Facial Clefting

What is a Facial Cleft?

A facial cleft is an opening or gap in the face, or a malformation of a part of the face. Facial clefting is a collective term for all sorts of clefts. All structures like bone, soft tissue, skin etc. can be affected. While extremely rare, there exist many variations of facial clefting, with classification systems needed to describe and classify each. The two most used classifications are the Tessier and the Van der Meulen classifications, with Tessier based on the anatomical position of the cleft and Van der Meulen on the embryogenesis. Ultimately still relatively unclear, theories for the causes of facial clefting vary from disorders in migration of neural crest cells to failure of the fusion process and failure of inwards growth of the mesoderm to simple genetic mutations.

How is a Facial Cleft Treated?

Because of the large amount of variation in these clefts, no one true treatment modality exists. 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. 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 esthetic 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, with the ultimate plan divided by the different areas of the face affected. This plan includes every operation needed in the first 18 years of the patient’s 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 versus those needing to be solved for a better cosmetic result. 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 a lower risk of a child being born with a facial cleft, but this remains unproven.