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Case 2.12
Published in Monica Fawzy, Plastic Surgery Vivas for the FRCS(Plast), 2023
You’ve mentioned the failure of the facial prominences to fuse as a possible cause of a facial cleft. What is the embryology of facial development?Development of the face occurs between the 3rd and 8th week of gestation.In the 3rd week, the neural folds fuse to form a neural tube: the cranial neural tube forms a central frontonasal prominence and six paired branchial arches – each of which form a cartilage precursor, an artery, nerve, muscle, and skeletal structure:The frontonasal prominence is destined to form the forehead, nose, and the central upper lip.The first branchial arch develops the maxillary and mandibular prominences, which form the midface and lower face respectively.The maxillary prominence will form the cheeks, maxillae, and lateral upper lips.The mandibular prominences become the lower lip, chin, and mandible.The second branchial arch forms the facial nerve and muscles of facial expression.
A Study of Facial Growth in Patients with Unilateral Cleft Lip and Palate Treated by the Oslo CLP Team
Published in Niall MH McLeod, Peter A Brennan, 50 Landmark Papers every Oral & Maxillofacial Surgeon Should Know, 2020
The skeletal and soft tissue features were characterised by a short and retrusive maxilla, vertical elongation of the anterior face, and a retrusive mandible. Posterior face height was reduced and cranial base angulation was slightly increased, as was interocular distance. The pattern of growth differed from non-cleft individuals, with almost no increase in length of the maxilla between 5 and 18 years of age. A marked and progressive reduction in maxillary prominence (S-N-SS) of 5.4 degrees was observed in the pooled UCLP patients which compares with an expected increase of 3.3 degrees in the non-cleft data. Mandibular retrusion was observed in the sample with an increase of only 3.8 degrees in mandibular prominence (S-N-PG), when compared with the 6.2 degree increase from pooled Bolton standards. The facial soft tissue profile differed from non-cleft individuals with nasal growth in a more backward and downward direction, a receded upper lip, and a progressively straighter profile. Further analysis of the surgical effects on facial growth failed to reveal any differences between the surgical groups and surgical variation during the 25-year period. The cephalometric outcomes are compared with outcomes from other centres and were found to be similar. Shortcomings of the previous reports in the literature in addition to those within the present study are acknowledged.
Common paediatric ENT viva topics
Published in Joseph Manjaly, Peter Kullar, Advanced ENT Training, 2019
Benjamin Hartley, Richard J Hewitt
The embryonic face is formed by the fusion of the frontonasal prominence, the paired right and left maxillary prominence and the right and left mandibular prominences. Week 4: Pharyngeal arch formation, first pharyngeal arch contributes to the mandible and maxillaWeeks 6–7: Primary palate formation, maxillary processes and frontonasal prominence form the lip and alveolusWeek 9: Secondary palate shelves fuse, separating oral and nasal cavities (palate is fused by week 12)
Multiple lacrimal drainage anomalies in proboscis lateralis
Published in Orbit, 2021
Nandini Bothra, Milind Naik, Mohammad Javed Ali
Embryologically, the development of PL is unclear. Sakamoto Y et al.6 proposed that at the end of 4th week of gestation, in Group 2 PL, during the proliferation of the medial nasal prominence, a concavity or fissure accidentally develops and divides the nasal prominence into two parts. The medial segment joins the unaffected part and forms the columella and the lateral segment merges with lateral nasal prominence to form the proboscis lateralis, instead of ala nasi. In Groups 3 and 4, this is associated with varying degrees of hypoplasia of the maxillary prominence. However, Group 1 shows a different developmental pattern since the PL is associated with a normal nasal structure but resembles that of a double nose.6 Prenatal diagnosis of proboscis lateralis has been documented previously.7 It is more important in cases that are associated with holopros-encephaly, as this condition is then associated with varying skeletal and developmental defects and can be fatal.
Pitfalls in the Diagnosis of β-Thalassemia Intermedia
Published in Hemoglobin, 2021
Shiromi Perera, Angela Allen, David C. Rees, Anuja Premawardhena
On clinical examination, she was found to be pale, mildly icteric, she had a very prominent ‘thalassemic face’ with frontal bossing, flat nasal bridge, and maxillary prominence. Abdominal examination revealed a large spleen with an abdominal span of 17 cm below the LCM. The liver was palpable 5 cm below the right costal margin. The patient had features of severe growth retardation (height below the 3rd percentile).
Single piece fronto-temporo-orbito-zygomatic craniotomy: a personal experience and review of surgical technique
Published in British Journal of Neurosurgery, 2018
Manish Sharma, Sridhar Shastri
The patient is positioned supine and head is turned by around 30 degrees to the opposite side of the lesion and fixed on head frame (Figures 1(A) and 3(A)). After infiltration with lignocaine, skin incision starts from just below the zygomatic arch within 1 cm of tragus and extends to opposite mid pupillary line along the skin crease (Figure 3(A)). Skin flap is elevated exposing the fronto-temporal bone, superior and lateral orbital rims and zygomatic arch (Figures 1(B) and 3(B)). We routinely use interfacial dissection as described by Yasargil in order to safeguard the branches of facial nerve. A fine chisel is used to release the supra-orbital neuro-vascular bundle, which is then retracted away along with peri-orbita (Figures 1(C) and 3(C)). Peri-orbita requires gentle dissection from the orbit and a few extra minutes are beneficial in doing so. Superior and inferior surface of zygomatic arch along with malar prominence is exposed. The anterior burr hole is made at the level of supraorbital neurovascular bundle, which has been dissected away, and extends into the orbit (Figure 3(D)). A fine chisel is used to open the supra-orbital rim without significant bone loss. Subsequent burr holes are made into the fronto-temporal bone similar to a routine craniotomy and depending on the extent of underlying lesion and exposure required. These burr hole are connected with craniotome except for the burr hole at orbit and Mc Carty’s point (Figure 3(E)). Further orbital cuts are made into the roof of the orbit using fine chisels when the peri-orbita is retracted with brain retractors. We routinely made bone-cut, inferior to the malar prominence so as to remove zygomatic arch along with lateral orbital rim (Figure 3(E)). This facilitates in maintaining the contour of malar prominence and the facial appearance of the patient postoperatively. Zygomatic arch is cut just near its root. Hereafter sphenoid bone is fractured so as to free the entire bone flap which is removed in one piece (Figure 1(D)). After the bone flap is removed bone work is done at sphenoid ridge and temporal bone so as to give extra manoeuvrable space which gives wider and shallower access to skull base. At the end of surgery the bone flap is replaced. Although the replaced bone appeared stable we used plates and screws at maxillary prominence and single craniofix to fix the bone. The temporalis muscle is replaced and stitched to myofascial cuff which is left behind during craniotomy to facilitate closure.