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Congenital-problems
Clefts: photo Cleft lip & palate is one of the most common congenital anomaly with incidence of about one in every 600 child. This problem may run in family. Cleft lip may be partial or complete or may be associated with cleft palate. These children may also have some associated anomalies. Rarely we may see cleft of the other parts of face as well photo e.g. from lip to eye (oro-ocular) or from lip to ear (oro-aural). Surgical correction of cleft lip is done after the age of ten weeks. In cases of complete clefts (cleft lip & palate) lip, alveolus and part of hard palate is repaired in first stage (after age of ten weeks). Remaining part of palate is repaired at about 15 months of age.
Cleft lip alone is mainly a cosmetic problem and can be corrected by the age of 3 months. Cleft palate children are difficult to feed. They can’t suck. They have to be fed by spoon. It’s preferable not to use bottle for their feeding. Special care is needed for their feeding otherwise growth may not be proper. Also they are at higher risk of catching common cold and ear infection. Management of this problem starts early in infancy. Surgical repair of cleft lip and anterior part of palate is done at about 3 months of age provided child’s weight is appropriate to its age. Cleft palate surgery is done between age of 12 to 18 months. This is important for proper speech development video of CP speech. These children have deformed nose that becomes more apparent as the child grows. This may be corrected at the time of lip repair or at a later age Photo of cleft nose. As these children grow, they need visit to speech therapist and orthodontist. With proper management and follow up till the age of about 15 years child can attain normal facial development
Absence, hypoplasia or other deformities of nose, eyelids or other parts; photo of eyelid from Dey NH, accessory nostril,7t, 7t1, 7t2, 7t3, 7t4,
Congenital nevi (black spots): Small spots may be removed in single stage with local skin flaps but
method of tissue expansion is better for larger lesions 7v, 7vv.
  • Congenital Problems of Ear
  • Ear deformities may be
  • Congenital
  • Mild ({e.g. skin tags in front of ear 77c, small coloboma 77, 77a, 77b,})
  • Severe {e.g. microtia i.e. total absence of ear pinna or presence of skin fold instead of ear pinna}.
  • Acquired - causes are usually trauma or burn injury
  • Partial
  • Total loss of ear.
Congenital problems are:
  • Absence of ear
  • Hypoplastic ear – with or without atresia of ext. auditory meatus
  • Hypoplasia of a part of ear
  • Cup shaped ear
  • Prominent ear
Some of the problems {e.g. cup ear, small colobomas} may be corrected in single sitting in early childhood but reconstruction of a major part of ear is always a staged procedure. Total ear reconstruction is done after the age of 7-8 years. Ear framework is inserted under the skin at the site where ear is to be reconstructed. In second stage this framework covered with skin, is elevated from the site where it was implanted and the defect (thus created – on posterior aspect of reconstructed ear and the site from where the framework has been elevated) is covered with split skin graft.
Two important things needed for total ear reconstruction are ear framework that is covered by skin on both sides.
- Ear Framework- Ear “framework” may be made from patient’s own rib cartilage (preferable) 7d or commercially available silicon or porex implant. Use of artificial material {silicon or porex} carries some risk of extrusion.
- Skin Cover- Skin on mastoid bone area ie behind the actual site of ear, is used for the cover. This skin may be expanded (by tissue expander) before insertion of “framework”. Results of pre-expanded skin cover are better. With the expansion of skin we can avoid the need of skin graft.
Completion of all stages may take one year or more. In cases of congenital absence of ear {microtia} there is also atresia of external auditory canal. These children may have problem in binaural hearing and in recognition of direction of sound {if deficiency in hearing is more than 15 decibel}. However any scar at the site of external auditory meatus may have its adverse impact on reconstructive ear surgery hence no surgery should be done for meatus or atretic canal before ear reconstruction.
  • Facial asymmetry
  • Commonest cause of facial asymmetry is congenital.
  • Facial clefts – eg. Hemifacial microsomia, apert syndrome
  • Rhomberg disease – atrophy of skin, fat, muscles or even bone on diseased area. photo
Torticollis – cause of problem lies in neck muscle. One of the major cause is supposed to be birth trauma. Because of muscle spasm or band on one side face looks to opposite side. If neglected it leads to growth impairment on affected side. Early treatment is regular guided splintage. If it fails, surgery is the only option.
Asymmetric growth of mandible – leads to deviation of chin to one side. Causes may be –
Temporomandibular Joint ankylosis – retarded growth of lower jaw on diseased side and chin is deviated to diseased side. photo
Condylar hyperplasia – over growth on diseaesed side and hence here chin deviation is towards healthy side.
  • Massetric muscle hypertrophy
  • Torticollis
  • Neck folds
  • Low set hairlines
Vascular malformations or hemangiomas: Modalities of treatment are sclerosant inj., local steroids in selected cases or surgery. Photos 92a, 92b and more photos
Facial palsy: Bells palsy usually recovers with time. In certain cases however residual weakness and asymmetry may persist e.g. incomplete eye closure, flattening of nasolabial fold or incompetence of oral commissure. These problems can be addressed by temporalis muscle transfer, nerve graft (cross facial), functioning muscle transfer.
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