Current and Emerging Treatments for Postsurgical Cleft Lip Scarring: Effectiveness and Mechanisms

Presentation, Management, and Outcomes of Pathologic Scars Within a Pediatric Otolaryngology Practice

OBJECTIVES

This study aims to review the spectrum of scarring that may present to an urban, pediatric otolaryngology practice and determine if associations exist between race, scar location, treatment modality, and outcomes following interventions for scarring.

METHODS

Retrospective cohort study among 115 pediatric patients with 138 unique keloids or hypertrophic scars (HTS), and 141 children presenting for tonsillectomy at Tufts Medical Center. Age at presentation and sex assigned at birth were collected for both populations. For those presenting for pathologic scars, income quintile, self-identified race/ethnicity, anatomical location, treatment number and type, and clinical outcome were also analyzed. Multivariate analyses calculated adjusted odds ratios (aORs) and 95% confidence intervals to assess associations between scar subsite, intervention type, and persistence after treatment.

RESULTS

Compared to individuals presenting for tonsillectomy, a disproportionate percentage of patients presenting for scarring identified as Black (26.6% vs. 13.5%) or Asian (17.4% vs. 7.1%, p = 0.016) or were male (61.7% vs. 49.7%, p = 0.053). Individuals identifying as Black or Asian were more likely to present with ear lobe and neck scars, respectively (50.0% vs. 45.5%, p = <0.001). Ear scars were significantly more likely to receive excision at initial treatment (aOR = 5.86 [1.43-23.96]) compared to other subsites, and were more likely to require >1 treatment (aOR = 5.91 [1.53-22.75]).

CONCLUSION

Among pediatric patients presenting with keloids or HTS, children who identified as Black or Asian were more likely to present with ear and neck scars, respectively. Ear scars were frequently treated with excision and appear more likely to require adjuvant treatments and multiple interventions.

LEVEL OF EVIDENCE

Level III Laryngoscope, 2024.

Stem cells and extracellular vesicles to improve preclinical orofacial soft tissue healing

Orofacial soft tissue wounds caused by surgery for congenital defects, trauma, or disease frequently occur leading to complications affecting patients' quality of life. Scarring and fibrosis prevent proper skin, mucosa and muscle regeneration during wound repair. This may hamper maxillofacial growth and speech development. To promote the regeneration of injured orofacial soft tissue and attenuate scarring and fibrosis, intraoral and extraoral stem cells have been studied for their properties of facilitating maintenance and repair processes. In addition, the administration of stem cell-derived extracellular vesicles (EVs) may prevent fibrosis and promote the regeneration of orofacial soft tissues. Applying stem cells and EVs to treat orofacial defects forms a challenging but promising strategy to optimize treatment. This review provides an overview of the putative pitfalls, promises and the future of stem cells and EV therapy, focused on orofacial soft tissue regeneration.

Assessing the Impact of Transcutaneous Maxillary Distraction Osteogenesis on Pharyngeal Airway Volume in Children with Cleft Lip and Palate: A 3D Evaluation Study

Cleft lip and cleft palate (CLCP) patients often have a retrusive maxilla and a severe skeletal Class III malocclusion, which can result in velopharyngeal insufficiency (VPI). The aim of this study was to evaluate the changes in the volume of the 3D airway in CLCP children after maxilla distraction using the transcutaneous maxillary distraction osteogenesis (TMDO) method. 15 children with bilateral or unilateral CLCP were included in the study. 3D CBCT images were taken before and after distraction and were segmented and reconstructed to create a 3D airway model. The airway was divided into three regions: the upper, oropharyngeal, and hypopharyngeal airway. Pearson correlation tests were used to assess correlations between volume changes and corresponding skeletal and dental landmark movements (Point N, ANS, A, B, Pog, U1, and L1). The results showed that the ANS point advanced 9.85 ± 3.60 mm, and the A point advanced 14.22 ± 4.57 mm. The total airway volume change increased by 2535.06 ± 2791.80 mm3. However, there was no significant correlation between the A/ANS/U1 and the three different airway regions. Only B/Pog/L1 showed a positive correlation with these airway regions, with a high correlation between B/Pog/L1 and the hypopharyngeal airway region. TMDO can result in greater anterior advancement of the maxilla and an increase in airway volume, but the changes in bony landmarks did not show a strong positive correlation with the increase in airway volume as expected. Further investigation is needed to analyze the influence of surrounding soft tissue on the changes in airway volume.

Evaluating the Effect of Low Power Diode Laser 806 nm on the Healing of Unilateral Cleft Lip Scar: An Open-Label Comparative Study

OBJECTIVE

To investigate the effect of laser bio-modulation irradiation therapy on the scar after surgical correction of unilateral cleft lip.

DESIGN

a comparative, open-label study.

SETTING

we conducted the study in a university based tertiary hospital that recruited early wound healers of unilateral cleft lip correction.

PATIENTS

Eighty patients were divided into two groups: In study's group, patients undergo laser bio-modulation irradiation (n = 60); in the control group, patients were followed-up without intervention (n = 20).

INTERVENTION

In the study's group, patients underwent low-power diode Laser with wavelength of 806 nm and power of 100 mw.

MAIN OUTCOME

The change in the scar of cleft lip patients, which was assessed by clinical examination and ultrasound.

RESULTS

The median pigmentation score was significantly lower in the laser group (median = 1; IQR = 1-2) than the control group (median 2; IQR 1-3), with p-value of <0.001. Likewise, the median height score was significantly lower in the laser group (median = 1; IQR = 1-1) than the control group (median 1.5; IQR 1.5-2), with p-value of 0.001. The median pliability score was significantly lower in the laser group (median = 1; IQR = 1-1) than the control group (median 2.5; IQR 1-3), with p-value of <0.001. Finally, the median vascularity score was significantly lower in the laser group (median = 1; IQR = 1-1) than the control group (median 1.5; IQR 1-2), with p-value of <0.001.

CONCLUSION

laser bio-modulation irradiation therapy demonstrates a potential efficacy in managing the hypertrophic scars after surgical repair of unilateral cleft lip.

The comparison of biomechanical effects of the conventional and bone-borne palatal expanders on late adolescence with unilateral cleft palate: a 3-dimensional finite element analysis

BACKGROUND

Patients with unilateral cleft lip and palate were associated with different nasomaxillary complex from the normal population. Although the biomechanical effects of conventional rapid palatal expansion (Hyrax expansion) and bone-borne rapid palatal expansion (micro-implant-assisted expansion) in non-cleft patients have been identified by multiple studies, little is known in patients with unilateral cleft lip and palate. The purpose of this study was to investigate and compare the biomechanical effects of the conventional and bone-borne palatal expanders in a late adolescence with unilateral cleft lip and palate.

METHODS

A cone beam CT scan of a late adolescence with unilateral cleft lip and palate was selected to construct the three-dimensional finite element models of teeth and craniofacial structures. The models of conventional and born-borne palatal expanders were established to simulate the clinical maxillary expansion. The geometric nonlinear theory was applied to evaluate the Von Mises stress distribution and displacements in craniofacial structures and teeth.

RESULTS

Bone-borne palatal expander achieved more transverse movement than conventional palatal expander in the whole mount of craniofacial regions, and the maximum amount of expansion was occurred anteriorly along the alveolar ridge on cleft-side. The expanding force from born-borne palatal expander resulted in more advancement in nasomaxillary complex than it in conventional palatal expander, especially in the anterior area of the minor segment of maxilla. Stresses from the both expanders distributed in similar patterns, but larger magnitudes and ranges were generated using the bone-borne expander around the maxillary buttresses and pterygoid plates of sphenoid bone. The maximum expanding stresses from born-borne palatal expander were concentrated on palatal slope supporting minscrews, whereas those from conventional palatal expander were concentrated on the anchoring molars. In addition, the buccal tipping effect of teeth generated using the bone-borne expander was less than it using the conventional palatal expander.

CONCLUSION

Bone-borne expander generated enhanced skeletal expansion at the levels of alveolar and palate in transversal direction, where the miniscrews contributed increased expanding forces to maxillary buttresses and decreased forces to buccal alveolar. Bone-borne expanders presented a superiority in correcting the asymmetric maxilla without surgical assistant in late adolescence with unilateral cleft lip and palate.

The Effectiveness of Plasma Skin Regeneration (PSR) in the Treatment of Chronic Cleft Lip Scars in an Adult Syrian Sample: A Cohort Study on a Novel Technique

Objectives The current study aimed to evaluate the effectiveness of plasma skin regeneration (PSR) in the treatment of cleft lip scars in cleft lip patients.  Materials and methods Twenty patients, 10 females and 10 males, with a mean age of 19 years and who had a cleft lip scar, were included in the current study. All patients were treated with a plasma skin regeneration pen device in one treatment session. The thickness, relief, and pliability of the scars were assessed by external observers using a 10-point numeric rating scale (NRS). Results The thickness, relief, and pliability of the scar were significantly improved according to the observers' opinions (51.67%, 50.25%, and 46.33%, respectively). Conclusions Within the limits of this study, the PSR appeared to be safe and effective for treating cleft lip scars with minimal complications.

RvD1n-3 DPA Downregulates the Transcription of Pro-Inflammatory Genes in Oral Epithelial Cells and Reverses Nuclear Translocation of Transcription Factor p65 after TNF-α Stimulation

Specialized pro-resolving mediators (SPMs) are multifunctional lipid mediators that participate in the resolution of inflammation. We have recently described that oral epithelial cells (OECs) express receptors of the SPM resolvin RvD1_{n-3 DPA} and that cultured OECs respond to RvD1_{n-3 DPA} addition by intracellular calcium release, nuclear receptor translocation and transcription of genes coding for antimicrobial peptides. The aim of the present study was to assess the functional outcome of RvD1_{n-3 DPA}-signaling in OECs under inflammatory conditions. To this end, we performed transcriptomic analyses of TNF-α-stimulated cells that were subsequently treated with RvD1_{n-3 DPA} and found significant downregulation of pro-inflammatory nuclear factor kappa B (NF-κB) target genes. Further bioinformatics analyses showed that RvD1_{n-3 DPA} inhibited the expression of several genes involved in the NF-κB activation pathway. Confocal microscopy revealed that addition of RvD1_{n-3 DPA} to OECs reversed TNF-α-induced nuclear translocation of NF-κB p65. Co-treatment of the cells with the exportin 1 inhibitor leptomycin B indicated that RvD1_{n-3 DPA} increases nuclear export of p65. Taken together, our observations suggest that SPMs also have the potential to be used as a therapeutic aid when inflammation is established.

Social attractiveness perception of a cleft lip repair in an adolescent via eye-tracking

PURPOSE

The present study was designed to investigate the perception of unilateral cleft lip (UCL) repair scar using an image of an adolescent and eye-tracking technology.

MATERIAL AND METHODS

Frontal and oblique views of an image of an adolescent with a unilateral upper lip scar result of a corrective surgery. Eighty-five laypeople respondents were divided into three groups: Group A (15-44 years of age); Group B (45-59 years of age); and Group C (≥ 60 years of age). Gaze tracking was carried out to assess the location on the image of greatest fixation, to create dot maps and to follow the trajectory of the gaze. Respondents also assessed six attention questionnaires. The answers and assessment of the VAS were compared. P-values &lt;0.05 were considered significant in the analyses.

RESULTS

The central focus of the visualization was concentrated on the upper lip and the region of the nostril, followed by the eyes. Time until 1st fixation upon right lip and mouth showed differences with regard to different images. Images of the model shown in various guises including smiling or not, in a frontal or oblique views showed significant differences in VAS scoring (p&lt;0.001).

CONCLUSION

The presence of a scar from the UCL repair in an adolescent was noted in the foreground by laypeople. The scar was associated with a lower degree of attractiveness, happiness, and intelligence, as well as with shyness and sympathy, although a visible scar did not influence the perception of "good hygiene habits".

Magnetoencephalographic evaluation of repaired lip sensation in patients with cleft lip

Background

Cleft lip is the most common congenital anomaly worldwide. Nevertheless, lip somatosensory characteristics of patients with cleft lip after cheiloplasty have not yet been determined. The present study used magnetoencephalography to objectively evaluate the lip sensation in patients with unilateral cleft lip to establish a new objective evaluation method.

Methods

Participants were 15 patients with unilateral cleft lip after cheiloplasty (UCL group), and 30 healthy young subjects (control group). Five points of the upper and lower lips were stimulated electrically to measure somatosensory evoked magnetic fields (SEFs). The sources of the magnetic fields were modeled as single equivalent current dipoles (ECDs). ECDs located on the central sulcus by superimposition on magnetic resonance images were analyzed. Latency and intensity at 50–75 ms (cP60m) observed in the UCL group were compared with those in the control group. Thresholds of tactile stimuli in both groups were obtained using Semmes–Weinstein monofilaments for subjective sensory evaluation.

Results

No significant difference was found in the intensity of the cP60m or subjective evaluation between the groups. However, the latency of the cP60m was significantly longer in the upper lip of the UCL group than in the control group.

Conclusions

SEFs showed a difference in lip sensation between the UCL group and the control group, suggesting that longer latency might be caused by the effects of surgical scarring on the neurotransmission pathway. These results suggest SEFs as useful for the objective evaluation of lip sensations. This study might improve future surgical procedures and lip functions of patients with cleft lip.

p38MAPK silencing attenuates scar proliferation after cleft palate repair surgery in rats via MRTF-A/SRF pathway

Scarring is the primary factor of maxilla growth restriction among people who have undergone cleft palate repair surgery. p38 mitogen-activated protein kinase (p38MAPK) promotes fibrosis in a variety of organs. However, its role in post-surgery scarring on the hard palate has not been fully understood. This study is designed to investigate the role of p38MAPK in scar formation and maxilla growth of rats. We removed the mucosa on the hard palate of rats and applied the p38MAPK silencing adenovirus vector on it two weeks after surgery. Then the scarring tissue and maxilla growth were evaluated by histological and morphological examination. The effect of p38MAPK silencing on scarring-related genes in fibroblasts was also studied. We found that local injection of Ad-p38MAPK-1 in vivo effectively reduces the expression of p38MAPK and scarring-related proteins and weakens the impact of scarring on the width of the hard palate. Mechanistically, p38MAPK silencing inhibits the expression of α-smooth muscle actin (α-SMA) via mediating the production and nuclear localization of myocardin-related transcription factor A (MRTF-A) in fibroblasts. These results reveal a molecular pathway of scar formation involving p38MAPK/MRTF-A stimulation and support targeting p38MAPK as a potentially effective treatment for post-surgery scarring on the hard palate.

Visual perception of repaired cleft lip scarring face associated with different malocclusions via eye-tracking

Background. This study aimed to evaluate the visual facial perception in response to scars associated with repaired cleft lip (CL) on a male adolescent patient, as assessed via eye-tracking. Methods. Index of orthodontic treatment need (IOTN) malocclusions, grades 1, 5, and 8 were added to the frontal view facial image of an adolescent male model showing asymmetries of the nose and upper lip after CL surgery using the software Photoshop CS5® software. The eye movements of 91 laypeople observers were tracked by an Eye Tribe infrared sensor connected to OGAMA© software. A Kruskal–Wallis test was used to identify differences in total fixation time and time until the first fixation for the areas of interest. A visual analog scale (VAS) of attractiveness was also used in the study. Statistical analysis was performed adopting a significance level of P<0.05. Results. The area of interest (AOI) were found to be the mouth and teeth, which were more focused on gazed at than any other area, regardless of the grade of IOTN. For observers of different ages, there were significant differences in the time until the first fixation on the scar of the repaired CL region for IOTN grade 1 (P=0.007). Images showing IOTN grade 1 repaired CL regions received the highest VAS scores. The older the age, the greater the tendency to give a higher VAS score for the same malocclusion. Conclusion. The presence of a CL scar on the upper lip did not attract the eye of laypeople observers of different ages, regardless of the degree of malocclusion in the non-smile image. The age of the observers did influence the perception of attractiveness, with older observers giving higher scores than younger ones. As the severity of the malocclusion increased, they were found to be less attractive.

Specialized Pro-Resolving Mediators Reduce Scarring After Cleft Lip Repair

Objective

Residual scarring after cleft lip repair surgery remains a challenge for both surgeons and patients and novel therapeutics are critically needed. The objective of this preclinical experimental study was to evaluate the impact of the methyl-ester of pro-resolving lipid mediator lipoxin A4 (LXA4-ME) on scarring in a novel rabbit model of cleft lip repair.

Methods

A defect of the lip was surgically created and repaired in eight six-week old New Zealand white rabbits to simulate human cleft lip scars. Rabbits were randomly assigned to topical application of PBS (control) or 1 ug of LXA4-ME (treatment). 42 days post surgery all animals were euthanized. Photographs of the cleft lip area defect and histologic specimens were evaluated. Multiple scar assessment scales were used to compare scarring.

Results

Animals treated with LXA4-ME exhibited lower Visual Scar Assessment scores compared to animals treated with PBS. Treatment with LXA4-ME resulted in a significant reduction of inflammatory cell infiltrate and density of collagen fibers. Control animals showed reduced 2D directional variance (orientation) of collagen fibers compared to animals treated with LXA4-ME demonstrating thicker and more parallel collagen fibers, consistent with scar tissue.

Conclusions

These data suggest that LXA4-ME limits scarring after cleft lip repair and improves wound healing outcomes in rabbits favoring the resolution of inflammation. Further studies are needed to explore the mechanisms that underlie the positive therapeutic impact of LXA4-ME on scarring to set the stage for future human clinical trials of LXA4-ME for scar prevention or treatment after cleft lip repair.

Effect of niche components on masseter satellite cell differentiation on fibrin coatings

In skeletal muscles, niche factors stimulate satellite cells to activate and induce muscle regeneration after injury. In vitro, matrigel is widely used for myoblast differentiation, however, is unsuitable for clinical applications. Therefore, this study aimed to analyze attachment and differentiation of satellite cells into myotubes on fibrin coatings with selected niche components. The attachment of satellite cells to fibrin alone and fibrin with niche components (laminin, collagen‐IV, laminin‐entactin complex [LEC]) were compared to matrigel. Only on matrigel and fibrin with LEC, Pax7‐positive cells attached well. Then, LEC was selected to analyze proliferation, differentiation, and fusion indices. The proliferation index at day 1 on fibrin‐LEC (22.5%, SD 9.1%) was similar to that on matrigel (30.8% [SD 11.1%]). The differentiation index on fibrin‐LEC (28.7% [SD 6.1%] at day 5 and 32.8% [SD 6.7%] at day 7) was similar to that on matrigel (40.1% [5.1%] at day 5 and 27.1% [SD 4.3%] at day 7). On fibrin‐LEC, the fusion index at day 9 (26.9% [SD 11.5%]) was similar to that on matrigel (25.5% [SD 4.7%]). Our results showed that the addition of LEC enhances the formation of myotubes on fibrin. Fibrin with LEC might be suitable to enhance muscle regeneration after surgery such as cleft palate repair and other muscle defects.

Orodispersible hyaluronic acid film delivery for oral wound healing in rats

Background/purpose

Oral wound healing undergoes a dynamic process of oral environment. This study aimed to investigate the effects of hyaluronic acid (HA) film on oral wound healing in a rat model.

Materials and methods

A total of 60 rats with tongue wounds (5 mm in diameter) were randomly divided into control (n = 20), HA gel (n = 20), and HA film groups (n = 20). The animals were sacrificed on either 3 or 7 days after the experiment. Clinical, histological, and quantitative reverse transcriptase-polymerase chain reaction analysis were performed to evaluate the healing rate, inflammation, re-epithelialization, and gene expression of wound healing biomarkers.

Results

The healing rates of HA gel (84.4 ± 9.2%) and HA film (74.0 ± 15.0%) were significantly higher than that of the control (51.7 ± 16.9%) on day 7 (P < 0.001 and P = 0.002, respectively). Histological analysis revealed no significant differences between the groups on day 3. On day 7, only the HA film showed significant improvement in inflammation (P = 0.038) and re-epithelialization (P = 0.011) compared to the control. Regarding wound healing biomarkers, both HA gel and HA film groups showed lower level of COL1α1 expression on day 3 compared to the control.

Conclusion

Within the limits of this study, HA film was found to be effective for oral wound healing, particularly for re-epithelialization. This finding suggests that HA film delivery can be beneficial not only for clinical convenience but also for promoting oral wound healing.

Endogenous Mechanisms of Craniomaxillofacial Repair: Toward Novel Regenerative Therapies

In the fields of oral and craniomaxillofacial surgery, regeneration of multiple tissue types-including bone, skin, teeth, and mucosal soft tissue-is often a desired outcome. However, limited endogenous capacity for regeneration, as well as predisposition of many tissues to fibrotic healing, may prevent recovery of normal form and function for patients. Recent basic science research has advanced our understanding of molecular and cellular pathways of repair in the oral/craniofacial region and how these are influenced by local microenvironment and embryonic origin. Here, we review the current state of knowledge in oral and craniomaxillofacial tissue repair/regeneration in four key areas: bone (in the context of calvarial defects and mandibular regeneration during distraction osteogenesis); skin (in the context of cleft lip/palate surgery); oral mucosa (in the context of minimally scarring repair of mucosal injuries); and teeth (in the context of dental disease/decay). These represent four distinct healing processes and outcomes. We will discuss both divergent and conserved pathways of repair in these contexts, with an eye toward fundamental mechanisms of regeneration vs. fibrosis as well as translational research directions. Ultimately, this knowledge can be leveraged to develop new cell-based and molecular treatment strategies to encourage bone and soft tissue regeneration in oral and craniomaxillofacial surgery.

Visual facial perception of postsurgical cleft lip scarring assessed by laypeople via eye-tracking

OBJECTIVES:

This study aimed to evaluate the visual facial perception in response to scars associated with repaired cleft lip (CL) on a male adolescent model, as assessed by eye-tracking technology.

MATERIAL AND METHODS:

Unilateral and bilateral facial images of repaired CL on the upper lip and nasal asymmetry were added to an image of a male adolescent model, using Photoshop CS5 software. 40 laypeople eye movements were tracked by an infrared sensor of the Eye Tribe hardware in conjunction with OGAMA software. An analysis of variance was used to identify differences in total fixation time for the added areas of interest. A visual analog scale of attractiveness with a questionnaire were also incorporated into the study. Statistical analysis was performed using a significance level of P < 0.05.

RESULTS:

Significant differences were noted between the image with no scar and the image featuring a unilateral scar for total fixation time associated with the right eye (p = 0.002) and right nose area (p = 0.003), in addition to the numbers of fixations for the right eye (p = 0.005) and right nose area (p = 0.007). Comparing the image with no scar with the image featuring a bilateral scar showed a significant difference only for the number of fixations on the right eye (p = 0.005). The heatmaps and fixation point maps for both the unilateral and bilateral scar images indicated increased fixation for the scar areas. For the image with no scar, increased fixation was captured for the right eye area. Pearson's correlation coefficient test showed a moderate positive (p = 0.692) relationship when comparing to unilateral and bilateral cleft scars.

CONCLUSIONS:

The participating laypeople perceived the cleft-repaired faces and did not perceive any difference in attractiveness between the images featuring the unilateral and bilateral postsurgical clefts and lip scarring.

Evaluating the Expression of Candidate Homeobox Genes and Their Role in Local-Site Inflammation in Mucosal Tissue Obtained from Children with Non-Syndromic Cleft Lip and Palate

Craniofacial development including palatogenesis is a complex process which requires an orchestrated and spatiotemporal expression of various genes and factors for proper embryogenesis and organogenesis. One such group of genes essential for craniofacial development is the homeobox genes, transcriptional factors that are commonly associated with congenital abnormalities. Amongst these genes, DLX4, HOXB3, and MSX2 have been recently shown to be involved in the etiology of non-syndromic cleft lip and palate. Hence, we investigated the gene and protein expression of these genes in normal and cleft affected mucosal tissue obtained from 22 children, along with analyzing their role in promoting local-site inflammation using NF-κB. Additionally, we investigated the role of PTX3, which plays a critical role in tissue remodeling and wound repair. We found a residual gene and protein expression of DLX4 in cleft mucosa, although no differences in gene expression levels of HOXB3 and MSX2 were noted. However, a significant increase in protein expression for these genes was noted in the cleft mucosa (p < 0.05), indicating increased cellular proliferation. This was coupled with a significant increase in NF-κB protein expression in cleft mucosa (p < 0.05), highlighting the role of these genes in promotion of pro-inflammatory environment. Finally, no differences in gene expression of PTX3 were noted.

Profiling and Characterization of Localized Cytokine Response in Congenital Cleft Affected Lip Tissue

(1) Background: Despite cleft lips and palates belonging to the most common orofacial congenital anomalies, their morphopathogenesis is not yet fully understood. The study aimed to determine the distribution and relation of cytokines interferon-γ (IFN-γ), tumor necrosis factor-alpha (TNF-α), interleukin (IL)-2, IL-7, IL-12, and IL-13 in the cleft affected mucosa of the lip. (2) Materials and Methods: Twenty cleft lip (CL) mucosal samples and seven control tissues of oral cavity mucosa were included in the study. Specimen were obtained during reconstruction surgeries and processed by hematoxylin and eosin staining and immunohistochemistry for IFN-γ, TNF-α, IL-2, IL-7, IL-12, and IL-13. (3) Results: The distribution of cytokines was higher overall in the cleft affected epithelium compared to the connective tissue, with TNF-a, IL-2, and IL-12 displaying the highest number of immunopositive cells. With the exception of IL-2, CL specimen showed higher immunoreactivity. IFN-γ displayed only minor immunoreactivity, with no expression in the control epithelium. Correlation analysis was strongest between CL epithelial IL-13 and IFN-γ (z = 0.71, p < 0.0001). (4) Conclusions: The CLP affected epithelium displays high degrees of plasticity in expressing different cytokines, pointing towards the stimulation of a local adaptive immune response based on consistent inflammatory processes.

Revisional Techniques for Secondary Cleft Lip Deformities

Secondary deformities of repaired cleft lips are an unfortunate complication despite the meticulous approach of modern primary procedures. Most of these surgeries take place in the patient's early life and must be strategically planned to provide optimal cosmesis with minimal interventions. Depending on the level of severity, treatment of the secondary deformities ranges from noninvasive or minimally invasive techniques to complete revision cheiloplasty. Many novel topical, injectable, and laser therapies have allotted physicians more technical flexibility in treating superficial distortions. Nonetheless, surgical techniques such as diamond excision and adjacent tissue transfer remain popular and useful reconstructive modalities. Deformities involving the orbicularis oris must be completely taken down to allow full access to the muscle. Complete revision cheiloplasty requires recreation of the cleft defect and reconstruction similar to the primary repair. Due to the myriad of presentations of these secondary deformities, familiarity with the various treatments available is imperative for any cleft surgeon.

Characterization of Macrophages and TNF-α in Cleft Affected Lip Tissue

Orofacial clefts are one of the most common congenital anomalies worldwide; however, morphopathogenesis of the clefts is not yet completely understood. Taking the importance of innate immunity into account, the aim of this work was to examine the appearance and distribution of macrophages (M) 1, M2, and TNF-α, as well as to deduce any possible intercorrelations between the three factors in cleft affected lip tissue samples. Twenty samples of soft tissue were collected from children during plastic surgery. Fourteen control tissue samples were obtained during labial frenectomy. Tissues were immunohistochemically stained, analysed by light microscopy using a semi-quantitative method, and the Mann–Whitney U and Spearman’s tests were used to evaluate statistical differences and correlations. A statistically significant difference in the distribution was observed only in regard to M1. A weak correlation was observed between M2 and TNF-α but a moderate one between M1 and M2 as well as M1 and TNF-α. However, only the correlation between M1 and M2 was statistically important. The rise in M1, alongside the positive correlation between M1 and TNF-α, suggested a more pro-inflammatory/inflammatory environment in the cleft affected lip tissue. The moderate positive correlation between M1 and M2 indicated an intensification of the protective mechanisms.

Determination of prognostic factors for orthognathic surgery in children with cleft lip and/or palate

OBJECTIVE

To determine the prognostic factors for orthognathic surgery (OGS) in children with cleft lip and/or palate (CL/P) using artificial intelligence (AI) systems.

DESIGN

Retrospective cohort study.

SETTING

An orthodontic department at a university dental hospital.

PARTICIPANTS

This study included 126 patients with bilateral and unilateral CL/P for whom lateral cephalograms were obtained at three time points: 7 (T1), 10 (T2) and 15 (T3) years of age.

MAIN OUTCOME MEASURES

Cleft type, severity of lip separation at birth, number of missing teeth, sex, palatal repair methods and surgeons, cephalometric variables at T1 and T2, and the total duration of orthodontic treatment were examined as predictors. The need for OGS and skeletal and dental discrepancies at T3 was examined as outcomes.

RESULTS

A total of six models were developed, with a mean area under the receiver operating characteristic curve of 0.93. Multiple prognostic factors for OGS were identified. In particular, the number of clefts in the lip and alveolus showed relatively high odds ratios, as did anterior crossbite at T3. Achieving palatal closure with the push-back method, rather than Furlow's method, was also found to be a predictive factor for anterior crossbite at T3, with high odds ratios.

CONCLUSIONS

The prognostic factors for OGS determined by the AI systems were the number of clefts in the lip and alveolus, the palatal repair method, male sex, several cephalometric variables for the sagittal and vertical dimensions, growth patterns and the number of missing teeth.

Osteocalcin and regulatory cytokine imbalance in children with congenital cleft lip and palate

The aim of the work was a comprehensive assessment of the cytokine system and peripheral blood osteocalcin with the establishment of features of their interconnections in children with congenital cleft lip and palate (CCLP) in comparison with corresponding controls at different age periods. Levels of IL17, IL4, IL6, IL1β, IFNγ and osteocalcin were analyzed by enzyme immunoassay in the peripheral blood of 80 children (0-12 months, 1-3 years, 4-9 years, 10-15 years) with CCLP and age-appropriate control of healthy individuals (40 people). An analysis of the obtained data shows that in children with CCLP we revealed significant differences between pro-inflammatory (IL1β, IL6, IL17), regulatory (IFNγ), anti-inflammatory (IL4) cytokines and osteocalcin compared with controls. Differences were found in the content of IL17, IFNγ, IL4 and osteocalcin in healthy children and in children with CCLP in postnatal ontogenesis. Cytokine deregulation of immunosteogenesis in CCLP, leading to a significant deficit of osteocalcin in the first year of life due to imbalance of the cytokine profile: discordant IL17, IFNγ and IL4 were detected. Obtained data are undoubtedly important in the future for developing new strategies for targeted therapy aimed at normalizing osteocalcin levels at different age periods in children with CCLP.

Force balance reconstruction of the orbicularis oris in unilateral incomplete cleft lip

PURPOSE

To demonstrate a maneuver for achieving optimal force balance of reconstructed orbicularis oris during primary unilateral incomplete cleft lip reconstruction.

METHODS

The surgical maneuver was performed as follows: the length of the orbicularis oris on the noncleft side is first isolated and adjusted to be equal to the length of the muscle on the cleft side. The remaining muscle from the noncleft side near the midline is used to fill in the vermilion tubercle, and finally, the two orbicularis oris muscles are sutured at the midline. Finite element analysis was utilized to model the biomechanics of our novel surgical method.

RESULTS

Finite element analysis showed that when the lengths of two orbicularis oris muscles were the same after primary cleft lip repair, the stress on this muscle system was minimized under different lip conformations. Seventeen cleft lip patients were enrolled to receive reconstruction with this new maneuver. Significant differences were found in (1) noncleft/cleft alar base width, nasal dorsum angle, columella length relationship between two sides, and columella angle under the comparison between preoperative and postoperative; (2) noncleft/cleft alar base width, nasal dorsum angle, and columella angle under the comparison between preoperative and follow-up; and (3) columella length relationship between two sides under the comparison between postoperative and follow-up.

CONCLUSION

Force balance of the orbicularis oris muscles is important during unilateral incomplete cleft lip repair. This surgical maneuver for achieving force balance of the orbicularis oris and the muscle system of the lips is easy to perform and can help avoid relapses.

[Secondary cheiloplasty in the treatment of cleft lip and palates]

In the course of treatment of cleft lip and palates, the quality of primary cheilo-rhinoplasty is essential to limit aesthetic and functional complications. This is why these primary reconstructions come under the domain of specialised centres with multidisciplinary teams. Unfortunately, residual imperfections often remain, especially in bilateral clefts, and secondary cheiloplasties represent for us a complex challenge. They aim at functional and aesthetic correction, and the choice of time is very random and depends largely on the psychological repercussions of the deformation in the child. It often occurs at the age of school entry and is combined with alveoloplasty. We then speak of alveolar transplantation with vestibulo and labio-plastie, the GPVP. Then we propose to combine all the resources of cosmetic surgery to improve the aesthetic and functional result of these children.

Characterization of Cytokines and Proliferation Marker Ki67 in Cleft Affected Lip Tissue

Backgroundandobjectives: Cleft lip palate takes the second place among all anomalies. The complex appearance of cytokines and proliferation markers has still not been clarified despite their possible crucial role in cleft tissue. Therefore, the aim of work was the detection of appearance of pro- and anti-inflammatory cytokines and proliferation marker Ki67, and their inter-correlations in cleft affected lip (CAL). MaterialsandMethods: The lip material was obtained from 16 children aged before primary dentition during plastic surgery. Control was obtained from 7 non-CAL oral tissue. Tissues were stained for IL-1, IL-4, IL-6, IL-8, IL-10 and Ki67 immunohistochemically. Non-parametric statistic, Mann–Whitney and Spearman’s coefficient were used. Results: All cytokines positive cells were observed more into the epithelium. Statistically significant difference was seen between epithelial IL-1, IL-10, IL-8 and Ki67 positive cells and IL-10-, IL-4-containing connective tissue cells in comparison to the control. Strong positive correlation was detected in CAL epithelium between IL-10 and IL-8, IL-10 and IL-4, IL-10 and IL-1, IL-1 and IL-8, IL-1 and IL-4, IL-4 and IL-8, IL-8 and Ki67, IL-10 and Ki67, but moderate—in connective tissue between IL-1 and IL-10, IL-1 and IL-4. Conclusions: The CAL epithelium is the main source for the interleukins. Rich similar expression of IL-1 and IL-10 suggests the balance between pro-and anti-inflammatory tissue response on basis of dysregulated tissue homeostasis (increase of IL-8). The correlations between the different ILs-1, -4, -8, -10 in CAL epithelium seem to indicate the self-protection compensatory mechanism for intensification of local inflammatory-immune response without involvement of IL-6. The correlations between Ki67 and cytokines indicate the involvement of IL-8 and IL-10 in stimulation of cellular proliferation. IL-4 and IL-10 expression from CAL connective tissue simultaneously to IL-1, IL-4 and IL-10 inter-correlations there suggests the intensification of local immune response regulated probably by main pro-inflammatory cytokine—IL-1.

The Spectrum of Scarring in Craniofacial Wound Repair

Fibrosis is intimately linked to wound healing and is one of the largest causes of wound-related morbidity. While scar formation is the normal and inevitable outcome of adult mammalian cutaneous wound healing, scarring varies widely between different anatomical sites. The spectrum of craniofacial wound healing spans a particularly diverse range of outcomes. While most craniofacial wounds heal by scarring, which can be functionally and aesthetically devastating, healing of the oral mucosa represents a rare example of nearly scarless postnatal healing in humans. In this review, we describe the typical wound healing process in both skin and the oral cavity. We present clinical correlates and current therapies and discuss the current state of research into mechanisms of scarless healing, toward the ultimate goal of achieving scarless adult skin healing.