interferon regulatory factor 6 gene. It is reported to be the most common syndromic cleft worldwide. This case series presents the phenotypic characteristics and treatment outcomes in a group of 9 patients diagnosed with VWS.

METHODS

A retrospective review was performed on records of patients given a diagnosis of VWS presenting to the Department of Plastic Surgery of Sohag University between July 2009 and November 2019. Data analyses included age and sex of affected patients, type of the cleft, associated anomalies, presence of lower lip pits, and history of lower lip pits/cleft in the family and treatment outcomes.

RESULTS

The study identified 9 patients (male = 2, female = 7). Age at first presentation ranged between 1 week and 7 years (mean = 1.3 years). Four patients had bilateral cleft lip and palate and 1 patient had unilateral cleft lip and palate (UCLP), whereas 4 patients had isolated cleft palate. Bilateral lower lip pits were presented in 8 patients, whereas the ninth patient has unilateral pit. Family history was positive in 3 patients. Most patients in this study developed after palatal repair speech problems with an increased rate of secondary surgical procedures needed for correction of velopharyngeal insufficiency.

CONCLUSIONS

All reviewed cases of VWS presented with lower lip pits and cleft palate with or without cleft lip. A positive family history of similar conditions was demonstrated in 33.3% of our patients. This study suggests an increased incidence of secondary palatal surgeries for velopharyngeal insufficiency in patients with VWS; this warrant further studies including control group of nonsyndromic cleft patients.

Treatment of lower lip pits in Van der Woude syndrome: a systematic review

The presence of lower lip pits in individuals with Van der Woude syndrome (VWS) may cause discomfort due to saliva secretion. Furthermore, one of the main complaints in relation to lip pits is poor aesthetics, which often affects quality of life. The aim of this systematic review was to identify the best technique for the surgical removal of lower lip pits in terms of aesthetic and functional characteristics. A search of the PubMed, Embase, Web of Science, Science Direct, and Scopus databases was performed on December 27, 2016, which retrieved 88 records without duplicates. Among these papers, three ultimately met all eligibility criteria. The three studies included a total of 61 individuals, with follow-up ranging from 6 months to 10 years and sample collection from 10 to 24 years. The findings demonstrated that the outcome of surgical removal of lower lip pits was better with the use of vertical wedge excision, inverted-T lip reduction, Mutaf-Goldstein technique and modified simple excision than with simple excision. Simple excision may result in postoperative complications, such as mucocele and pit recurrence.

Surgical management of lower lip pits in Van der Woude syndrome

Van der Woude syndrome (VDWS) is characterized by the presence of lower lip pits which may be of concern to patients due to aesthetic considerations. By presenting three clinical cases, we provide an overview of the surgical techniques currently available to treat labial pits. Fusiform excision with dissection of the entire pit is still the most commonly used procedure and it generally yields good functional and aesthetic outcomes. The split-lip advancement technique and the inverted T-lip reduction nonetheless represent good surgical alternatives. Proper management of the lower pits that occur with VDWS requires thorough knowledge of the available surgical procedures.

Van der Woude syndrome presenting as a single median lower lip pit with associated dental, orofacial and limb deformities: a rare case report

Although it is a rare developmental malformation, van der Woude syndrome is the most common form of syndromic orofacial clefting, accounting for approximately 2% of all cleft cases. The lower lip pits with or without a cleft lip or palate is characteristic of the syndrome. Findings, such as hypodontia, limb deformities, popliteal webs, ankylogossia, ankyloblepheron, and genitourinary and cardiovascular abnormalities, are rarely associated with the syndrome. This paper reports a rare case of van der Woude syndrome in a 10-year-old male patient with a single median lower lip pit and a repaired bilateral cleft lip and cleft palate that were associated with microstomia, hypodontia, and clubbing of the left foot with syndactyly of the second to fifth lesser toes of the same foot.

Management of Lip Pits in Van der Woude Syndrome: A Clinical Classification With Difficulty Index

PURPOSE

Numerous case reports have been published on lip pits in Van der Woude syndrome explaining the morphology and genetics in detail; however, thus far, no article has focused on the classification of lip pits as an aid in surgical management. Although the procedure for lip pits in Van der Woude syndrome appears straightforward, even in the best of hands, the excision can be very challenging with no guarantee of esthetically desirable results. Therefore, we have devised a classification based on a difficulty index in the management of lower lip pits to assist in predicting the treatment outcome before surgery, as well as to offer the choice of a particular technique in a specific situation.

MATERIALS AND METHODS

We reviewed 19 cases of Van der Woude syndrome having lower lip pits that were operated on at our unit from May 2005 to June 2015 with a minimum follow-up of at least 6 months. The data analyzed included the patient's age and gender, location of the lip pits with regard to their proximity to the white skin roll, number of lip pits, presurgical depth of the lip pits, and discharge of mucous secretion from the pits, as well as timing of lip pit excision. Four techniques of excision were performed via routine excision, modified routine excision, vertical wedge excision, and inverted-T lip reduction. The data were tabulated and analyzed. On the basis of our experience in managing lip pits, a clinically relevant classification with a difficulty index was then proposed.

RESULTS

Among the 12 patients having preoperative involvement of the white skin roll, 8 had distortion of the white skin roll when operated on by either routine excision (n = 2), modified routine excision (n = 3), or inverted-T lip reduction (n = 3). The remaining 4 patients had no distortion of the white skin roll after surgery when the vertical wedge excision technique was performed. The 7 patients who had no distortion of the white skin roll preoperatively presented with esthetic results when operated on by either the routine excision, modified routine excision, or inverted-T lip reduction technique. In 2 patients with a presurgical pit depth greater than 6 mm, mucocele formation was observed after surgery. Using the data obtained, we proposed a classification based on 2 parameters: involvement of the white skin roll and presurgical depth. A difficulty index also was proposed using these same variables.

CONCLUSIONS

Classification and evaluation of the difficulty of lip pit excision are essential in planning the surgical treatment to give improved esthetic results. This proposed classification and difficulty index will provide the operating surgeon with a standardized scheme to evaluate the difficulty of the excision as well as to predict the overall outcome of the procedure before surgery.

Prenatal diagnosis and management of Van der Woude syndrome

We report the postnatal diagnosis of Van der Woude syndrome (VWS) in a foetus found to have an isolated right cleft lip and palate by ultrasound examination. After prenatal genetic counselling, the parents declined further evaluation by amniocentesis. At delivery, the infant was also found to have labial pits in the lower lip in addition to the cleft lip and palate identified by ultrasound consistent with VWS. Although VWS is rare, its autosomal dominant inheritance and variable penetrance should prompt additional modalities to more thoroughly evaluate the extent of other organ system and more extensive craniofacial anomalies.

Inverted-T lip reduction for lower lip repair in Van der Woude syndrome: a review and comparison of aesthetic results

Elimination of cosmetic deformity of lower lip pits and lower lip protrusion is the most common indication for lower lip repair in Van der Woude syndrome. 34 patients with lower lip pits that were operated on between 1982 and 2006 were reviewed. Surgical correction was performed with one of three different techniques: simple excision, vertical wedge resection, or inverted-T lip reduction. The aesthetic results were evaluated by two groups of raters. One group consisted of 10 medical professionals, and the other 10 lay people. A rating scheme was utilized, with a score of 3 for good, 2 for fair, and 1 for poor results. The final results were compared based on the mean score for each patient and inter-rater reliability was assessed using a weighted kappa coefficient. There was a fair agreement on the ratings between raters within groups. Inverted-T lip reduction received the best aesthetic result score from both groups of evaluators, with a mean score of 2.38±0.30 in the professional group, and 2.43±0.29 in the lay group. The results conclude that inverted-T lip reduction is a simple, safe and effective technique that achieves a better aesthetic result in lower lip repair of Van der Woude syndrome.

[Van der Woude syndrome: An unrecognised clinical entity]

Van der Woude syndrome is known to be the first syndromic cause of oral cleft. Apart clefts the cardinal signs are lower lip pits and hypodontia. IRF6 gene mutations have been recently identified as potential cause in this syndrome which permits to better understand its phenotype heterogeneity. Based on a literature review, we tried to cover the different aspects of this syndrome with an emphasis on genetic counselling and surgical correction of lip pits.

Isolated lower lip fistulas in Van der Woude syndrome

Van der Woude syndrome (VWS) is a dominantly inherited disease of orofacial region. Characteristic features of this syndrome are bilateral lower lip sinuses along with cleft lip or palate deformity. However, isolated lower lip pits in VWS without any cleft syndrome is uncommon. Lip pits in VWS are usually asymptomatic; however, patients may complain of watery drainage and/or infection. In this report, asymptomatic isolated lower lip sinuses without any cleft syndrome in a patient and his father are presented.