Commissural Facial Cleft

Commissural facial cleft is a rare birth problem where the corner of the mouth (the “commissure”) is too wide or even open toward the cheek or ear.[1] It is part of the group of facial clefts called Tessier number 7 clefts, which are also called lateral facial clefts or macrostomia (macro = big, stomia = mouth).[1][2] In this condition, the soft tissues of the face and sometimes the bones do not form or fuse in the normal way in early pregnancy.[1][3] The cleft can be only on one side of the mouth or on both sides, and it can be short (just a small notch) or long (going toward the ear).[2][3]

Commissural facial cleft (also called macrostomia or Tessier 7 cleft) is a rare birth defect where the corner of the mouth is abnormally wide and may extend toward the ear. It happens because some facial parts do not fully join while the baby is growing in the womb. This can affect the skin, the muscles that move the lips, and sometimes the bones. Children may have problems with feeding, drooling, speaking clearly, and facial appearance. The main treatment is surgery done by a craniofacial or plastic surgeon to rebuild the mouth corner so it looks and works as normally as possible. [1]

Doctors think commissural facial cleft starts when the upper jaw area (maxillary process) and lower jaw area (mandibular process) do not fuse properly while the baby is still an embryo.[4] This is similar to how cleft lip and cleft palate form, but the position is more to the side of the face instead of the center.[4][5]

Commissural facial cleft is very rare; lateral facial clefts (Tessier 7) are reported in about 1 in 80,000 to 1 in 300,000 babies, so most doctors will see only a few cases in their whole career.[2][6] Because it is rare, many reports come from case series and small studies, not huge trials, but they still give useful, evidence-based information.[2][6]

Other names

Doctors and books may use several names for the same basic problem.[1] These names are: commissural facial cleft, commissural lip cleft, macrostomia, transverse facial cleft, Tessier number 7 cleft, lateral facial cleft, and oral commissure cleft.[1][2]

All these names mean that the main issue is at the mouth corner, where the lips and cheek meet, and the cleft runs sideways (transverse) instead of up and down.[1] Some names are used more in surgery papers (like “Tessier 7 cleft”), and some are used more in general descriptions (like “transverse facial cleft”).[1][2]

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Types

There is no single “official” list of 20 types, but doctors describe many patterns based on side, length, soft tissue, bone, and related syndromes.[2] Below are 20 helpful “types” or patterns that you may see described in practice or in studies.[2][3]

1. Unilateral right commissural facial cleft – cleft is only on the right side of the mouth corner.[1] The left side looks normal; this is a common pattern.[1][2]

2. Unilateral left commissural facial cleft – cleft is only on the left side of the mouth corner.[1] Studies say the left side may be affected a bit more often.[1][8]

3. Bilateral commissural facial cleft – clefts are on both corners of the mouth.[3] The mouth can look very wide, from cheek to cheek.[3][6]

4. Isolated soft-tissue commissural cleft – only the skin and mucosa (inner lining) are affected, with little or no bone change.[2] This type may be easier to repair surgically.[2][14]

5. Commissural cleft with maxillary bone changes – the upper jaw bone on that side may be short or shaped differently.[3] This can change the bite and the midface shape.[3][4]

6. Commissural cleft with zygomatic (cheek bone) defect – part or all of the cheek bone arch (zygomatic arch) may be missing.[3] This can make the cheek look flat or sunken on that side.[3][4]

7. Commissural cleft with mandibular (lower jaw) defect – the lower jaw side may be small (hypoplastic) or misshapen.[3] This often gives facial asymmetry and bite problems.[3][6]

8. Mild commissural notch – only a small split or notch at the corner of the mouth, without a long cleft line.[1] It may be noticed later because it is subtle.[1][2]

9. Moderate macrostomia – the mouth opening is clearly wider than normal but does not reach the ear.[1] This is the typical look seen in many photos in case reports.[1][2]

10. Severe macrostomia extending toward the ear – the cleft runs far across the cheek, sometimes almost up to the ear area.[3] This type often has bigger muscle and bone problems.[3][4]

11. Commissural cleft with facial muscle diastasis – facial muscles that should meet at the mouth corner are spread apart.[2] This can make facial movements weak or uneven.[2][15]

12. Commissural cleft with ear (auricular) anomalies – the child may have small ears, ear tags, or missing parts of the external ear on the same side.[3] This often happens in craniofacial syndromes.[3][22]

13. Commissural cleft in hemifacial microsomia – the cleft is part of a syndrome where one side of the face is under-developed.[6] The jaw, ear, and soft tissues on that side are small.[6][23]

14. Commissural cleft in Treacher Collins syndrome – the cleft appears with typical Treacher Collins features, like down-slanting eyes and cheek bone loss.[6] This pattern shows the link with first and second branchial arch defects.[6][22]

15. Commissural cleft with accessory maxilla – extra small bone pieces or extra tooth-bearing bone can be present near the cleft.[3] This is very rare but reported in case studies.[3][2]

16. Commissural cleft with osseous (bone) choristoma – a small piece of bone grows in an abnormal soft-tissue place around the cleft.[3] This again is a very rare reported pattern.[3][2]

17. Commissural cleft with associated cleft lip – the child has both a side (lateral) cleft and a more central cleft lip.[11] This makes surgery more complex and needs detailed planning.[11][7]

18. Commissural cleft with cleft palate – the roof of the mouth (palate) is also open.[5] This adds problems with feeding, ears, and speech.[5][9]

19. Prenatally detected isolated lateral commissural cleft – the cleft is seen on prenatal ultrasound without clear other problems.[5] This type is discussed in fetal medicine reports.[5][22]

20. Syndromic multisite craniofacial cleft including Tessier 7 – the commissural cleft is only one part of a larger pattern of facial clefts (for example Tessier 3, 4, and 7 together).[7] These complex cases need very specialized care.[7][23]

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Causes and risk factors

Experts think commissural facial cleft has a multifactorial cause, meaning genes and environment both play a role.[4] Often there is no single clear reason for one baby, but we know several risk factors from cleft research and syndromic reports.[4][13]

1. Failure of fusion of maxillary and mandibular processes – in early pregnancy, side parts of the upper and lower jaw should grow and join; if they do not fuse, a lateral facial cleft can form.[4] This is the central basic cause.[4][17]

2. Abnormal migration of neural crest cells – these special cells form much of the face.[4] If they do not move or survive correctly, clefts and bone defects can appear.[4][6]

3. First and second branchial arch defects – these are early structures that later form the jaws, ears, and some muscles.[23] Problems here are linked with lateral facial clefts and related syndromes.[23][6]

4. Genetic syndromes (like Treacher Collins, OAVS, hemifacial microsomia) – in these syndromes, genes controlling face development are changed.[6] Commissural clefts can be one feature.[6][22]

5. Family history of craniofacial clefts – having relatives with rare facial clefts may slightly raise risk, though data are limited because cases are so few.[4] This is similar to cleft lip/palate genetics.[4][9]

6. Chromosome changes – some children with complex craniofacial clefts have chromosome number or structure changes.[11] These can be found with karyotype or microarray tests.[11][20]

7. Maternal diabetes – pre-existing or poorly controlled diabetes in the mother is a known risk for facial clefts in general.[9] It may also play a role in lateral facial clefts.[9][10]

8. Maternal alcohol use – heavy alcohol use in early pregnancy can disturb facial development and is linked with clefts in general.[9] It may increase risk for rare clefts as well.[9][13]

9. Maternal smoking – smoking, especially in the first trimester, is linked with a higher chance of cleft lip and palate and may also affect lateral clefts.[9] Nicotine and other chemicals can harm forming tissues.[9][10]

10. Certain medicines in early pregnancy – some anti-seizure drugs and other medicines are known to raise risk of clefts in general.[9] Doctors try to avoid high-risk drugs when possible.[9][18]

11. Folate (folic acid) deficiency – low folate is famous for neural tube defects but can also increase risk for orofacial clefts in general.[9] Good folate may help lower risk.[9][5]

12. Maternal infections – some infections in early pregnancy can disturb embryo growth, although links with Tessier 7 are not well proven.[4] Still, infections are part of general cleft risk lists.[4][9]

13. Exposure to toxins (for example, heavy metals, some chemicals) – animal and population studies show that toxic exposures can cause facial clefts.[9] This might also influence rare lateral clefts.[9][6]

14. Poor general maternal nutrition – lack of key vitamins and protein can affect facial development.[9] This is more common in low-resource settings.[9][13]

15. High maternal age in some reports – some cleft studies note higher rates with increasing maternal age, though results are mixed.[9] For such a rare cleft, data are limited.[9][10]

16. Low maternal age in other reports – in some groups, teenage pregnancy is linked to higher cleft rates, likely related to social and health factors.[9] This again is more about general cleft risk.[9][13]

17. Multiple pregnancy (twins, etc.) – some studies show more clefts with multiple pregnancies, perhaps from shared blood supply issues.[9] Evidence for Tessier 7 specifically is weak but possible.[9][10]

18. Mechanical forces on the embryo (amniotic bands, uterine factors) – these can physically disturb the forming face.[4] They are more often linked with other facial clefts but may play a role.[4][23]

19. Random (sporadic) events in early cell growth – sometimes a gene or cell error happens by chance in one embryo. Many rare clefts are likely caused by this kind of sporadic event.[4] This means parents often did nothing wrong.[4][5]

20. Combination of several mild factors together – often no single strong factor is found, but many small genetic and environmental factors add up.[4] This “multifactorial” model best explains most cases.[4][13]

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Symptoms and signs

Symptoms depend on how wide the cleft is and whether bones and other organs are also affected.[1] Some children have a mostly cosmetic issue, and others have feeding, speech, and ear problems as well.[1][2]

1. Wide mouth (macrostomia) – the mouth opening is larger than normal, especially on the affected side.[1] This is the main obvious sign.[1][2]

2. Visible gap or line from mouth toward cheek or ear – the cleft may look like a line or groove in the skin and inner lining.[3] In severe cases it reaches near the ear.[3][4]

3. Asymmetry of the face – one side of the face looks different from the other side.[6] This can be due to soft-tissue and bone differences.[6][2]

4. Drooling (saliva leaking) – because the mouth corner does not close properly, saliva may leak out, especially when the child eats or drinks.[1] This can cause skin irritation.[1][15]

5. Feeding problems in infancy – babies may find sucking hard because lips and muscles cannot seal well around the nipple or bottle.[15] Feeding support is often needed.[15][11]

6. Speech difficulties – later in childhood, some children may have unclear speech due to lip movement or associated palate issues.[5] Speech therapy often helps.[5][19]

7. Trouble blowing or whistling – tasks that need tight lip closure like blowing balloons or whistling may be hard.[1] This is due to muscle imbalance at the mouth corner.[1][0]

8. Ear anomalies (tags, small ear, missing parts) – ear changes often appear on the same side as the cleft in syndromic cases.[6] These may be cosmetic or may affect hearing.[6][22]

9. Hearing loss – fluid behind the eardrum or structural ear problems can cause hearing issues.[6] Hearing tests are important in these children.[6][18]

10. Eye and eyelid changes in some syndromes – in Treacher Collins and other syndromes, the child may have down-slanting eyes, missing lashes, or eyelid notches along with the cleft.[6] This shows that the problem involves a wider facial area.[6][22]

11. Dental and bite problems (malocclusion) – teeth may not meet well because the jaws are uneven or small on one side.[2] Orthodontic and jaw surgery may be needed later.[2][20]

12. Small lower jaw on one side (hemimandibular hypoplasia) – the jaw may look shorter or thinner on the affected side.[3] This is common in hemifacial microsomia.[3][6]

13. Cheek fullness or flattening – missing or changed cheek bone and soft tissue can cause a flat or unusual cheek contour.[3] This is more obvious in severe bony types.[3][2]

14. Psychological and social impact – facial difference can affect self-esteem, social interactions, and mental health.[1] Support from family, school, and health professionals is very important.[1][19]

15. Issues linked to other clefts – if there is also cleft palate or other craniofacial clefts, the child may have nasal speech, more ear infections, or breathing problems.[5] These are similar to those seen in classic cleft lip and palate.[5][10]

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Diagnostic tests

Doctors do not use all 20 tests for every child, but these are tests that can be used in reports and cleft centers to understand the problem and plan treatment.[1] Basic diagnosis is by careful physical exam, but imaging and other tests help when the case is complex or part of a syndrome.[1][2]

A. Physical exam tests (mainly looking and observing)

1. Full facial inspection – the doctor carefully looks at the face from front and side, checking the position and length of the cleft, how wide the mouth is, and how symmetric the face looks.[1] Photos and measurements are often taken for records and planning.[1][4]

2. Oral cavity inspection – the inside of the mouth, gums, tongue, and palate are checked with a light.[1] The doctor looks for extra clefts, missing tissue, or abnormal tooth positions.[1][5]

3. Ear, nose, and eye examination – ears are checked for shape and canal opening, nose for shape and airway, and eyes for lid or eyeball changes.[6] This helps find syndromes that include commissural clefts.[6][22]

4. Skin and scalp exam – doctors look for skin tags, hairline changes, and other small clues of syndromes.[6] Many craniofacial conditions have extra minor signs on the skin.[6][23]

5. Growth and development check – height, weight, and head size are measured, and the child’s development is compared with age norms.[5] This helps see if the cleft is part of a wider growth problem.[5][11]

B. Manual tests (hands-on clinical tests)

6. Palpation (feeling) of facial bones – the doctor uses their hands to feel the jaw and cheek bones to see if they are present, smooth, or under-developed.[3] This simple test guides the need for imaging.[3][2]

7. Manual mouth opening and closing test – the doctor gently helps the child open and close the mouth, feeling how the joints and muscles move.[15] Limited or uneven movement suggests joint or muscle problems.[15][14]

8. Manual facial muscle strength testing – older children can be asked to smile, frown, puff cheeks, and close eyes tightly while the doctor gives gentle resistance.[15] This checks the power and coordination of facial muscles.[15][0]

9. Bite (occlusion) assessment with fingers and tongue depressor – by looking and feeling how the teeth meet and how the jaw shifts, the doctor can judge occlusion.[2] This helps decide if orthodontic care is needed.[2][20]

10. Manual airway and breathing check – simple tests like watching chest movement, listening with a stethoscope, and seeing if the child can breathe through nose and mouth help find airway issues.[5] This is important before any surgery.[5][18]

C. Laboratory and pathological tests

11. Basic blood tests (full blood count, biochemistry) – these do not diagnose the cleft but check general health, anemia, and organ function before surgery.[11] They are standard for any surgical patient.[11][19]

12. Genetic blood tests (gene panels or exome) – when a syndrome is suspected, doctors can test for known genes linked to craniofacial syndromes like Treacher Collins.[6] Finding a gene change can confirm the cause.[6][22]

13. Chromosome analysis (karyotype or microarray) – this test looks at the number and structure of chromosomes.[11] It can find larger deletions or duplications linked with complex clefts.[11][20]

14. Pathology study of removed tissue (if surgery done) – tissue cut away during repair (for example, skin tags or extra bone) can be looked at under a microscope.[3] This confirms what the tissue is (like accessory maxilla or choristoma).[3][2]

15. Hearing-related lab tests (like metabolic or infection screens when hearing loss is present) – if hearing loss is unexplained, lab tests may look for infections or metabolic conditions.[18] These are not routine for all but can be useful in selected patients.[18][6]

D. Electrodiagnostic tests

16. Facial nerve conduction studies – small electrodes are placed on the skin, and gentle electrical signals test how fast the facial nerve carries signals.[18] This can show if the nerve is damaged or working well in complex cases.[18][15]

17. Facial electromyography (EMG) – tiny needles or surface electrodes measure the electrical activity of facial muscles.[18] EMG helps understand which muscles are active and how strongly they contract around the cleft.[18][0]

18. Auditory brainstem response (ABR) or brainstem evoked response audiometry (BERA) – this test plays sounds into the ears and measures brain responses with electrodes on the scalp.[18] It is very useful to check hearing in babies and children who cannot do regular hearing tests yet.[18][22]

E. Imaging tests

19. Prenatal and postnatal ultrasound of the face – during pregnancy, detailed ultrasound can sometimes see a lateral facial cleft and related problems.[5] After birth, ultrasound can look at soft tissues and sometimes joints.[5][22]

20. CT scan (computed tomography) with 3D reconstruction – CT shows the bones of the face in detail, including the jaw, cheek bone, and skull base.[2] It is very useful for planning surgery in severe cases of Tessier 7 cleft.[2][12]

21. MRI (magnetic resonance imaging) – MRI gives very good pictures of soft tissue like muscles, nerves, and brain.[2] It can help when doctors suspect brain or deep soft-tissue problems in addition to the cleft.[2][6]

22. Plain X-rays of the jaw and skull – these older tests give a basic view of jaw length, tooth buds, and skull shape.[9] Many centers now prefer CT, but X-rays are still used in some places.[9][13]

23. 3D photography or surface scanning – special cameras or scanners create a 3D model of the face without radiation.[1] Surgeons use this for planning and for seeing changes over time after surgery.[1][0]

Non-pharmacological treatments (therapies and others)

Below are supportive treatments used around the time of surgery. They do not “cure” the cleft but help function, healing, speech, and emotional health. Always follow your specialist team’s plan.

1. Feeding support and positioning
   A speech-language therapist or nurse teaches safe feeding positions, nipple types, and pacing. Purpose is to reduce choking, coughing, and milk leaking from the side of the mouth. Mechanism: better head and body position helps milk move safely to the back of the throat while gravity and muscle coordination reduce aspiration and improve weight gain. This support often starts soon after birth and continues until the baby feeds well. [2]

2. Early speech and language therapy
   Speech therapists help children learn to make clear sounds and use language. Purpose is to improve speech clarity and communication confidence. Mechanism: exercises train lip closure, tongue placement, and breath control, especially after surgery when muscles have been repositioned. Regular practice rewires brain–muscle patterns so the child can speak more clearly and join in at school and with friends. [2]

3. Oral-motor exercises
   Therapists guide simple mouth movements like lip pursing, blowing, and sucking through straws or whistles. Purpose is to strengthen mouth muscles and improve lip seal. Mechanism: repeating targeted movements builds muscle strength and coordination, which helps with eating, drinking, speech, and drooling control. These exercises are usually done at home every day as “play games” with the child.

4. Physiotherapy for facial symmetry
   Some children have mild facial weakness or asymmetry. Purpose is to improve balanced facial movements. Mechanism: physiotherapists use gentle exercises, tapping, and mirror feedback so the child learns to move both sides of the face more evenly, supporting smiling, chewing, and eye–mouth coordination.

5. Occupational therapy for daily activities
   Occupational therapists help the child manage eating, brushing teeth, and social activities. Purpose is to support independence and self-care. Mechanism: they adapt tools (special cups, spoons) and teach easier ways to handle daily routines so the child feels capable and less frustrated.

6. Psychological counseling for child and parents
   Living with a visible facial difference can cause worry or bullying. Purpose is to support emotions, self-esteem, and family coping. Mechanism: counselors use talking therapy, play therapy, and coping skills training so the child and parents can manage stress, respond to questions from others, and build a positive self-image. [3]

7. Parental education sessions
   Doctors and nurses explain the condition, surgeries, and expected outcomes. Purpose is to reduce fear and misinformation. Mechanism: clear information and written plans help families make informed choices, prepare for hospital stays, and notice early signs of infection or feeding problems.

8. Multidisciplinary cleft team follow-up
   Care is usually provided by a team (plastic surgeon, pediatrician, speech therapist, orthodontist, psychologist). Purpose is complete, coordinated care. Mechanism: team meetings and shared notes reduce duplicated tests and make sure timing of surgery, orthodontics, and therapy are all planned together over years. [1][2]

9. Pre-surgical planning with photos and measurements
   Surgeons use clinical photos and facial measurements to plan where the new mouth corner will be placed. Purpose is to achieve symmetry and good function. Mechanism: careful markings and planning ensure the repaired side matches the normal side as closely as possible. [4]

10. Scar-care (massage and silicone gel after surgery)
    After healing, gentle scar massage and silicone gel/strips may be recommended. Purpose is to keep scars soft and less visible. Mechanism: massage improves blood flow, and silicone helps regulate collagen, which may reduce thick or raised scars.

11. Sun protection of scars
    Fresh scars darken easily in sunlight. Purpose is to prevent dark, noticeable scars. Mechanism: hats, clothing, and high-SPF cream reduce UV damage so scars fade better over time.

12. Orthodontic monitoring
    If jaw or teeth are affected, children need early dental review. Purpose is to guide tooth eruption and bite alignment. Mechanism: braces or other appliances can gently move teeth and help the upper and lower jaws fit together, improving chewing and appearance.

13. Dental hygiene coaching
    Wide mouth openings and drooling can make oral hygiene harder. Purpose is to prevent cavities and gum disease. Mechanism: dentists teach brushing methods, fluoride use, and cleaning of difficult areas, protecting teeth that are important for speech and chewing.

14. Nutritional counseling
    Dietitians support good growth before and after surgery. Purpose is to avoid under-nutrition which could delay healing. Mechanism: they adjust calorie intake, texture of food, and feeding schedules so the child gains weight properly, which helps the body recover from operations.

15. Post-operative wound care education
    Parents learn how to clean the wound, look for redness or discharge, and protect sutures. Purpose is to prevent infection and wound breakdown. Mechanism: proper cleaning and avoiding trauma to the repair line help the tissues knit together securely. [4]

16. School and social support planning
    Teachers are informed in a respectful way about the child’s needs. Purpose is to prevent bullying and support learning. Mechanism: teachers can watch for teasing, allow time off for appointments, and help classmates understand differences in a kind, age-appropriate way.

17. Support groups and peer networks
    Families may join cleft or craniofacial support groups. Purpose is to reduce feelings of isolation. Mechanism: sharing real-life experiences about surgeries, feeding, and school helps families feel understood and learn practical tips from others.

18. Telehealth follow-up
    In some places, long distances make hospital visits hard. Purpose is to maintain specialist care. Mechanism: video calls allow doctors and therapists to check healing, speech, and growth remotely, so problems are noticed earlier. [1]

19. Pre-operative anesthesia assessment
    Anesthesiologists check heart, lungs, and airway before surgery. Purpose is safe sleep during surgery. Mechanism: they adjust anesthesia plans for age, weight, and any other health problems, reducing risk while under general anesthesia.

20. Long-term outcome monitoring
    Even after apparently successful surgery, the face and jaws keep growing. Purpose is to detect late changes such as scar tightening or asymmetry. Mechanism: periodic reviews through childhood and adolescence allow small problems to be corrected early rather than needing major operations later. [2][4]

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Drug treatments (supportive medicines, evidence-based)

Important safety note: There is no special drug that “cures” commissural facial cleft. Medicines are used for anesthesia, pain relief, infection prevention, and other supportive reasons around surgery. Doses and schedules must always be decided by qualified doctors, especially in children. Information below is general and based on FDA-approved drug labeling but must not be used for self-prescribing. [5]

1. Amoxicillin (antibiotic)
   Class: penicillin-type antibiotic. Purpose: used before or after surgery if doctors think the infection risk is high. Mechanism: stops bacteria from building cell walls, so they die. FDA labeling lists common side effects such as diarrhea, rash, vomiting, and nausea. Dosing and timing are based on the child’s weight, kidney function, and infection risk, and must be set by the pediatrician or surgeon. [5]

2. Amoxicillin–clavulanate
   Class: penicillin antibiotic plus beta-lactamase inhibitor. Purpose: sometimes chosen when broader coverage is needed. Mechanism: amoxicillin kills susceptible bacteria; clavulanate blocks enzymes that would destroy amoxicillin, extending its effect. Side effects can include stomach upset, diarrhea, and rash according to FDA label data. Dosing is weight-based and timed around meals as directed by the doctor. [5]

3. Cefazolin (intravenous antibiotic)
   Class: first-generation cephalosporin. Purpose: often used as a single dose right before surgery as prophylaxis in many clean-contaminated operations. Mechanism: interferes with bacterial cell wall formation. Common side effects include allergic reactions and gastrointestinal upset. Dose and timing (usually just before incision, possibly repeated in long operations) are strictly controlled in hospital.

4. Cefuroxime or similar cephalosporins
   Class: second-generation cephalosporin. Purpose: alternative when different bacteria coverage is needed or allergy patterns require a change. Mechanism: also blocks bacterial cell wall synthesis. Side effects can include rash and diarrhea. Doctors choose exact drug, dose, and timing based on local infection guidelines.

5. Metronidazole
   Class: nitroimidazole antibiotic. Purpose: sometimes combined with other antibiotics when anaerobic bacteria coverage is needed (for example, in oral surgery). Mechanism: damages bacterial DNA. Side effects may include metallic taste, nausea, and rarely nerve symptoms. It must be dosed at intervals chosen by the surgeon or pediatrician.

6. Paracetamol (acetaminophen) – pain and fever control
   Class: non-opioid analgesic and antipyretic. Purpose: first-line medicine for post-operative pain and fever. Mechanism: acts in the brain to reduce pain perception and lower temperature set-point. FDA labeling warns about liver toxicity if more than the recommended total dose is taken. Doctors calculate safe single and daily doses according to weight and schedule doses through the day. [6]

7. Ibuprofen oral suspension
   Class: non-steroidal anti-inflammatory drug (NSAID). Purpose: short-term relief of mild to moderate pain and inflammation after surgery. Mechanism: blocks cyclo-oxygenase enzymes and prostaglandin production. FDA labeling notes possible stomach upset, kidney effects, and rare allergic or bleeding problems, so use is limited in very young infants or children with certain conditions. Timing and dose are set by the doctor and must not exceed label recommendations. [7]

8. Opioid pain medicines (for example, morphine in hospital)
   Class: opioid analgesics. Purpose: manage strong pain immediately after surgery. Mechanism: bind to opioid receptors in the brain and spinal cord to reduce pain signals. Side effects include sleepiness, nausea, itchiness, and slowed breathing, so these drugs are given by healthcare staff with monitoring and are tapered as soon as possible.

9. Local anesthetic with epinephrine (e.g., lidocaine with adrenaline)
   Class: local anesthetic plus vasoconstrictor. Purpose: numb the area during surgery and reduce bleeding. Mechanism: lidocaine blocks nerve signals; epinephrine tightens blood vessels. Side effects, if absorbed in high amounts, can include heart rhythm problems or nervous system symptoms, so dose is carefully limited by the anesthetist.

10. Topical local anesthetic gels
    Class: local anesthetic preparations. Purpose: sometimes used on the lip lining before minor procedures or suture removal. Mechanism: temporarily blocks small nerve endings to reduce pain. Side effects are usually mild but overuse can cause toxicity, so they must be used in small amounts as directed.

11. Antiemetic medicines (e.g., ondansetron)
    Class: serotonin receptor antagonists. Purpose: prevent or treat nausea and vomiting after anesthesia. Mechanism: block serotonin receptors in the gut and brain involved in vomiting reflex. Side effects can include headache or constipation. Dosing is usually a single dose around the time of surgery, determined by weight.

12. Proton pump inhibitors or H₂ blockers (e.g., omeprazole, ranitidine where appropriate)
    Class: acid-suppressing medicines. Purpose: sometimes used if the child has reflux or when long-term NSAID use is required. Mechanism: lower stomach acid production, helping protect the stomach lining. Side effects may include headache, stomach upset, or, very rarely, other issues with long-term use.

13. Saline nasal and oral rinses
    Class: non-drug medical solutions. Purpose: keep the mouth and nose moist and clean, especially when breathing through the mouth. Mechanism: gentle irrigation removes mucus and debris, supporting healing and comfort. Side effects are rare if used correctly.

14. Chlorhexidine or similar antiseptic mouthwash (age-appropriate use)
    Class: antiseptic solution. Purpose: reduce oral bacteria after surgery when brushing is difficult. Mechanism: damages bacterial cell membranes, lowering infection risk in the wound area. Overuse can stain teeth, so frequency is limited and supervised.

15. Topical antibiotic ointments (e.g., mupirocin around skin sutures if prescribed)
    Class: topical antibiotic. Purpose: prevent local skin infection at incision sites. Mechanism: stops bacterial protein production on the skin surface. Side effects may include mild irritation or allergic reaction. Used in thin layers for a short time only.

16. Antihistamines (e.g., cetirizine)
    Class: H₁-antagonists. Purpose: treat itch or mild allergic reactions, including reaction to dressings or medicines. Mechanism: block histamine from binding to its receptors, reducing redness, itch, and swelling. Side effects often include sleepiness in some drugs, so dosing is tailored to the child’s needs.

17. Systemic corticosteroids (e.g., dexamethasone during surgery)
    Class: glucocorticoids. Purpose: sometimes used in the operating room to reduce swelling, nausea, and airway inflammation. Mechanism: lower inflammatory responses and stabilize cell membranes. Short-term side effects are usually limited; long-term or repeated use can affect growth, so dosing is tightly controlled.

18. Lubricating eye drops or ointment in theatre
    Class: ocular lubricants. Purpose: protect the eyes when the child is under anesthesia and cannot blink. Mechanism: form a protective film over the eye surface, preventing drying and scratches. Side effects are rare.

19. Intravenous fluids
    Class: electrolyte and glucose solutions. Purpose: maintain proper hydration, sugar levels, and blood pressure during and after surgery. Mechanism: replace fluid losses and support circulation so organs receive enough oxygen and nutrients. Rates are carefully adjusted by anesthetists and pediatricians.

20. Routine childhood vaccines (not specific to the cleft)
    Class: various vaccines. Purpose: keep the child protected against common infections so surgery is safer and recovery is smoother. Mechanism: train the immune system to recognize germs. Side effects are usually mild, like low-grade fever or soreness at the injection site, as listed in vaccine information sheets.

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Dietary molecular supplements (always doctor-supervised)

There are no special supplements proven to fix the cleft, but good nutrition and, in some cases, supplements can support growth and wound healing. Never start supplements for a child without medical advice.

1. Balanced energy-dense formula or fortified milk
   Used when babies struggle to take enough calories by mouth. Purpose is to prevent poor weight gain. Mechanism: higher calorie and protein content in a small volume helps growth even when feeds are slow or limited. Doctors and dietitians decide the right type and amount.

2. Protein powders or modular protein added to foods
   For older children with poor intake, extra protein may be mixed into soft foods. Purpose: support tissue repair after surgery. Mechanism: amino acids are building blocks for wound healing and muscle growth. Dose is calculated from body weight and kidney function.

3. Omega-3 fatty acids (fish oil when appropriate)
   Purpose: may gently support anti-inflammatory balance and general health. Mechanism: long-chain omega-3 fats are used in cell membranes and can modulate inflammatory messenger molecules. Side effects can include stomach upset or fishy aftertaste. Use only if the doctor agrees.

4. Vitamin D supplements (if deficient)
   Purpose: support bone and immune health. Mechanism: helps calcium absorption and influences immune cell function. Dose is based on blood levels and local guidelines; excess vitamin D can be harmful, so testing and medical supervision are important.

5. Iron supplements (for confirmed iron-deficiency anemia)
   Purpose: correct anemia that could affect oxygen delivery during healing. Mechanism: iron is needed to make hemoglobin in red blood cells. Side effects can include constipation and dark stools. Dose and duration are based on blood tests.

6. Zinc supplements (short-term, if low)
   Purpose: assist wound healing and immune function. Mechanism: zinc is a co-factor in many enzymes involved in tissue repair. Too much zinc can upset the stomach or affect copper levels, so doctors limit the dose and length of use.

7. Multivitamin liquid or chewable (age-appropriate)
   Purpose: cover small gaps in diet when feeding is difficult. Mechanism: provides small doses of many vitamins involved in energy production and tissue repair. Doses stay within recommended daily amounts to avoid toxicity.

8. Probiotic preparations (if doctor recommends)
   Purpose: help maintain a healthy gut microbiome, especially during or after antibiotics. Mechanism: beneficial bacteria compete with harmful ones and may support digestion and immunity. Side effects are usually mild gas or bloating, but safety should be checked in very sick or immune-weakened children.

9. Arginine-enhanced medical nutrition (special formulas)
   In some complex surgical cases, formulas enriched with arginine may be used. Purpose: support collagen synthesis and wound strength. Mechanism: arginine is a semi-essential amino acid important in nitric oxide pathways and protein synthesis. These products are used only under dietitian and surgical guidance.

10. High-antioxidant fruits and vegetables (natural sources)
    Rather than pills, doctors often prefer real food like berries, leafy greens, carrots, and citrus. Purpose: provide vitamins C, E, and plant antioxidants that help protect cells from stress. Mechanism: antioxidants neutralize free radicals generated during healing. Soft textures are chosen to make chewing easier.

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Immunity-booster / regenerative / stem cell” drug concepts

Right now, there are no routine “stem cell drugs” or special immune drugs approved specifically for commissural facial cleft repair. Research in regenerative medicine and tissue engineering is mostly limited to clinical trials. Below are concepts you might see in scientific articles; they are not home treatments and can only be used inside regulated research programs. [8]

1. Mesenchymal stem cell–based tissue engineering
   Researchers are studying stem cells taken from bone marrow or fat, combined with scaffolds, to repair bone or soft tissue defects. Purpose is to regenerate missing tissue. Mechanism: stem cells can turn into bone or cartilage cells and release growth factors that guide healing. This work is experimental and not standard care for facial clefts.

2. Growth factor–enriched biomaterials (e.g., BMPs in bone grafts)
   Bone morphogenetic proteins (BMPs) may be added to bone grafts in some craniofacial surgeries. Purpose: encourage bone formation. Mechanism: BMPs send signals that tell local cells to form new bone. Possible risks include abnormal bone growth, so use is tightly controlled and not usually needed for simple commissural cleft repair.

3. Platelet-rich plasma (PRP)
   PRP is made from the patient’s own blood and concentrated platelets. Purpose: potentially enhance soft tissue and wound healing. Mechanism: platelets release growth factors that may speed tissue repair. Evidence in facial clefts is still limited, and protocols vary; it is not essential for good outcomes.

4. Immunonutrition formulas (arginine, omega-3, nucleotides)
   Special feeds combining certain nutrients may be used around major surgery. Purpose: support immune function and wound healing. Mechanism: specific nutrients influence immune cell activity and inflammation. Evidence is stronger in adult major surgery than in simple pediatric facial clefts, so they are used selectively.

5. Gene-based therapies (experimental)
   In the future, gene therapy might target pathways involved in craniofacial development, but currently this remains in laboratory and early research stages. Purpose: correct or modulate gene expression to prevent or repair defects. Mechanism: delivering genetic material into cells. This is not available as a clinical treatment for commissural facial cleft.

6. Immune-modulating biologic drugs (not used for this cleft)
   Biologic medicines used for autoimmune diseases are not part of standard management for commissural facial cleft. They are mentioned here only to explain that “immune booster drugs” seen online are usually meant for other conditions and can be dangerous if misused.

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Surgeries (main procedures and why they are done)

1. Primary commissuroplasty (macrostomia repair)
   This is the key operation to correct commissural facial cleft. Purpose: create a normal-sized mouth opening and restore the muscle ring around the lips. Mechanism: the surgeon removes extra tissue, repositions the orbicularis oris muscle, and carefully designs the new mouth corner to match the other side, then closes the tissues in layers. [9]

2. Z-plasty or W-plasty skin closure
   These are special ways of cutting and sewing the skin to reduce scar tension and make scars less visible. Purpose: improve cosmetic result and reduce contracture. Mechanism: by using small angled flaps, the scar line is broken into shorter segments that blend better with natural skin folds.

3. Revision commissuroplasty
   Sometimes, as the child grows, the scar may stretch or the corner of the mouth may look uneven. Purpose: fine-tune appearance and function. Mechanism: the surgeon revises the scar and may adjust muscle or skin position to restore symmetry. [9]

4. Associated ear or jaw surgeries (if other anomalies present)
   Some children have ear tags, microtia, or jaw differences (part of hemifacial microsomia). Purpose: improve hearing, facial symmetry, and chewing. Mechanism: separate operations reshape or reconstruct the ear or correct jaw deformities, usually staged over several years.

5. Orthognathic surgery in late teens (rarely needed)
   If significant jaw asymmetry remains after growth, jaw surgery may be suggested. Purpose: align jaws and teeth for better chewing and appearance. Mechanism: the surgeon cuts and repositions jaw bones, then holds them in place with plates and screws. This is only for selected patients after full growth.

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Preventions (risk reduction where possible)

For most families, commissural facial cleft happens without any clear cause, and parents should not blame themselves. Some general pregnancy health steps may reduce the risk of many birth defects:

1. Plan pregnancy when possible and attend early prenatal visits.

2. Take folic acid and other prenatal vitamins as advised before and during early pregnancy.

3. Avoid smoking and second-hand smoke.

4. Do not drink alcohol during pregnancy.

5. Avoid non-prescribed drugs and discuss all medicines with an obstetrician.

6. Manage chronic illnesses such as diabetes with proper medical care.

7. Avoid known toxic chemicals and radiation exposure where possible.

8. Keep vaccinations up to date before pregnancy to reduce severe infections.

9. Maintain a balanced diet and healthy weight.

10. Seek genetic counseling if there is a family history of craniofacial anomalies. [10]

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When to see a doctor

Parents should see a doctor or specialist team:

• As soon as a wide mouth or unusual mouth corner is noticed after birth.

• If the baby has trouble feeding, poor weight gain, frequent choking, or coughing with feeds.

• If there is constant drooling, repeated chest infections, or noisy breathing.

• Before planning any surgery, to discuss timing and options with a cleft or craniofacial team.

• If the scar after surgery becomes very red, swollen, painful, or starts to leak fluid.

• If the child has speech delay, unclear speech, or is being teased at school about appearance.

• If parents feel worried, sad, or overwhelmed; emotional support is also important medical care.

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Things to eat and to avoid

Helpful to eat (as recommended by your care team):

1. Soft, easy-to-chew foods like mashed potato, soft rice, porridge, and well-cooked pasta after surgery.

2. Protein-rich foods such as eggs, yogurt, soft lentils, and minced meat to support healing.

3. Fruits without hard skins or seeds (banana, ripe mango, stewed apples) for vitamins.

4. Cooked vegetables that are soft and easy to chew, like carrots and pumpkin.

5. Plenty of fluids (water, milk, oral rehydration solutions) to stay hydrated unless the doctor says otherwise.

Often best to limit or avoid (especially soon after surgery):

6. Very hard or crunchy foods like chips, nuts, or hard biscuits that can damage the wound.

7. Very spicy, salty, or acidic foods that might sting the incision line.

8. Sugary drinks and sweets that increase risk of tooth decay, especially if drooling makes cleaning teeth harder.

9. Sticky foods like chewy candy that cling to teeth and scars.

10. Very hot food or drinks that can burn healing tissues—let them cool to warm before eating.

A dietitian can individualize this advice based on age, culture, and local foods.

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Frequently asked questions (FAQs)

1. Is commissural facial cleft my fault as a parent?

No. In most cases, doctors cannot find a single clear cause. It usually happens because several genetic and environmental factors mix in a complex way during early pregnancy. Parents almost never did anything “wrong.” Counseling can help if you feel guilt or worry.

2. Will my child be able to eat and speak normally after treatment?

Many children do very well after properly timed surgery and therapy. Early repair can improve lip seal, reduce drooling, and make speech clearer. Ongoing speech therapy and follow-up are often needed, but with good care many children eat a normal diet and communicate effectively. [2][9]

3. What age is best for surgery?

Timing depends on the child’s health, feeding ability, and local protocols. Some centers repair macrostomia in early infancy, others wait a little longer but still within the first few years of life. Your craniofacial team will choose the safest time based on growth, anesthesia safety, and family circumstances.

4. Will my child have a big scar?

There will be a scar at the corner of the mouth, but surgeons plan incisions to lie in natural skin lines and use special closure techniques to make it as discreet as possible. Over time, with good scar care and sun protection, many scars fade and become less noticeable. [4]

5. Will my child need more than one operation?

Sometimes one operation is enough. In other cases, growth can change the shape of the face or stretch the scar, and a small revision may be needed later. If other problems like ear or jaw differences are present, those may require separate surgeries at different ages.

6. Are there medicines that can fix the cleft without surgery?

No. Medicines can control pain, prevent infection, and support healing, but they cannot move or rebuild the mouth muscles and skin. Surgery is the main treatment to correct the structure. Any website promising “pills” or “injections” to replace surgery should be viewed with great caution.

7. Is surgery very risky?

All operations and anesthesia carry some risk, but macrostomia repair is a planned, standard procedure in experienced centers. Before surgery, the team checks your child’s heart, lungs, and general health, and monitors them closely during and after the operation to keep risk as low as possible.

8. Will my child be in pain after surgery?

Some discomfort is expected, but doctors use a combination of medicines, such as paracetamol, ibuprofen, and sometimes opioids in hospital, to keep pain under control. Pain usually improves quickly over several days. Parents are taught how and when to give pain medicines safely at home. [5][7]

9. Can my child go to a normal school?

Yes. Most children with a repaired commissural facial cleft attend regular schools. Some may need speech therapy, psychological support, or extra help at certain times, but they can learn, play, and make friends like other children. Talking with teachers early helps create a supportive environment.

10. Will other children notice or tease my child?

Children sometimes comment on visible differences. Preparing simple, confident answers and involving teachers early can help. Psychological support and peer groups are useful. Many children develop strong resilience and friendships when adults around them respond kindly and firmly to bullying.

11. Can commissural facial cleft happen again in future pregnancies?

The exact risk is usually low but may be slightly higher than in the general population. A genetics specialist can review your family history and, in some cases, arrange extra scans or tests in future pregnancies to look closely at the baby’s face.

12. What tests are needed before surgery?

Common tests include general blood tests, sometimes imaging of the face and jaw, and an anesthesia assessment. If there are other health issues, the child may see a cardiologist, neurologist, or other specialists to be sure surgery is safe.

13. How long does recovery take?

Initial wound healing usually takes a couple of weeks, but full maturation of the scar can take months. Speech and feeding abilities may keep improving for a long time, especially with regular therapy. Follow-up visits allow the team to track progress and adjust care.

14. Are stem cell treatments available for this condition now?

No routine stem cell treatment is approved specifically for commissural facial cleft. Most regenerative medicine research is still in clinical trials or laboratory stages. If you read about such treatments online, discuss them with your craniofacial team; avoid any unregulated clinic offering “miracle cures.” [8]

15. What can parents do right now to help their child?

Parents can make a big difference by keeping all appointments, following feeding and medicine instructions, practicing exercises from speech and physiotherapists, and providing emotional support. Asking questions, taking notes, and joining support groups can also help you feel more confident and informed as your child grows.

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

The article is written by Team RxHarun and reviewed by the Rx Editorial Board Members

Last Updated: February 25, 2025.