AAPS, American Association of Plastic Surgeons
AAPS, American Association of Plastic Surgeons
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AAPS 2007 Annual Meeting, May 19 - 22, 2007, The Coeur d'Alene Resort, Coeur d'Alene, Idaho.
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Facial Clefts--Case Series and Treatment Protocol

Purpose: The treatment of major facial clefts in our Unit has evolved greatly over the last 40 years. Early in our experience, soft tissues were treated by direct approximation or by local flap rotation. Bony defecits were treated with bone grafts, as necessary. These techniques resulted in suboptimal aesthetic results. In 1985, we developed a treatment protocol that resolves these issues, and its tenents have formed the foundation of our treatment since then.
Methods: From 1965 to 2005 a series of 490 patients with major facial clefts were treated in our Unit. 54% were females and 46% were males (ratio 1:0.8). 66% had multiple clefts and 34% had a single cleft. In 32% the clefts were bilateral and 68% unilateral. The most frequent location of multiple clefts was 0-14 (35%) and 1-13 (22%). In 71% of the patients both soft tissues and skeleton were involved; 23% affected only the soft tissues; and 6% only the skeleton. 1% were associated with craniosynostosis. Microphthalmia and anophthalmia was observed in 9%. 15 patients (1.5%) had a partial or complete arrhythmia.
The treatment protocol in our Unit since 1985 is as follows:
1. Reconstruct with skin and soft tissues of the same color and texture, avoiding skin grafts and distant flaps. Tissue expanders are used when necessary.
2. Resulting scars should be located at the limits of the aesthetic subunits.
3. Reconstruct complete aesthetic subunits. If greater than 50% of a subunit is affected, replace the entire subunit.
4. Reposition important facial landmarks--medial and lateral canthi, nasal base, and buccal commissures-- in their normal location.
5. Restore the craniofacial skeleton by osteotomies, bone grafts, etc.

Results: All patients who underwent primary reconstruction were successfully reconstructed using the aesthetic subunit principle; only half of the secondary cases achieved reconstruction by aesthetic subunits. Tissue expansion was employed in 68% of all cases, and in 100% of cases involving nasal reconstruction. Local flap reconstruction of soft tissues was achieved in 100% of cases, eliminating the need for skin grafts or distant flaps.
53% of patients required formal craniofacial osteotomy, and 24% required bone grafting to restore proper skeletal alignment. In 49 cases of median and paramedian clefts, the combination of hypertelorism, anterior open bite, and shortened midface was treated with hemifacial rotation with satisfactory resolution.
By standardizing our treatment protocol, complications have been minimized. Hypertrophy or widening of the scars occurred in 9 cases, and was usually located in the region of the lip. 3 patients required removal of osteosynthesis material.

Conclusions: Our final results have improved considerably both in primary and secondary reconstruction. We have reduced scar visibility and facial asymmetry, allowing these patients to live more normal lives.

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