Morphometric Assessment of Facial Morphology in Infants with Orofacial Clefts up to two Years of Age: A Three-Dimensional Cross-Sectional Study

OBJECTIVE

To assess modelled facial development of infants with unilateral cleft lip (CL) and cleft lip and palate (UCLP) compared to controls up to two years of age.

DESIGN AND PARTICIPANTS

A total of 209 facial images of children (CL: n = 37; UCLP: n = 39; controls: n = 137) were obtained in four age categories (T0 = 0.2-0.5; T1 = 0.6-1.0; T2 = 1.1-1.5; T3 = 1.6-2.0 years) and were evaluated using stereophotogrammetry and geometric morphometry. All patients underwent lip surgery before T0, patients with UCLP underwent palatoplasty (T0, T1 before palatoplasty; T2, T3 after palatoplasty).

RESULTS

In patients with CL, the forehead was significantly retracted (p ≤ 0.001), while the supraorbital and ocular regions were prominent (p ≤ 0.001). The oronasal region appeared convex (p ≤ 0.001). The lower lip and chin were non-significantly protruded. In patients with UCLP, a significantly retracted forehead and prominent supraorbital region were apparent (p ≤ 0.001). A retrusive oronasal region (p ≤ 0.001) was observed in the middle face. The chin was anteriorly protruded (p ≤ 0.01). No progression of deviations was found with increasing age. After the first year, a slight improvement in the morphological features became apparent. The shape variability of the clefts and controls overlapped, suggesting a comparable modelled facial development.

CONCLUSIONS

The facial morphology of individuals with cleft was comparable to the norm. Shape deviation was apparent in the oronasal region, forehead, and chin, which minimised with increasing age even in complete clefts.

Hyaluronic acid concentration in the middle ear fluid as an indicator of severity of the secretory otitis in newborns with cleft palate

The aim of the study was to investigate the hyaluronic acid concentration in middle ear fluid of patients with cleft palate as an indicator of the severity of the disease. Hyaluronic acid was examined in the middle ear fluid of 65 children (48 boys and 17 girls) subjected to cleft lip surgery in neonatal period up to 10 days of age. Patients were divided into 3 groups according to the course of the disease. First group consists of 15 patients with favorable course, second group consist of 25 patients with moderate course, third group included 25 patients with an adverse course. Hyaluronic acid levels were determined by commercially available immunoassay. The concentrations of hyaluronic acid in the middle ear fluid were as follows (mean+SEM): favorable course: 14253+2393 µg/l, moderate course: 7503+1345 µg/l, adverse course: 5905+2393 µg/l. Patients with adverse course and moderate course had significantly decreased hyaluronic acid levels in middle ear fluid compared to the patients with favorable course (P=0.02 and P=0.0018). Hyaluronic acid concentration is related to the course of the disease and the lowest values are most frequent in patients with an adverse course.

Three-dimensional assessment of facial asymmetry in preschool patients with orofacial clefts after neonatal cheiloplasty

OBJECTIVES

To evaluate facial asymmetry changes in pre-school patients with orofacial clefts after neonatal cheiloplasty and to compare facial asymmetry with age-matched healthy controls.

METHODS AND MATERIALS

The sample consisted of patients with unilateral cleft lip (UCL), unilateral cleft lip and palate (UCLP), and bilateral cleft lip and palate (BCLP). The patients were divided in two age groups with a mean age of 3 years (n = 51) and 4.5 years (n = 45), respectively, and 78 age-matched individuals as controls. Three-dimensional (3D) facial scans were analyzed using geometric morphometry and multivariate statistics.

RESULTS

Geometric morphometry showed positive deviations from perfect symmetry on the right side of the forehead in the intervention groups and the controls. The UCL groups showed the greatest asymmetric nasolabial area on the cleft-side labia and the contralateral nasal tip. The UCLP group showed, moreover, asymmetry in buccal region due to typical maxillar hypoplasia, which was accentuated in the older group. The BCLP groups showed slightly similar but greater asymmetry than the control groups, except for the philtrum region.

CONCLUSIONS

Asymmetry of each of the cleft groups significantly differed from the controls. Except for the buccal region in the UCLP and BCLP groups, asymmetry did not significantly increase with age.

Analysis of dermal fibroblasts isolated from neonatal and child cleft lip and adult skin: Developmental implications on reconstructive surgery

The nonsyndromic cleft is one of the most frequent congenital defects in humans. Clinical data demonstrated improved and almost scarless neonatal healing of reparative surgery. Based on our previous results on crosstalk between neonatal fibroblasts and adult keratinocytes, the present study focused on characterization of fibroblasts prepared from cleft lip tissue samples of neonates and older children, and compared them with samples isolated from normal adult skin (face and breast) and scars. Although subtle variances in expression profiles of children and neonates were observed, the two groups differed significantly from adult cells. Compared with adult cells, differences were observed in nestin and smooth muscle actin (SMA) expression at the protein and transcript level. Furthermore, fibroblast to myofibroblast differentiation drives effective wound healing and is largely regulated by the cytokine, transforming growth factor-β1 (TGF-β1). Dysregulation of the TGF-β signalling pathway, including low expression of the TGF-β receptor II, may contribute to reducing scarring in neonates. Fibroblasts of facial origin also exhibited age independent differences from the cells prepared from the breast, reflecting the origin of the facial cells from neural crest-based ectomesenchyme.

In vitro differences of neonatal and later postnatal keratinocytes and dermal fibroblasts

Skin healing process is postnatally always associated with scarring of various extent. Based on the clinical experience of plastic surgeons, the healing after lip cleft reconstruction is surprisingly almost scar-less when it is carried out within a few first days after birth. This phenomenon is not seen in delayed cases. In order to decipher causative mechanism, we have isolated and studied principal cell populations, keratinocytes and fibroblast, from residual tissue samples after reconstructive operation (N=39) performed at various age (0-9 years). These cells play the pivotal role in the healing and that is why we focused on description of their phenotype and also functionality with respect to age. We have identified a population of remarkably small cells in explants from newborns (day 0-10). These small cells were strongly positive for markers of low differentiated keratinocytes, keratin-8 and -19, and moreover also for vimentin. In the explants cultures from older babies this population was missing. Fibroblasts from newborns and older patients differed namely in terms of nestin expression and also in the production of extracellular matrix components. We conclude that in vitro described properties of keratinocytes and fibroblasts in newborns could participate on the almost scar-less wound healing in earliest neonatal period.

Facial growth and development in unilateral cleft lip and palate: comparison between secondary alveolar bone grafting and primary periosteoplasty

OBJECTIVE

To describe the effect of secondary alveolar bone grafting in patients with unilateral cleft lip and palate by comparison with a sample of patients who have undergone primary periosteoplasty.

DESIGN

Cephalometric analysis of lateral x-ray films in a retrospective semilongitudinal study.

PATIENTS

Lateral x-ray films of 18 secondary alveolar bone grafting patients and 48 primary periosteoplasty patients at 10 years of age and again at 15 years of age.

SETTINGS

The treatment of secondary alveolar bone grafting patients included lip repair according to Tennison, palatoplasty including retropositioning, pharyngeal flap surgery, and secondary alveolar bone grafting. The lips of primary periosteoplasty patient were repaired using the methods of Tennison and Veau, followed by primary periosteoplasty, palatoplasty including retropositioning, and pharyngeal flap surgery.

METHODS

Lateral radiographs were assessed using classical morphometry.

RESULTS

There were few significant differences at 10 years of age between the secondary alveolar bone grafting and primary periosteoplasty patients. At 15 years of age, there were several significant differences. Compared with primary periosteoplasty patients, subsequent development in patients who had undergone secondary alveolar bone grafting was characterized by a significantly better position of the upper and lower dentoalveolar components in relation to the facial plane, a higher increase in the global convexity of the soft profile, a significantly better maxillary inclination, and a more favorable development of vertical intermaxillary relationships.

CONCLUSION

Craniofacial development in secondary alveolar bone grafting patients was better than that in primary periosteoplasty patients due to the more marked facial convexity, the increased prominence of the nose, and better vertical intermaxillary relationships.

Penis augmentation by application of silicone material: complications and surgical treatment

BACKGROUND

Complications resulting from enlargement of the penis by applications of unknown types of silicone and mineral oils are well described. Surgical removal of the tissue altered by inflammation leads to the development of defects of various sizes, often circular from the glans penis to the scrotum. The options of subsequent surgical treatment described in literature are not very extensive. Most defects are managed with skin grafting, rarely V-Y advancement or bilateral scrotal flaps.

METHODS

We present a 36-year-old patient after application of unknown silicone material into the penis for cosmetic enlargement. After the application developed severe inflammation with ulceration and necrosis around the penis. Conservative treatment was not effective, therefore, the infiltrated skin with subcutaneous tissue of the entire penis was surgically removed. The resulting defect was covered by implantation of the penis under the skin of the scrotum.

RESULT

There were no complications in the postoperative course, pain that was present before the surgery immediately subsided. Skin suture healed completely within 14 days. Three months after the surgery the patient returned to normal sexual life.

CONCLUSIONS

Implantation of the penis under the skin of the scrotum is a fast, safe and effective method that can treat most of the circular skin defects of the penis. Scrotal skin is thin, soft, elastic and creates abundant and good cover around the entire penis.

Surface facial modelling and allometry in relation to sexual dimorphism

Sexual dimorphism is responsible for a substantial part of human facial variability, the study of which is essential for many scientific fields ranging from evolution to special biomedical topics. Our aim was to analyse the relationship between size variability and shape facial variability of sexual traits in the young adult Central European population and to construct average surface models of adult males and females. The method of geometric morphometrics allowed not only the identification of dimorphic traits, but also the evaluation of static allometry and the visualisation of sexual facial differences. Facial variability in the studied sample was characterised by a strong relationship between facial size and shape of sexual dimorphic traits. Large size of face was associated with facial elongation and vice versa. Regarding shape sexual dimorphic traits, a wide, vaulted and high forehead in combination with a narrow and gracile lower face were typical for females. Variability in shape dimorphic traits was smaller in females compared to males. For female classification, shape sexual dimorphic traits are more important, while for males the stronger association is with face size. Males generally had a closer inter-orbital distance and a deeper position of the eyes in relation to the facial plane, a larger and wider straight nose and nostrils, and more massive lower face. Using pseudo-colour maps to provide a detailed schematic representation of the geometrical differences between the sexes, we attempted to clarify the reasons underlying the development of such differences.

Extension of orofacial cleft size and gestational bleeding in early pregnancy

OBJECTIVE

The oronasal cavity in humans develops during embryonic day 30-60. There are three critical periods when this process can be affected, resulting in a specific type of orofacial cleft: cleft lip (CL), cleft palate (CP), or most serious, total cleft lip+palate (CLP). We assessed whether gestational bleeding during early pregnancy might act to produce a non-specific worsening of embryo status resulting in extension of the basic cleft type (CL or CP) into more serious CLP.

STUDY DESIGN

In a group of the child patients with orofacial clefts, the cleft spectrum was correlated with first trimester gestational bleeding reported by the mother. Data were also related to the gender of patients, hereditary factors and additional malformations.

RESULTS

Among 2524 mothers who gave birth to babies with an orofacial cleft in the Czech Republic during 1983-2009, 253 (10.0%) had gestational bleeding. Among the children with an orofacial cleft, 497 (19.7%) had an orofacial cleft among relatives and 297 (11.8%) exhibited an additional congenital malformation. In comparison with mothers without bleeding, there was significant increase of children with CLP (p < 0.01) at the expense of children with CP, whose number significantly decreased (p < 0.01) in the bleeding mothers. In the group of children with clefts among relatives we did not find any significant change associated with bleeding. The maternal bleeding was more frequent in children with additional malformations, but this difference was not significant (p = 0.112).

CONCLUSION

We hypothesize that size/extent and therefore seriousness of orofacial cleft might increase as a consequence of hypoxia resulting from gestational bleeding.

Our first experience with primary lip repair in newborns with cleft lip and palate

The article summarizes the results of early primary lip repair in 44 newborns with cleft lip and palate. We present a study of the first 44 patients to undergo the surgery before the age of 1 week as performed by a surgeon who used a modified method according to Tennison with a nasal correction. Early lip surgeries started in 2005. Cleft patients are under the care of a multidisciplinary team. Preliminary results are very encouraging; we observed excellent esthetic results concerning lip scars and the appearance of the nose. We did not notice any impact on the maxillary development due to the short time interval. We consider early lip surgery with nasal correction the best method, and we would like to continue with it, monitoring its impact on the maxillary and nasal development.

Influence of primary septal cartilage reposition on development of the nose in UCLP

The preceding study (Smahel, 1987) showed that after the abolishment of osteoplasty and introduction of primary reposition of nasal septum base in the 1970's the nasal deviation and asymmetry of nasal wing length in patients with unilateral cleft lip and palate had been reduced. The present study shows that this reduction continues after the introduction of total septum reposition. The deviation of septal base (columella) from the median plane and asymmetry in nostril position is reduced as well. The surgeon's experience however is the decisive factor determining the final shape of the nose.

Care of patients with facial clefts at the Department of Plastic Surgery in Prague

The multidisciplinary care of cleft defects in the Prague Department of Plastic Surgery has a long tradition. The authors describe the team care of patients including the timing of the surgery as well as the conservative therapy.