Author Information
From the Department of Plastic and Reconstructive Surgery, Osaka Medical College, Takatsuki, Osaka, Japan.
Received for publication October 14, 2015; accepted March 21, 2016.
Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.
Koichi Ueda, MD, Department of Plastic and Reconstructive Surgery, Osaka Medical College, Takatsuki, Osaka 569–8686, Japan, E-mail: pla007@poh.osaka-med.ac.jp
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Abstract
Summary: The Treacher Collins syndrome is characterized by both soft and hard tissue deficiencies. To reconstruct malar hypoplasia with both soft and hard tissues, we designed a new method using cartilage grafts, Y-V advancement flaps, and Z plasty with tissue expansion.
Treacher Collins syndrome is an uncommon hereditary malformation, and the hallmarks of the syndrome are malar hypoplasia and eyelid coloboma. It was reported by Berry1 in 1889 and Collins2 in 1900. The syndrome is characterized by both soft and hard tissue deficiencies. To reconstruct malar hypoplasia with both soft and hard tissues, we designed a new method using cartilage grafts, Y-V advancement flaps, and Z plasty with tissue expansion.
METHODS
Tissue expanders are inserted bilaterally cranially to the zygomatic arch and posteriorly to the frontal process on the deep temporal fascia of the lower temporal region from a small incision of the upper temporal area. Expansion of this location helps both to make space for cartilage graft and to reconstruct the lower eyelid. After tissue expansion, 2 Y-V advancement flaps are designed (Figs. 1 and 2). The base of the larger lateral flap is situated on the expanded flap. Recently, a lambda incision3 has been added to the flap.
After removal of the tissue expander, T-shaped rib cartilage grafts are implanted bilaterally in the hypoplastic malar regions (Fig. 3). A hole was drilled through the zygomatic bone, and the lateral canthal ligament was repositioned and pulled through it in the upper and lateral direction. Two Y-V advancement flaps were inserted, and the positions of their tips were exchanged in a Z-plasty like fashion (Fig. 2).
Fig. 2 Image Tools |
Fig. 3 Image Tools |
This method was used from January 1993 to February 2014 in 4 patients with Treacher Collins syndrome (Table 1). Three of the 4 patients were female, and 1 was male, aged 12 to 26 years. The 4 patients were followed up postoperatively for 1 to 16 years. In 1 case, a dermal fat graft was performed because of a small depression in the malar region.
Case 1
A 25-year-old woman had bilateral lower lid coloboma, hearing disturbance, micrognathia, and malar hypoplasia (Fig. 4). She presented for the treatment of the lower lid coloboma, malar hypoplasia, and micrognathia. Sleep apnea was not noted.
During the first operation, 28 cm3 tissue expanders were inserted bilaterally cranially to the zygomatic arch and posteriorly to the frontal process on the deep temporal fascia of the lower temporal region. Segmental osteotomy and mentoplasty of the mandible were performed simultaneously.
Four months later, T-shaped cartilage grafts were performed in both malar regions with 2 Y-V advancement flaps. Reconstruction of the coloboma, Y-V advancement, and Z-plasty were performed bilaterally.
Holes were drilled in the zygomatic bones, and the bilateral lateral canthal ligaments were pulled through them in the upper and lateral direction. Thirteen years later, bilateral dermal fat grafts were performed because of small depressions in the malar regions. The condition 14 years after the first malar cartilage grafts is shown inFigure 4.
Case 2
A 10-year-old boy had bilateral lower lid coloboma, microtia, hearing disturbance, micrognathia, malar hypoplasia, and sleep apnea.
The patient underwent distraction osteogenesis of the mandible at the age of 10 years. At 12 years of age, 28 and 95 cm3 tissue expanders were inserted in the right lower temporal and microtia regions, respectively. Four months after harvesting of the right rib cartilage, grafts were fashioned for the right ear and the right malar regions. From 2 Y-V advancement flaps, T-shaped cartilage grafts were grafted in the malar region, and for reconstruction of the right coloboma, Y-V advancement and Z-plasty were performed, and a part of the cartilage was grafted for microtia. The same operations were performed at the age of 13 years on the left side by harvesting left rib cartilage.
Mentoplasty to pull the muscles attached to the tongue and hyoid bone was performed to improve sleep apnea at the age of 16 years.
DISCUSSION
Treacher Collins syndrome is characterized by both soft and hard tissue deficiencies and is thought to be the bilateral occurrence of combined Tessier numbers 6, 7, and 8 craniofacial cleft.4 Menard et al5 reported tissue expansion in the reconstruction of a series of Tessier craniofacial clefts: primary correction of facial clefts and preparation for bone grafting or osteotomy. They concluded that long-term bone graft viability demanded coverage with tissue of adequate vascularity and that tissue expansion was effective in tension-free reconstruction for osteotomy and bone grafting. Therefore, the use of tissue expansion is ideal for the reconstruction of soft tissue and establishing good conditions for bone or cartilage grafts.
For treating Treacher Collins syndrome, placement of a tissue expander in the malar area has been reported.6 In this study, expanders were inflated gradually over several years. In a secondary procedure, the expander was removed and a cranial or rib graft was placed directly into the space formed by the expander.
In Treacher Collins syndrome, there is also coloboma of the lower eyelid. For its reconstruction, a composite upper lid flap has been reported.7 In this method, a full-thickness incision through the lower lid is made to release the coloboma, and an upper lid flap is transferred to the lower lid defect. In a similar method, an advancement rotation flap from the upper eyelid has been reported8; the temporal osteoperiosteal flap was used for the reconstruction of malar hypoplasia. The report notes that construction with an osteomuscular flap is a major procedure with an extra operative risk, which is acceptable when it is balanced by the obvious advantages. For approaching the donor sites, a coronal incision was done. For the coloboma, an advancement rotation flap was performed secondarily.
In our method, the expanded skin for coverage of cartilage grafts can also be used to reconstruct the lower eyelid by using Y-V advancement flaps. An upper eyelid incision to make an upper lid flap is unnecessary. A coronal incision is also not needed. From the flap incisions, we can approach both the malar region and the coloboma. However, an incision for harvesting rib cartilage and an operation for placing a tissue expander are necessary. Autologous costal cartilage seems to retain some growth potential.9 The expanded skin must provide cartilage grafts with good vascularization10 and absence of tension. Costal cartilage can be harvested safely and plentifully even in children. If absorption occurs, additional cartilage grafts can be performed.
PATIENT CONSENT
Patients, parents, or guardians provided written consent for the use of their images.
REFERENCES
1. Berry GANote on a congenital defect (coloboma?) of the lower lid.R Land Ophtahlmol Hosp Rep188912255–270
2. Collins ETCase with symmetrical congenital notches in the outer part of each lower lid and defective development of the malar bones.Trans Ophthalmol Soc UK190020190–210
3. Ueda K, Hara M, Okada M, et al.Lambda incision for effective tissue expansion.J Plast Reconstr Aesthet Surg2010631682–1687
4. Tessier PAnatomical classification facial, cranio-facial and latero-facial clefts.J Maxillofac Surg1976469–92
5. Menard RM, Moore MH, David DJTissue expansion in the reconstruction of Tessier craniofacial clefts: a series of 17 patients.Plast Reconstr Surg1999103779–786
6. Argenta LC, Iacobucci JJTreacher Collins syndrome: present concepts of the disorder and their surgical correction.World J Surg198913401–409
7. Jackson ITReconstruction of the lower eyelid defect in Treacher Collins syndrome.Plast Reconstr Surg198167365–368
8. van der Meulen JC, Hauben DJ, Vaandrager JM, et al.The use of a temporal osteoperiosteal flap for the reconstruction of malar hypoplasia in Treacher Collins syndrome.Plast Reconstr Surg198474687–693
9. Stoll DA, Furnas DWThe growth of cartilage transplants in baby rabbits.Plast Reconstr Surg197045356–359
10. Cherry GW, Austad E, Pasyk K, et al.Increased survival and vascularity of random-pattern skin flaps elevated in controlled, expanded skin.Plast Reconstr Surg198372680–687
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