Craniofacial cleft

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A facial cleft is an opening or gap in the face, or a malformation of a part of the face. Facial clefts is a collective term for all sorts of clefts. All structures like bone, soft tissue, skin etc. can be affected. Facial clefts are extremely rare congenital anomalies. There are many variations of a type of clefting and classifications are needed to describe and classify all types of clefting. Facial clefts hardly ever occur isolated; most of the time there is an overlap of adjacent facial clefts. [1]

Contents

Classifications

There are different classifications about facial clefts. Two of the most used classifications are the Tessier classification [2] and the Van der Meulen classification. [3] Tessier is based on the anatomical position of the cleft and Van der Meulen classification is based on the embryogenesis.

Tessier classification

Tessier classification. Left: boney clefts, Right: Soft tissue clefts. Picture Tessier classification.jpg
Tessier classification. Left: boney clefts, Right: Soft tissue clefts.

In 1976 Paul Tessier published a classification on facial clefts based on the anatomical position of the clefts. The different types of Tessier clefts are numbered 0 to 14. These 15 different types of clefts can be put into 4 groups, based on their position: [4] midline clefts, paramedian clefts, orbital clefts and lateral clefts. The Tessier classification describes the clefts at soft tissue level as well as at bone level, because it appears that the soft tissue clefts can have a slightly different location on the face than the bony clefts.[ citation needed ]

Midline clefts

The midline clefts are Tessier number 0 ("median craniofacial dysplasia"), number 14 (frontonasal dysplasia), and number 30 ("lower midline facial cleft", also known as "median mandibular cleft"). These clefts bisect the face vertically through the midline. Tessier number 0 bisects the maxilla and the nose, Tessier number 14 comes between the nose and the frontal bone. The Tessier number 30 facial cleft is through the tongue, lower lip and mandible. The tongue may be absent, hypoplastic, bifid, or even duplicated. [5] People with this condition may be tongue-tied. [5]

Paramedian clefts

Tessier number 1, 2, 12 and 13 are the paramedian clefts. These clefts are quite similar to the midline clefts, but they are further away from the midline of the face. Tessier number 1 and 2 both come through the maxilla and the nose, in which Tessier number 2 is further from the midline (lateral) than number 1. Tessier number 12 is in extent of number 2, positioned between nose and frontal bone, while Tessier number 13 is in extent of number 1, also running between nose and forehead. Both 12 and 13 run between the midline and the orbit.[ citation needed ]

Orbital clefts

Bilateral number 4 orbital clefts Gould Pyle 101.jpg
Bilateral number 4 orbital clefts
Partial 3-11 orbital cleft Gould Pyle 102.jpg
Partial 3-11 orbital cleft

Tessier number 3, 4, 5, 9, 10 and 11 are orbital clefts. These clefts all have the involvement of the orbit. Tessier number 3, 4, and 5 are positioned through the maxilla and the orbital floor. Tessier number 9, 10 and 11 are positioned between the upper side of the orbit and the forehead or between the upper side of the orbit and the temple of the head. Like the other clefts, Tessier number 11 is in extent to number 3, number 10 is in extent to number 4 and number 9 is in extent to number 5.

Lateral clefts

The lateral clefts are the clefts which are positioned horizontally on the face. These are Tessier number 6, 7 and 8. Tessier number 6 runs from the orbit to the cheek bone. Tessier number 7 is positioned on the line between the corner of the mouth and the ear. A possible lateral cleft comes from the corner of the mouth towards the ear, which gives the impression that the mouth is bigger. It's also possible that the cleft begins at the ear and runs towards the mouth. Tessier number 8 runs from the outer corner of the eye towards the ear. The combination of a Tessier number 6-7-8 is seen in the Treacher Collins syndrome. Tessier number 7 is more related to hemifacial microsomia and number 8 is more related to Goldenhar syndrome.

Van der Meulen classification

Van der Meulen classification divides different types of clefts based on where the development arrest occurs in the embryogenesis. A primary cleft can occur in an early stage of the development of the face (17 mm length of the embryo). The developments arrests can be divided in four different location groups: internasal, nasal, nasalmaxillar and maxillar. The maxillar location can be subdivided in median and lateral clefts.

Internasal dysplasia

Internasal dysplasia is caused by a development arrest before the union of the two nasal halves. These clefts are characterized by a median cleft lip, a median notch of the cupid's bow or a duplication of the labial frenulum. Besides the median cleft lip, hypertelorism can be seen in these clefts. Also sometimes there can be an underdevelopment of the premaxilla.

Nasal dysplasia

Nasal dysplasia or nasoschisis is caused by a development arrest of the lateral side of the nose, resulting in a cleft in one of the nasal halves. The nasal septum and cavity can be involved, though this is rare. Nasoschisis is also characterized by hypertelorism.

Nasomaxillary dysplasia

Nasomaxillary dysplasia is caused by a development arrest at the junction of the lateral side of the nose and the maxilla, which results in a complete or non-complete cleft between the nose and the orbital floor (nasoocular cleft) or between the mouth, nose and the orbital floor (oronasal-ocular cleft). The development of the lip is normal.

Maxillary dysplasia

Maxillary dysplasia can manifest itself on two different locations in the maxilla: in the medial or the lateral part of the maxilla.

  • Median maxillary dysplasia is caused by a development failure of the medial part of the maxillary ossification centers. This results in secondary clefting of the lip, philtrum and palate. Clefting from the maxilla to the orbital floor has also been reported.
  • Lateral maxillary dysplasia is caused by a development failure of the lateral part of the maxillary ossification centers, which also results in secondary clefting of the lip and palate. Clefting of the lateral part of the lower eyelid is typical for lateral maxillary dysplasia.

Causes

It is possible that facial clefts are caused by a disorder in the migration of neural crest cells. [6]

Another theory is that facial clefts are caused by failure of the fusion process and failure of inwards growth of the mesoderm.

Other theories are that genetics play a part in the development of facial clefts [7] or that they are caused by amniotic bands. [8]

Genetics

Overview

Around one in 700 individuals are born with craniofacial clefts. [9] There are multiple genetic and environmental factors which contribute to craniofacial development. Within craniofacial disorders and abnormalities, orofacial clefts, and specifically cleft lip (CL) and cleft palate (CP) are the most common in humans. [9] Occurrences of CL/P are most often (around seventy percent of cases) isolated and nonsyndromic, meaning they are not associated with a syndrome or inherited genetic conditions. [9] [10] Around thirty percent occur with other structural variances, and over 500 syndromes have been identified in which clefting is a principal feature. [9] [10] Clefting can result from teratogens, an agent that disrupts embryo development such as, radiation, maternal infection, chemicals, or drugs. [9] [10] Chromosomal abnormalities or mutations at single gene loci have also contributed to clefting development. [9] [10] Genetic causes are linked with most craniofacial syndromes, and CL/P and other orofacial clefts are recognized as heterogeneous disorders, meaning there are multiple recognized causes. [9] [11] Orofacial clefts have great phenotypic diversity, and their associated genetic environments have called for vast research and investigation.

Environmental Interaction

Craniofacial disorders have high variance in phenotypic expression, and researchers have suggested this variance could be due to interactions between the mutated/deviated genes and other genes, along with interactions with environmental factors. [12] [13] Environmental causes have been found to contribute to craniofacial clefting, however, these are still influenced by and supported by genetic factors. Many studies, for example, have linked maternal smoking to increased CLP risk; however, the increased risk suggests that genes in metabolic pathways could still contribute to susceptibility or formation of CL/P. [14]

Development and Inheritance

The craniofacial complex begins its progress in the fourth week of development, and results from neural crest cells migrating to form and fuse the facial primordia. [9] [10] Failures or deviations in this process result in craniofacial clefts, either CL or CP. [6] The range of variation in phenotype aligns with ancestry. [9] [14] Studies have found increased amounts of clefting in the relatives of patients with clefts, suggesting genetic factors are the underlying cause for CL/P. [9] Inheritance has a known and significant role in human craniofacial morphology. This is supported through cephalometric and anthropometric comparisons of family members including between triplets, twins, siblings, and parents and children. [15]

Genetic Experimentation

Genetic factors of craniofacial clefting can be investigated and tracked through several methods including sequencing in humans, Genome-wide association studies (GWAs), fate mapping, expression analysis, and animal studies (knockout experiments or models with clefting from chemical mutagenesis). [16] Twin studies and familial clustering have also revealed that facial structure and formation are genetically linked. Several genes have been associated with craniofacial disorders through experimentation, including sequencing Mendelian clefting syndromes. [9] Over 25 loci have been identified as potential influencers of craniofacial clefts across populations. [12]

Linked Genes

The transforming growth factor (TGF) family has provided multiple candidate genes linked with craniofacial development and malformation. [17] [18] [14] [10] TGF is involved in cell migration, differentiation, and proliferation, as well as regulating the extracellular matrix. [17] Another gene that has been flagged as causal for craniofacial disorders, including CL/P, is interferon regulatory factor 6 or, IRF6 . [9] [14] [19] Mutations in IRF6 cause Van der Woude syndrome, the most common clefting syndrome. [9] Ventral anterior homeobox 1, VAX1, and noggin, NOG, were identified with genome-wide significance for contributing to CL/P. [14] Additionally, mutations in SPECC1L have recently been identified as influential to facial structure formation, and as causal for syndromic facial clefting. [19] [20] Nonsyndromic CL/P has been associated with the transcription factor forkhead box protein E1 (FOXE1), as mutations have resulted in cases of CL/P in mice. [10] Other genes which have been found to interact with or contribute to craniofacial clefting include FGFRs, TWIST, MSXs, GREM1, TCOF1, PAXs, MAFB, ABCA4, and WNT allowing great cause for more research into the genetic basis for craniofacial disorders. [11] [18] [12] [13] [14]

Prevention

Because the cause of facial clefts still is unclear, it is difficult to say what may prevent children being born with facial clefts. It seems that folic acid contributes to lowering the risk of a child being born with a facial cleft. [21]

Treatment

There is no single strategy for treatment of facial clefts, because of the large amount of variation in these clefts. Which kind of surgery is used depends on the type of clefting and which structures are involved. There is much discussion about the timing of reconstruction of bone and soft tissue. The problem with early reconstruction is the recurrence of the deformity due to the intrinsic restricted growth. This requires additional operations at a later age to make sure all parts of the face are in proportion. [22] A disadvantage of early bone reconstruction is the chance to damage the tooth germs, which are located in the maxilla, just under the orbit. The soft tissue reconstruction can be done at an early age, but only if the used skin flap can be used again during a second operation. The timing of the operation depends on the urgency of the underlying condition. If the operation is necessary to function properly, it should be done at early age. The best aesthetic result is achieved when the incisions are positioned in areas which attract the least attention (they cover up the scars). If, however, the function of a part of the face isn't damaged, the operation depends on psychological factors and the facial area of reconstruction.

The treatment plan of a facial cleft is planned right after diagnosis. This plan includes every operation needed in the first 18 years of the patients life to reconstruct the face fully. In this plan, a difference is made between problems that need to be solved to improve the health of the patient (coloboma) and problems that need to be solved for a better cosmetic result (hypertelorism).

The treatment of the facial clefts can be divided in different areas of the face: the cranial anomalies, the orbital and eye anomalies, the nose anomalies, the midface anomalies and the mouth anomalies.

Treatment of the cranial anomalies

The most common cranial anomaly seen in combination with facial clefts is encephalocele.

Encephalocele

The treatment of encephalocele is based on surgery to repair the bony gap and provide adequate protection of the underlying brain. The question remains if the external brain tissue should be put back into the skull or if it is possible to cut off that piece of brain tissue, because its claimed that the external piece of brain tissue often isn't functional, [23] with the exception of a basal encephalocele, in which the pituitary gland can be found in the mouth.

Treatment of orbital / eye anomalies

The most common orbital /eye anomalies seen in children with facial clefts are colobomas and vertical dystopia.

Coloboma

The coloboma which occurs often in facial clefts is a cleft in the lower or upper eyelid. This should be closed as soon as possible, to prevent drought of the eye and a consecutive loss of vision. [24]

Vertical orbital dystopia

Vertical orbital dystopia can occur in facial clefts when the orbital floor and/or the maxilla is involved in the cleft. Vertical orbital dystopia means that the eyes do not lay on the same horizontal line in the face (one eye is positioned lower than the other). The treatment is based on the reconstruction of this orbital floor, by either closing the boney cleft or reconstructing the orbital floor using a bone graft. [25]

Hypertelorism

There are many types of operations which can be performed to treat a hypertelorism. 2 options are: box osteotomy and facial bipartition [26] (also referred to as a median fasciotomy). The goal of the box osteotomy is to bring the orbits closer together by removing a part of the bone between the orbits, to detach both orbits from the surrounding bone structures and move both orbits more to the centre of the face. The goal of the facial bipartition is not only to bring the orbits closer together, but also to create more space in the maxilla. This can be done by splitting the maxilla and the frontal bone, remove a triangular shaped piece of bone from the forehead and nasal bones and pulling the two pieces of forehead together. Not only will the hypertelorism be solved by pulling the frontal bone closer together, but because of this pulling, the space between the both parts of the maxilla will become wider.

Treatment of nose anomalies

The nose anomalies found in facial clefts vary. The main goal of the treatment is to reconstruct the nose to get a functional and esthetic acceptable result. A few possible treatment options are to reconstruct the nose with a forehead flap or reconstruct the nasal dorsum with a bone graft, for example a rib graft. The nasal reconstruction with a forehead flap is based on the repositioning of a skin flap from the forehead to the nose. A possible downside of this reconstruction is that once you performed it at a younger age, you can't lengthen the flap at a later stage. A second operation is often needed if the operation is done on early age, because the nose has a restricted growth in the cleft area. Repair of the ala (wing of the nose) often requires the inset of cartilage graft, commonly taken from the ear. [27]

Treatment of midface anomalies

The treatment of soft tissue parts of midface anomalies is often a reconstruction from a skin flap of the cheek. This skinflap can be used for other operations in the further, as it can be raised again and transposed again. In the treatment of midface anomalies there are generally more operations needed. Bone tissue reconstruction of the midface often occurs later than the soft tissue reconstruction. The most common method to reconstruct the midface is by using the fracture/ incision lines described by René Le Fort. When the cleft involves the maxilla, it is likely that the impaired growth will result in a smaller maxillary bone in all 3 dimensions (height, projection, width).

Treatment of mouth anomalies

There are several options for treatment of mouth anomalies like Tessier cleft number 2-3-7 . These clefts are also seen in various syndromes like Treacher Collins syndrome and hemifacial microsomia, which makes the treatment much more complicated. In this case, treatment of mouth anomalies is a part of the treatment of the syndrome.

See also

Related articles

Syndromes

Related Research Articles

<span class="mw-page-title-main">Cleft lip and cleft palate</span> Birth defect of the palate and upper lip

A cleft lip contains an opening in the upper lip that may extend into the nose. The opening may be on one side, both sides, or in the middle. A cleft palate occurs when the palate contains an opening into the nose. The term orofacial cleft refers to either condition or to both occurring together. These disorders can result in feeding problems, speech problems, hearing problems, and frequent ear infections. Less than half the time the condition is associated with other disorders.

<span class="mw-page-title-main">Rhinoplasty</span> Surgical procedure to enhance or reconstruct a human nose

Rhinoplasty, commonly called nose job, medically called nasal reconstruction is a plastic surgery procedure for altering and reconstructing the nose. There are two types of plastic surgery used – reconstructive surgery that restores the form and functions of the nose and cosmetic surgery that changes the appearance of the nose. Reconstructive surgery seeks to resolve nasal injuries caused by various traumas including blunt, and penetrating trauma and trauma caused by blast injury. Reconstructive surgery can also treat birth defects, breathing problems, and failed primary rhinoplasties. Rhinoplasty may remove a bump, narrow nostril width, change the angle between the nose and the mouth, or address injuries, birth defects, or other problems that affect breathing, such as a deviated nasal septum or a sinus condition. Surgery only on the septum is called a septoplasty.

<span class="mw-page-title-main">Crouzon syndrome</span> Genetic disorder of the skull and face

Crouzon syndrome is an autosomal dominant genetic disorder known as a branchial arch syndrome. Specifically, this syndrome affects the first branchial arch, which is the precursor of the maxilla and mandible. Because the branchial arches are important developmental features in a growing embryo, disturbances in their development create lasting and widespread effects. The syndrome is caused by a mutation in a gene on chromosome 10 that controls the body's production of fibroblast growth factor receptor 2 (FGFR2).

<span class="mw-page-title-main">Orthognathic surgery</span> Surgery of the jaw

Orthognathic surgery, also known as corrective jaw surgery or simply jaw surgery, is surgery designed to correct conditions of the jaw and lower face related to structure, growth, airway issues including sleep apnea, TMJ disorders, malocclusion problems primarily arising from skeletal disharmonies, and other orthodontic dental bite problems that cannot be treated easily with braces, as well as the broad range of facial imbalances, disharmonies, asymmetries, and malproportions where correction may be considered to improve facial aesthetics and self-esteem.

<span class="mw-page-title-main">Cherubism</span> Medical condition

Cherubism is a rare genetic disorder that causes prominence in the lower portion in the face. The name is derived from the temporary chubby-cheeked resemblance to putti, the chubby-faced infants featured in Renaissance paintings, which were often mistakenly described as cherubs.

<span class="mw-page-title-main">Hypertelorism</span> Abnormally increased distance between two body parts, usually the eyes

Hypertelorism is an abnormally increased distance between two organs or bodily parts, usually referring to an increased distance between the orbits (eyes), or orbital hypertelorism. In this condition the distance between the inner eye corners as well as the distance between the pupils is greater than normal. Hypertelorism should not be confused with telecanthus, in which the distance between the inner eye corners is increased but the distances between the outer eye corners and the pupils remain unchanged.

<span class="mw-page-title-main">Encephalocele</span> Neural tube defect in which the brain protrudes out of the skull

Encephalocele is a neural tube defect characterized by sac-like protrusions of the brain and the membranes that cover it through openings in the skull. These defects are caused by failure of the neural tube to close completely during fetal development. Encephaloceles cause a groove down the middle of the skull, or between the forehead and nose, or on the back side of the skull. The severity of encephalocele varies, depending on its location.

Vomer flap surgery was used prior to 1975 as a surgical treatment for children with cleft palate. In this procedure, the vomer bone was used to reconstruct the palate and cover the cleft.

<span class="mw-page-title-main">Arrhinia</span> Medical condition

Arrhinia is the congenital partial or complete absence of the nose at birth. It is an extremely rare condition, with few reported cases in the history of modern medicine. It is generally classified as a craniofacial abnormality.

<span class="mw-page-title-main">Craniofrontonasal dysplasia</span> Medical condition

Craniofrontonasal dysplasia is a very rare X-linked malformation syndrome caused by mutations in the ephrin-B1 gene (EFNB1). Phenotypic expression varies greatly amongst affected individuals, where females are more commonly and generally more severely affected than males. Common physical malformations are: craniosynostosis of the coronal suture(s), orbital hypertelorism, bifid nasal tip, dry frizzy curled hair, longitudinal ridging and/or splitting of the nails, and facial asymmetry.

<span class="mw-page-title-main">Human nose</span> Feature of the human face

The human nose is the first organ of the respiratory system. It is also the principal organ in the olfactory system. The shape of the nose is determined by the nasal bones and the nasal cartilages, including the nasal septum, which separates the nostrils and divides the nasal cavity into two.

<span class="mw-page-title-main">Le Fort fracture of skull</span> Type of head injury

The Le Fortfractures are a pattern of midface fractures originally described by the French surgeon, René Le Fort, in the early 1900s. He described three distinct fracture patterns. Although not always applicable to modern-day facial fractures, the Le Fort type fracture classification is still utilized today by medical providers to aid in describing facial trauma for communication, documentation, and surgical planning. Several surgical techniques have been established for facial reconstruction following Le Fort fractures, including maxillomandibular fixation (MMF) and open reduction and internal fixation (ORIF). The main goal of any surgical intervention is to re-establish occlusion, or the alignment of upper and lower teeth, to ensure the patient is able to eat. Complications following Le Fort fractures rely on the anatomical structures affected by the inciding injury.

<span class="mw-page-title-main">Frontonasal dysplasia</span> Medical condition

Frontonasal dysplasia (FND) is a congenital malformation of the midface. For the diagnosis of FND, a patient should present at least two of the following characteristics: hypertelorism, a wide nasal root, vertical midline cleft of the nose and/or upper lip, cleft of the wings of the nose, malformed nasal tip, encephalocele or V-shaped hair pattern on the forehead. The cause of FND remains unknown. FND seems to be sporadic (random) and multiple environmental factors are suggested as possible causes for the syndrome. However, in some families multiple cases of FND were reported, which suggests a genetic cause of FND.

<span class="mw-page-title-main">Jaw abnormality</span> Medical condition

A jaw abnormality is a disorder in the formation, shape and/or size of the jaw. In general abnormalities arise within the jaw when there is a disturbance or fault in the fusion of the mandibular processes. The mandible in particular has the most differential typical growth anomalies than any other bone in the human skeleton. This is due to variants in the complex symmetrical growth pattern which formulates the mandible.

Binder's syndrome, Binder syndrome or maxillo-nasal dysplasia is a developmental disorder primarily affecting the anterior part of the maxilla and nasal complex. It is a rare disorder and the causes are unclear.

<span class="mw-page-title-main">Maxillary hypoplasia</span> Medical condition

Maxillary hypoplasia, or maxillary deficiency, is an underdevelopment of the bones of the upper jaw. It is associated with Crouzon syndrome, Angelman syndrome, as well as Fetal alcohol syndrome. It can also be associated with Cleft lip and cleft palate. Some people could develop it due to poor dental extractions.

Malpuech facial clefting syndrome, also called Malpuech syndrome or Gypsy type facial clefting syndrome, is a rare congenital syndrome. It is characterized by facial clefting, a caudal appendage, growth deficiency, intellectual and developmental disability, and abnormalities of the renal system (kidneys) and the male genitalia. Abnormalities of the heart, and other skeletal malformations may also be present. The syndrome was initially described by Georges Malpuech and associates in 1983. It is thought to be genetically related to Juberg-Hayward syndrome. Malpuech syndrome has also been considered as part of a spectrum of congenital genetic disorders associated with similar facial, urogenital and skeletal anomalies. Termed "3MC syndrome", this proposed spectrum includes Malpuech, Michels and Mingarelli-Carnevale (OSA) syndromes. Mutations in the COLLEC11 and MASP1 genes are believed to be a cause of these syndromes. The incidence of Malpuech syndrome is unknown. The pattern of inheritance is autosomal recessive, which means a defective (mutated) gene associated with the syndrome is located on an autosome, and the syndrome occurs when two copies of this defective gene are inherited.

<span class="mw-page-title-main">Alveolar cleft grafting</span> Surgical procedure

Alveolar cleft grafting is a surgical procedure, used to repair the defect in the upper jaw that is associated with cleft lip and palate, where the bone defect is filled with bone or bone substitute, and any holes between the mouth and the nose are closed.

<span class="mw-page-title-main">Bifid nose</span> Medical condition

A bifid nose is an uncommon congenital malformation which is characterized by the presence of a cleft between the two nostrils of the nose. It is the result of a disturbance during embryological nose development.

Eric Liao is an American pediatric surgeon-scientist. He specializes in plastic and reconstructive craniofacial surgery, especially in the surgical treatment of cleft lip and palate, rhinoplasty, otoplasty, and nasal reconstruction. Liao's research interests are focused on the genetics and developmental biology that govern facial formation and craniofacial anomalies. He is the founding director of the Center for Craniofacial Innovation at the Children’s Hospital of Philadelphia, the Vice Chair of Academic Affairs in the Department of Surgery, and a Professor of Surgery at the University of Pennsylvania Perelman School of Medicine.

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  23. ↑ Kamerer, Donald B.; Caparosa, Ralph J. (1982). "Temporal Bone Encephalocele ??? Diagnosis and Treatment". The Laryngoscope. 92 (8): 878–882. doi:10.1288/00005537-198208000-00008. PMID   7098736.
  24. ↑ Patipa M et al., "Surgical management of congenital eyelid coloboma", Ophthalmic Surg. 1982 Mar;13(3):212-216 Patipa, M; Wilkins, RB; Guelzow, KW (1982). "Surgical management of congenital eyelid coloboma". Ophthalmic Surgery. 13 (3): 212–6. PMID   7088491.
  25. ↑ Tabrizi, Reza; Ozkan, Taha Birkan; Mohammadinejad, Cyrus; Minaee, Nasim (2010). "Orbital Floor Reconstruction". Journal of Craniofacial Surgery. 21 (4): 1142–1146. doi:10.1097/SCS.0b013e3181e57241. PMID   20613583. S2CID   44665427.
  26. ↑ Marchad D & Arnaud E, "Midface surgery from Tessier to distraction", Childs Nerv Syst. 1999 Nov;15(11-12):681-94, Marchac, D.; Arnaud, Eric (1999). "Midface surgery from Tessier to distraction". Child's Nervous System. 15 (11–12): 681–694. doi:10.1007/s003810050458. PMID   10603010. S2CID   27558780.
  27. ↑ Tardy, M. Eugene; Denneny, James; Fritsch, Michael H. (1985). "The Versatile Cartilage Autograft in Reconstruction of the Nose and Face". The Laryngoscope. 95 (5): 523–533. doi:10.1288/00005537-198505000-00003. PMID   3990484.
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