Large Clefts Research Articles

Basal Cell Carcinoma Cleft: The Missing Piece of the Puzzle.

This study aims to explore the tumor-stroma separation or the cleft characterizing basal cell carcinoma (BCC). In this retrospective cohort investigation, we enrolled 244 patients who received a confirmed diagnosis of BCC through histopathological examination in the period of 2019-2020 at the Pathology Laboratory of the "Sfântul Apostol Andrei" Emergency Clinical Hospital located in Galați, Romania. The identification of patients was accomplished by utilizing electronic health records, and relevant clinical, demographic, and histopathological data were retrieved from the physical database of the Pathology Laboratory. Key tumor characteristics were gathered, and an in-depth analysis of case slides was performed. The average tumor-stroma cleft's width measurement was 48.136 µm, while its respective tumor island's width was on average 952.587 µm. The cleft's width and its respective tumor island's width are dependent on the BCC subtype, just like the ratio between the tumor island's measurement and its cleft's width are, being larger in basosquamous BCC, micronodular BCC, infiltrative BCC, and morpheaform BCC. The BCC tumor islands were found to have a minimal approximately equal measurement to the tumor-stroma separation cleft, but they were always larger than the latter. Large clefts and their respective tumor islands were found in specific tumor subtypes such as basosquamous BCC, micronodular BCC, infiltrative BCC, and morpheaform BCC, but in nodular BCC also.

Long-Term Follow-Up of Pediatric Excimer Laser-Assisted Penetrating Keratoplasty for Congenital Stromal Corneal Dystrophy.

The purpose of this study was to highlight characteristic clinical and microscopic findings and report the long-term follow-up of pediatric excimer laser-assisted penetrating keratoplasty (excimer-PKP) for congenital stromal corneal dystrophy (CSCD). A 2-year-old Greek child presented with CSCD at our department. Clinical examination showed bilateral flake-like whitish corneal opacities affecting the entire corneal stroma up to the limbus. Genetic testing identified a mutation of the decorin gene (c.962delA). The variant was not present in the parents and represented a de novo mutation. The uncorrected visual acuity was 20/100 in both eyes. Excimer-PKP (8.0/8.1 mm) was performed on the right eye at the age of 2.5 years and on the left eye at the age of 3 years. Postoperatively, alternating occlusion treatment was performed. The light microscopic examination demonstrated a disorganized extracellular matrix of the corneal stroma characterized by a prominent irregular arrangement of stromal collagen lamellae with large interlamellar clefts containing ground substance, highlighted by periodic acid-Schiff- and Alcian blue-positive reaction detecting acid mucopolysaccharides. Electron microscopy showed disorganization and caliber variation of collagen lamellae and thin filaments within an electron-lucent ground substance. The postoperative course was unremarkable. Both grafts remained completely clear 14 years postoperatively. Corneal tomography showed moderate regular astigmatism with normal corneal thickness. The corrected distance visual acuity was 20/25 in both eyes. Excimer-PKP for CSCD might be associated with excellent long-term results and a good prognosis, particularly when the primary surgery is performed at a very young age. However, this requires close postoperative follow-up examinations by an experienced pediatric ophthalmologist to avoid severe amblyopia.

Effectiveness and Pitfalls of Intraoral Distraction in Wide Alveolar Clefts: An Experience

Statement of the problemRestoration of alveolar cleft defects is both essential and challenging for the craniofacial team. The technique of distraction is useful in large alveolar clefts, especially after the failure of conventional grafting procedures. The study aimed to analyze the effectiveness and problems of an intraoral tooth-borne distraction device. Materials and methodsSince 2015, 16 patients with nonsyndromic clefts were operated on. Because the defect was large, a trifocal distraction appliance was designed wherein the distractor appliance was completely tooth-borne and incorporated 2 hyrax screws. All distraction devices were individualized according to the patients’ situation. The appliance was cemented intraoperatively, and a latent period of 1 week was allowed. The distraction was performed twice daily at the rate of 0.5 mm/day. Methods of data analysisSingle-institution prospective study. ResultsAll patients were treated with distraction strictly following the natural curve of the dental arch. CBCT was taken prior to surgery and after 8 months of the last activation to visualize bone formation. Only 2 patients needed additional bone grafting procedure to fill the residual defect. In these patients, the required bone was small and was harvested intraorally. A failure of gingivoperioplasty (dehiscence) was observed in 1 patient. Outcomes dataAll patients were treated with distraction strictly following the natural curve of the dental arch. The mean width of the alveolar cleft was found between 11 and 17 mm. CBCT was taken after 8 months of the last activation to visualize bone formation. The continuity of bone could be seen in the majority of cases. The area of the residual defect was found to be between 28.24 and 39.24 mm. ConclusionThe intraoral distraction appliance was successful in the closure of a large alveolar cleft with the 2 transport segments docking successfully. Thus, a hyrax expansion screw used as a distractor could bring about controlled bony transport with the desired directional vectors. Its exclusive tooth-borne usage minimizes the invasiveness of the procedure, and the simplicity of the appliance eliminates the need for costly distractors, making such therapy feasible for a greater number of patients. The intraoral distraction appliance can be used successfully for the controlled closure of large alveolar clefts.

Minding the Gap in Vertebroplasty: Vertebral Body Fracture Clefts and Cement Nonunion

Vertebroplasty and kyphoplasty are leading treatments for patients with vertebral body compression fractures. Although cement augmentation has been shown to help relieve pain and instability from fractures containing a cleft, there is some controversy in the literature regarding the procedure's efficacy in these cases. Additionally, some of the literature blurs the distinction between clefts and cement patterns (including cement nonunion and cement fill pattern). Both clefts and cement patterns have been mentioned in the literature as risks for poorer outcomes following cement augmentation, which can result in complications such as cement migration. This study aims to identify the prevalence of fracture clefts and cement nonunion, the relationship between them as well as to cement fill pattern, and their association with demographics and other variables related to technique and outcomes. Retrospective cohort study. Interventional radiology department at a single site university hospital. This retrospective cohort study assessed 295 vertebroplasties/kyphoplasties performed at the University of Colorado Hospital from 2008 to 2018. Vertebral fracture cleft and cement nonunion were the main variables of interest. Presence and characterization of a fracture cleft was determined on pre-procedural imaging, defined as an air or fluid filled cavity within the fractured vertebral body on magnetic resonance or computed tomography. Cement nonunion was evaluated on post-procedural imaging, defined as air or fluid surrounding the cement bolus on magnetic resonance or computed tomography or imaging evidence of cement migration. Cement fill pattern was assessed on procedural and/or post-procedural imaging. Pain improvement scores were based on a visual analog score immediately prior to the procedure and during clinical visits in the short-term follow-up period. Additional patient demographics, medical history, and procedure details were obtained from electronic medical chart review. Pre-procedural vertebral fracture clefts were demonstrated in 29.8% of our cases. Increasing age, secondary osteoporosis, and thoracolumbar junction location were associated with increased odds of clefts. There was no significant difference in pain improvement outcomes in patients following cement augmentation between clefted and non-clefted compression fractures. Clefts, especially large clefts, and cleft-only fill pattern were associated with increased odds of cement nonunion. Procedure techniques (vertebroplasty, curette, and balloon kyphoplasty) demonstrated similar proportion of cement nonunion and distribution of cement fill pattern. Cement nonunion was observed in only 6.8% of cases. Due to this low proportion, statistical inference tends to have low power. Multiple levels were treated in nearly half of the study's patients undergoing a single vertebroplasty/kyphoplasty session; in these cases, each level was treated as independent rather than spatially correlated within the same study patient. Vertebral body fracture clefts are not uncommon and are related to (but distinct from) cement nonunion and cement fill patterns. Our study shows that, although patients with clefts will benefit from cement augmentation just as much as patients without a cleft, the performing provider should take note of cement fill and take extra steps to ensure optimal cement fill. These providers should also identify cement nonunion and associated complications (such as cement migration) on follow-up imaging.

Closure of large alveolar defect by maxillary alveolar distraction using a vector-controlled distractor appliance in cleft patients: A pilot study

ObjectiveTo assess the treatment outcome of custom made maxillary transport distractor appliance for closure of large alveolar clefts. MethodA pilot study was conducted on 12 large alveolar cleft defects present in 11 non-syndromic cleft lip and palate patients (1 bilateral and 10 unilateral) in the age group of 16–25 years. All the subjects underwent pre-surgical orthodontics followed by alveolar distraction using custom-made distractor appliance. Study models, lateral cephalogram, panoramic radiograph and cone beam computed tomograms were obtained pre-surgically (T0) and after distractor removal (T1). The reduction in the width and volume of the alveolar cleft defect and change in the mesiodistal axial inclination of the teeth in transport segment following distraction were recorded. P value ​< ​0.05 was considered statistically significant. ResultsSignificant reduction in cleft width (9.18 ​mm), volume (89.82 ​mm3) and the change in the mesiodistal axial inclination of the teeth in the transport segment (3.05°) (P ​< ​0.05) were observed. SNA (1.75°), ANB (1.58°), maxillary length (1.58 ​mm), upper incisor inclination (3°) and distal movement of anchorage teeth (0.95 ​mm) also showed significant change (P ​< ​0.05). ConclusionThe custom-made tooth borne distraction appliance successfully closed the large alveolar cleft defect with minimal or no inadvertent effects on the oral tissues.

Creation of a planned or central-clefted puncture combined with a second puncture during vertebroplasty to treat osteoporotic vertebral compression fractures with large clefts

BackgroundCemented vertebrae frequently re-fracture after vertebroplasty to treat osteoporotic vertebral compression fractures (OVCFs) with large clefts. We compared the efficacy of planned and central-clefted puncture, both followed by a second puncture, as treatments for OVCFs with large clefts.MethodsWe retrospectively studied 38 patients. 18 of whom underwent planned puncture (group A) and 20 central-clefted puncture (group B). A second puncture was performed when the initially injected cement was restricted to the cleft. We recorded a visual analog scale (VAS) pain scores, vertebral kyphotic angles (KAs), and compression ratios (CRs) preoperatively and at 2 days and 6 months postoperatively. We recorded the cement dispersion patterns and complications.ResultsSecond punctures succeeded in 15/18 and 7/20 patients of groups A and B, respectively. At 2 days postoperatively, the VAS score, KA, and CR were significantly better than the preoperative values (P < 0.01); no significant difference was found between the two groups (P > 0.05). At the 6-month follow-up, all scores were poorer than at 2 days postoperatively (all P < 0.05), significantly more so in group B than group A (P < 0.05). Significant differences in terms of the cement dispersion patterns, and the cemented vertebral re-fracture and cement leakage rates, were observed between the two groups (all P < 0.05).ConclusionThe two-puncture techniques were initially effective when treating large-clefted OVCFs. However, compared to the central-clefted puncture, the planned puncture improved the success rate of the second puncture, allowed better cement dispersion, and reduced the incidence of vertebral re-fracture during follow-up.

Intrascleral sewing-machine technique: A Grooveless/flapless cyclopexy technique for large traumatic Cyclodialysis cleft repairs in pars plana vitrectomy.

To describe a minimally invasive technique for the repair of large traumatic cyclodialysis clefts using intrascleral sewing machine suture and overhand friction knot techniques in pars plana vitrectomy. This prospective, noncomparative, interventional case series included seven eyes of seven patients with a large traumatic cyclodialysis cleft. The sewing machine technique was modified by an intrascleral approach. The procedure was transconjunctival or subconjunctival performed without scleral flaps/grooves. An overhand friction knot was used to lead the cutting ends of the suture buried in the scleral tunnel. The closure of the cyclodialysis cleft was achieved in seven eyes. The mean follow-up duration was 49.1 ± 15.6 weeks (range, 30-70 weeks). The intraocular pressure increased from 7.3 ± 2.1 mm Hg (range, 5-11 mmHg) preoperatively to 13.6 ± 2.4 mm Hg (range, 10-17 mmHg) postoperatively ( P < 0.01). The best-corrected visual acuity improved from a mean of 2.76 ± 2.77 logarithm of the minimum angle of resolution preoperatively to 0.63 ± 0.82 logarithm of the minimum angle of resolution at the final follow-up ( P < 0.01). In conclusion, the present technique is safe and effective in the treatment of large traumatic cyclodialysis clefts with minimal surgical trauma and a decreased surgical duration.

Interfacial Binding Sites for Cholesterol on TRP Ion Channels

Transient receptor potential (TRP) channels are members of a large family of ion channels located in membranes rich in cholesterol, some of whose functions are affected by the cholesterol content of the membrane. Here, cholesterol binding to TRPs is studied using a docking procedure that allows the transmembrane surface of a TRP to be swept rapidly for potential binding sites at the interfaces on the two sides of the membrane. Cholesterol docking poses determined in this way match 89% of the cholesterol hemisuccinate molecules in published TRP structures when cholesterol hemisuccinate molecules unlikely to represent typical bound cholesterols are excluded. TRPs are tetrameric, with large clefts at the interfaces between subunits; cholesterol poses are located in hollows, largely within these clefts. Comparison of cholesterol poses with phospholipid binding sites suggests that binding of cholesterol to a TRP need not result in displacement of phospholipid molecules from the TRP surface.

Regression of Corneal Vascularization Occurring after Corneal Suturing in a Case of Acute Hydrops Managed with a Combination Therapy of Argon Laser Photocoagulation and Intrastromal Ranibizumab Injection: A Case Report

ABSTRACT Aim To report a case of acute hydrops with a large stromal cleft, in a case of keratoconus, managed with compression sutures and perfluoropropane (C3F8) descemetopexy and subsequent management of corneal vascularization in that eye with combination therapy of laser and anti-vascular endothelial growth factor (anti-VEGF). Background Acute hydrops in keratoconus occurs following a tear or rupture in the Descemet's membrane (DM), resulting in aqueous percolating into the stroma. The presence of large stromal clefts in acute hydrops has been described as a known risk factor for delayed resolution and persistent edema, which in turn can incite inflammation and vascularization and thereby adversely affect the chances of graft survival later. We describe such a case managed effectively with a combination of different treatment modalities. Case description A 12-year-old boy with keratoconus presented with acute hydrops in his left eye. The acute hydrops was managed with compression sutures along with C3F8 descemetopexy. Subsequent development of persistent deep corneal vascularization and recurrence of inflammation after the resolution of hydrops was managed with a combination of argon laser photocoagulation and intrastromal anti-VEGF injections, resulting in complete regression of the deep vascularization and resolution of inflammation. Conclusion In our case, a combination of management modalities to address severe acute hydrops and its subsequent complications resulted in complete regression of the superficial and deep vessels, thus heralding an optimal outcome for a future corneal graft. Clinical significance There are no definite guidelines for the management of acute hydrops in keratoconus. A customized and judicious combination of various treatment modalities described in the literature for acute hydrops and its sequelae can result in an accepted outcome, which can pave the way for an optimum result with elective treatments like keratoplasty later on. How to cite this article Kurian A, Reghunadhan I, Soman M, et al. Regression of Corneal Vascularization Occurring after Corneal Suturing in a Case of Acute Hydrops Managed with a Combination Therapy of Argon Laser Photocoagulation and Intrastromal Ranibizumab Injection: A Case Report. Int J Kerat Ect Cor Dis 2019;8(2):46–49.

Stent-screw-assisted internal fixation: the SAIF technique to augment severe osteoporotic and neoplastic vertebral body fractures

ObjectivesTo describe a new technique to obtain minimally invasive but efficient vertebral body (VB) reconstruction, augmentation, and stabilization in severe osteoporotic and neoplastic fractures, combining two pre-existing procedures. The implant...

Segmental Maxillary Osteotomy to Close Wide Alveolar Clefts

Wide alveolar clefts are challenging to treat and are often associated with a higher chance of failure requiring repeated bone grafts. Even if successful, an excessively large cleft leads to a wide edentulous space, and patients are faced with prolonged orthodontic treatment. We present a series of large alveolar clefts closed with the aid of segmental maxillary osteotomies. Cases of alveolar clefts treated by segmental maxillary osteotomy from 2014 to 2016 were reviewed. Preoperative and postoperative computed tomography scans were analyzed to assess the alveolar gap and bone filling. Demographic characteristics, diagnoses, and operative techniques were reviewed and described. A total of 10 alveolar fistulae were addressed, using 6 segmental osteotomies in 6 patients. Of the cases, 66% were bilateral. There were 4 female and 2 male patients with an average age of 12.6years. The average preoperative cleft width was 14.2mm on computed tomography scans. Postoperatively, all clefts were successfully closed and no adverse effects were observed. Segmental maxillary osteotomy with concurrent bone grafting and fistula closure is an effective approach to treat excessively wide alveolar clefts. This enables a prudent dental substitution or prosthodontic planwhile minimizing prolonged orthodontia, in addition to achieving the traditional goals of alveolar bone grafting (stabilizing the maxillary arch, closing fistulae, and permitting canine eruption).

Low Power Laser Therapy: A Strategy to Promote the Osteogenic Differentiation of Deciduous Dental Pulp Stem Cells from Cleft Lip and Palate Patients.

Dental pulp stem cells (DPSCs) can undergo several types of differentiation, including osteogenic differentiation. One osteogenesis-inducing factor that has been previously described is in vitro low-power laser irradiation of cells. Laser irradiation promotes the acceleration of bone matrix mineralization of the cell strain. However, no consensus exists regarding the dose and treatment time. We used DPSC strains from cleft lip and palate patients because new bone tissue engineering strategies have used DPSCs in preclinical and clinical trials for the rehabilitation of alveolar bone clefts. Optimizing bone tissue engineering techniques for cleft and lip palate patients by applying low-power laser therapy (LPLT) to DPSCs obtained from these patients can help improve current strategies to quickly close large alveolar clefts. The aim of this study was to investigate the effects of LPLT at different energy densities in DPSC strains obtained from cleft lip and palate patients during in vitro osteogenic differentiation. Ten DPSC strains were obtained from cleft lip and palate patients and then used in the following study groups: group 1: control, the strains underwent osteogenic differentiation for 21 days; and groups 2, 3, and 4: the strains were irradiated each day with a low-power red laser (660 nm) (5, 10, and 20 J) during 21 days of osteogenic differentiation. Using Bonferroni's test, a statistically significant difference in the mean values was found between the irradiated groups (2, 3, and 4) and the control group (p < 0.001). However, no significant difference in osteogenic potential was found among the irradiated groups. Our findings showed that the osteogenic potential of DPSCs increases with red laser irradiation at 5, 10, and 20 J, and this treatment could be considered a new approach for preconditioning these cells to be used in bone tissue engineering.

Difference between respiratory epithelial adenomatoid hamartomas and small malignant tumours of the olfactory cleft on CT scans in forty-six patients.

Misdiagnosis of respiratory epithelial adenomatoid hamartomas for malignant tumors can lead to an aggressive surgical procedure, which is not necessary in the case of a respiratory epithelial adenomatoid hamartoma. Detailed analysis of sinonasal CT scans without contrast can help to distinguish respiratory epithelial adenomatoid hamartomas of the olfactory cleft from small malignant tumors (T1 and T2) of the olfactory clefts. Criteria in favor of diagnosis of small malignant tumors of the olfactory clefts on CT scans without contrast were unilaterality of masses in the olfactory clefts, large olfactory clefts /small olfactory clefts ratio ≥ 2 (sensibility at 91% and specificity at 100%), and presence of bone erosion. Imaging criteria for the diagnosis of respiratory epithelial adenomatoid hamartomas of the olfactory cleft were the bilaterality of masses in the olfactory cleft, large olfactory cleft /small olfactory cleft ratio < 2, and no bone erosion. This article is protected by copyright. All rights reserved.

Surgical repair of large cyclodialysis clefts.

To describe a new surgical technique to effectively close large (>180 degrees) cyclodialysis clefts. Our method involves the use of procedures commonly associated with repair of retinal detachment and complex cataract extraction: phacoemulsification with placement of a capsular tension ring followed by pars plana vitrectomy and gas tamponade with light cryotherapy. We also used anterior segment optical coherence tomography (OCT) as a noninvasive mechanism to determine the extent of the clefts and compared those results with ultrasound biomicroscopy (UBM) and gonioscopy. This technique was used to repair large cyclodialysis clefts in 4 eyes. All 4 eyes had resolution of hypotony and improvement of visual acuity. One patient had an intraocular pressure spike requiring further surgical intervention. Anterior segment OCT imaging in all 4 patients showed a more extensive cleft than UBM or gonioscopy. This technique is effective in repairing large cyclodialysis clefts. Anterior segment OCT more accurately predicted the extent of each cleft, while UBM and gonioscopy both underestimated the size of the cleft.

Fabrication of a Feeding Obturator for Infants.

Large clefts in the lip and palate are common congenital anomalies. If the cleft palate is large enough, conventional feeding techniques may not provide proper nutrition for the infant. Feeding obturators will aid in the ability of the infant to attain suction and help the infant to feed adequately. It is necessary for the infant to have sustained weight gain prior to surgery to correct the cleft lip and/or palate. Fabrication of an infant feeding obturator is a simple technique using materials found in every dental office. An impression is made using modeling plastic impression compound. This impression is relined using irreversible hydrocolloid, and the resulting cast is used to enable a vacuum-formed obturator to be fabricated. The vacuum-formed obturator is smoothed and adjusted in the infant's mouth to ensure closure of the palate but allows pace posteriorly to allow normal breathing. The resulting obturator is well retained in the infant's mouth, allowing feeding.

An Update on Diagnosis of Tracheomalacia in Children.

Congenital tracheomalacia is the most common congenital tracheal abnormality and occurs in approximately 1:2,100 children. Tracheomalacia can be isolated or associated with other airway anomalies such as laryngomalacia, bronchomalacia, and large laryngeal clefts. Also, an abnormal division of the embryonic foregut is frequently associated with congenital tracheomalacia; mostly in the form of proximal esophageal atresia with distal tracheoesophageal fistula. In such cases, the ratio between the cartilage ring and the posterior membranous wall drops from the normal ratio of 4 to 5:1 to 2 to 3:1. The diagnosis can be made upon clinical history and physical examination as well as by pulmonary function testing, computed tomography, dynamic magnetic resonance imaging, and fiberoptic bronchoscopy. Other approaches such as tracheobronchography have been used, but have not been validated for the diagnosis of tracheomalacia; fluoroscopy can be specific for diagnosing tracheomalacia, but lacks a reasonable sensitivity. Tracheomalacia is often self-limited and will resolve or become asymptomatic by the second year of life without intervention. For patients who remain symptomatic, possible treatments include pharmacotherapy, positive pressure application, and surgery.

New Neonatal Classification of Unilateral Cleft Lip and Palate Part 2: To Predict Permanent Lateral Incisor Agenesis and Maxillary Growth

Objectives : To bring a neonatal classification system of unilateral cleft lip and palate and to correlate this classification with the distribution of the permanent lateral incisor and maxillary growth. Design : Retrospective with longitudinal follow-up. Setting : Tertiary. Patients : A total of 112 individuals with treated unilateral cleft lip and palate and 30 controls. Main Outcome Measures : Unilateral cleft lip and palate neonatal casts were classified anatomically in four categories, in which Class 1 corresponds to a maxillary arch with a narrow alveolar cleft; Class 2 corresponds to a balanced form; Class 3 corresponds to a wide cleft and short maxilla; and Class 4 corresponds to a wide cleft and long maxilla. The classification was correlated with the distribution of the permanent lateral incisor. Maxillary growth was evaluated using a cephalometric analysis after the age of 10 years. Results : Clinical classification of unilateral cleft lip and palate found 10 cases of Class 1 (8.9%), 34 cases of Class 2 (30.4%), 46 cases of Class 3 (41.1%), and 22 cases of Class 4 (19.6%). The permanent lateral incisor was most often present in narrower clefts (Classes 1 and 2); whereas, large clefts (Classes 3 and 4) were relatively more frequently associated with an agenesis of the permanent lateral incisor (P = .019). Maxillary growth impairment was most severe in Class 3, with a mean sella-nasion-A point angle at 71.9° ± 4.6° (P < .001). Conclusions : Using the cleft width, arch form, and shape of the nasal septum, unilateral cleft lip and palate can be classified into four different classes at birth, which can all give information about permanent lateral incisor agenesis and maxillary growth.

Repair of a wide sternal cleft in a young female

Sternal clefts are rare congenital malformations of the anterior chest wall. Surgical correction is typically recommended as early as possible due to the compliance and growth potential of the infant sternum. Several operative techniques have been employed with great success. However, there is a paucity of data regarding repair in large clefts refractory to standard reparative techniques. We report the successful surgical repair in a 15-month-old female with an excessively large, superior sternal cleft.

Combined Contraction and Distraction of the Facial Skeleton in Staged Treatment of an Atypical Facial Cleft Using Distraction Devices

The purpose of this clinical report was to present a case of a rare Tessier 2/12 craniofacial cleft, which was treated by using mandibular distractors in a reverse manner for the reapproximation of the craniofacial skeleton allowing for closure of the soft tissue component and palate of this cleft. The changes in the bony portions of the cleft were accomplished without osteotomies taking advantage of the mobility of the facial bones involving both normal bony sutures and the cleft bone. The bone movement allowed for easier adhesion of the midline lower facial soft tissue during the first year of life. The outcomes were both functionally and aesthetically satisfactory. Although the ability of distractor devices to regenerate bone is well documented, they can also accomplish the same effect in a reverse manner. This new use of distraction devices in a reverse manner to contract the craniofacial skeleton without osteotomies to the author's knowledge has not been previously reported and adds a valuable tool to closing large facial clefts. However, considering the severity and complexity of the deformities, long-term follow-up will be necessary to assess the benefits of the surgical interventions and the patient's quality of life.

Myocardial Clefts, Crypts, or Crevices

With the increasing accuracy of cardiac imaging techniques, new findings, not or rarely observed before, come to light. In particular, the improvement in high spatial resolution of a multiplanar imaging technique such as cardiac magnetic resonance (CMR), associated with its increased contrast between blood and endocardial border surface of current cine images, led the appreciation of subtle left ventricular (LV) wall structural features, not seen or neglected by 2-dimensional echocardiography. This is the case of myocardial clefts, described both in hypertrophic cardiomyopathy (HCM) and in healthy volunteers, thus providing another hot potato to the hands of the clinical cardiologist. Article see p 259 These myocardial invaginations have been variably called clefts, crypts, fissures, crevices, and atypical LV noncompaction. Although the etiopathogenesis remains a matter of debate, it is a common belief that they represent a failure to resorb the trabeculated part of ventricular wall during normal embryological development, as seen in isolated LV noncompaction.1,2 Before the development of coronary circulation, the myocardium consists of a spongy meshwork of interwoven myocardial fibers organized into trabeculae with deep recesses, the latter communicating with the LV cavity and enabling a direct blood supply to the myocardium. Myocardial crypts have been described within the LV wall of patients with HCM since early postmortem studies.3–5 In particular, to the best of our knowledge, the first pathological description of a myocardial cleft dates back to 1958, in the historical publication of Donald Teare.3 Noteworthy, Teare …