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, 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. 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. hypertelorism there are many types of operations which can be performed to treat a hypertelorism. 2 options are: box osteotomy and facial bipartition (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. box osteotomy facial bipartition 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. 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.