目前还没有针对Tessier No .0 面裂鼻畸形的测序研究，故本研究拟采用全外显子技术对3对表型不一致的Tessier No .0 面裂鼻畸形同卵双胞胎家系进行全外显子测序，以期找到突变的基因位点，分析可能的致病机制。并分析Tessier No .0 面裂鼻畸形患者的畸形表皮与正常表皮的mRNA、LncRNA表达谱之间的差异，再根据生物信息学功能分析筛选出相关的致病基因。

Tessier No .0 面裂鼻畸形涉及颅面骨骼及软组织的发育不全，尽管其形态特征多由于软组织发育异常引起，但是了解该畸形群体的颅骨发育，有助于更进一步了解该疾病的发育特点。应用客观的三维CT重建技术进行颅骨测量，探索其冠状面、矢状面、角度变化等方面的发生发展，了解各个解剖位置在空间结构位置的变化关系。

目前对于Tessier No .0 面裂鼻畸形没有统一的最佳手术时间及手术方法，只有有限的病例报道。因此回顾性分析我们中心的Tessier No .0 面裂鼻畸形病例，提出我们的治疗方案和手术效果。

客观地分析Tessier No .0 面裂鼻畸形患者手术前后的面部测量情况，比较患者和普通人之间的差异。并希望通过此项测量能够表明，我们的手术方法可以达到良好的美学效果。

方法

通过外显子组测序及生物信息学分析对3对表型不同的同卵双胞胎及父母的DNA样品进行筛选，找出可疑的突变基因并进行Sanger测序验证；同时并对5个鼻再造2期的患者收集皮肤样本，进行LncRNA和mRNA测序分析。实验组是鼻部畸形皮肤，对照组是正常的额部扩张皮肤，根据生物信息学功能分析筛选出差异基因。并将二者筛选的靶基因取交集进行GO及KEGG分析，以及构建PPI网络，预测Hub基因。

本部分研究纳入了96个患者的颅骨CT结果（Tessier No .0面裂鼻畸形患者，n=48；正常人对照，n=48）。分成0至0.5岁[0,0.5）、0.5至2岁[0.5,2)、2至6岁[2,6)、6至18岁[6,18)和18岁以上[18,+ ∞)共五个组别。对于颅骨的测量学指标，我们采用Mimics软件来进行测量分析。

分析及随访2012年至2022年间在我院手术后的Tessier No .0面裂鼻畸形患者，并对手术方法进行总结。

对24名在本中心接受多次手术治疗且对鼻部形态满意的患者进行手术前后面部测量，数据测量采用MB Ruler 4.0软件进行分析。

结果

通过全外显子测序发现了4个可疑位点，但是经sanger测序验证后并未得出阳性的结果。对mRNA表达谱的测定，鉴定出4691个差异表达的mRNAs；而对于LncRNA的测定，最终鉴定出2692个差异表达的LncRNAs。将LncRNA靶基因预测的基因及差异的mRNAs取交集，共得到差异表达的基因487个，其中上调的基因有381个，下调的基因有106个，通过Cytoscape软件计算出来10个Hub基因，分别为TTN、TNNI1、TNNT3、TPM2、TPM1、TPM3、MYH8、MYH3、TMOD3及 MYL3，其中最有可能与畸形相关的是TOMD3基因，但需要进一步的验证及功能实验来证明。

Tessier No .0面裂鼻畸形患者中、后颅底较正常人长度增加。同时，蝶-枕软骨联合闭合较早，可能伴有蝶鞍向上移位。年龄亚组分析显示，颅底畸形大多始于2岁，主要影响鼻骨及后颅窝的发育。通过分析测量鼻咽和上呼吸道的径线，发现其发育过程并不影响患者的呼吸。

本部分总共纳入了33例患者，其平均手术年龄是8.79±5.59岁，平均随访时间是5.5年（5个月至10年）。对于轻度畸形的患者，如仅鼻尖凹陷、鼻背部皮肤赘皮或平坦而宽大的鼻背，采用局部皮瓣+硅胶或肋软骨作为支架的鼻整形术。然而，对于一些严重畸形的患者，由于累及多个鼻部亚单位而难以进行局部皮瓣修复，采用额部扩张皮瓣+硅胶或肋软骨鼻再造术。随访期间，28名患者（84.85%）对术后效果满意，4名患者（12.12%）对术后效果部分满意，1名患者（3.03%）对效果不满意。

通过对面部数据的测量可以得出男性患者相比正常人的鼻额角明显较大，而女性患者的鼻面角相对较大。男性和女性患者相比的内眦-鼻宽指数、鼻深-鼻宽指数、鼻宽-鼻翼长度指数均有显著性地差异。采用前额扩张皮瓣鼻再造+肋软骨移植术方法，可以更好地改善鼻尖-鼻长指数，更好地塑造鼻部长度及鼻翼的形态。

结论

通过对Tessier No .0面裂鼻畸形患者形态学分析可以看出他们在发育过程中存在中后颅底长度的增加，同时，可能存在蝶枕软骨联合早期闭合及鞍部的移位情况。此外对于不同畸形程度的患者采取不同的手术策略，以求最大程度上改善患者的缺陷，患者的随访结果也都令人满意。通过面部测量的方法让我们更加全面的认识该畸形特点并且进一步改善了手术方法。遗憾的是本研究未能在二代测序中发现导致这三对Tessier No .0面裂鼻畸形同卵双胞胎家系的变异基因位点。另外发现LncRNAs和mRNAs的表达在正常皮肤组织和异常组织之间存在明显的差异，他们可能通过某些信号通路来影响着面部的发育，但未发现明确可疑的基因，需要进一步的验证及功能实验来证明。

At present, there is no sequencing study on Tessier No. 0 cleft with nose deformity. This study intends to use the whole exome sequencing to sequence three pairs of identical twins with Tessier No. 0 cleft with nose deformity, in order to find the mutation gene site and analyze the possible pathogenesis. Analyzed the difference between the mRNAs and LncRNAs expression profiles of abnormal epidermal cells and normal epidermal cells in patients with Tessier No. 0 cleft with a bifid nose, and screen out the relevant LncRNAs and mRNAs according to the bioinformatics function analysis.

Tessier No. 0 cleft with nose deformity involves hypoplasia of craniomaxillofacial bone and soft tissue. Although its morphological characteristics are mostly caused by dysplasia of soft tissue, understanding the skeletal development of the malformation population will help to further understand the development characteristics of the disease. Three-dimensional CT reconstruction technology was used to measure the skull, explored the mechanism and time of its occurrence and development in coronal, sagittal and angular changes, and understood the relationship between the spatial structure and position changes of each anatomical position.

At present, there is no recognized surgical method and the best time for Tessier No. 0 cleft with nose deformity, and there were only limited case reports. Therefore, we retrospectively analyzed the Tessier No. 0 cleft with nose deformity in our center, and proposed our surgical strategies and results.

Analyzed the facial measurement before and after the operation of Tessier No. 0 cleft with nose deformity, and found the gap between patients and ordinary people and the defects of the operation. We also hope that this measurement could show that our surgical method could achieve good aesthetic effect.

Methods

DNA samples from peripheral blood were extracted from three pairs of identical twins and their parents with different phenotypes, and suspicious variant genes were screened out through exon group sequencing and bioinformatics analysis. Sanger sequencing verification was performed after that. In addition, skin samples were collected from 5 patients with stage 2 nasal reconstruction, and LncRNAs and mRNAs were sequenced. The experimental group was nasal deformed skin, and the control group was normal forehead expanded skin. According to the bioinformatics function analysis, the relevant LncRNAs and mRNAs were selected. And based on the intersection of the target genes of the LncRNAs and mRNAs, GO and KEGG analysis were performed, and a PPI network was constructed to predict the Hub genes.

96 computed tomographic scans were collected from all Tessier No.0 clefts with nose deformity and age- and sex-matched normal people. All patients were divided into five subgroups based on their ages: 0 to 6 months, 6 months to 2 years, 2 to 6 years, 6 to 18 years, and over 18 years old. Mimics software was used to analyze and measure the craniometric indexes of the above time periods.

We analyzed and followed up the patients with Tessier No. 0 cleft with nose deformity who had undergone surgery in our hospital from 2012 to 2022, and summarized the surgical methods.

24 patients who have received multiple surgical treatments in the center and were generally satisfied with the shape of the nose were measured before and after the operation, and the data measurement was analyzed using MB Ruler 4.0 software.

Results

Four suspicious sites were found by whole exon sequencing, but no positive results were obtained after sanger sequencing. According to the determination of mRNA expression profile, 4691 differentially expressed mRNAs were finally identified. In addition, according to the determination of LncRNA expression profile, 4691 differentially expressed LncRNAs were finally identified. Intersecting the predicted genes of LncRNA target genes and differentially expressed mRNAs, a total of 487 differentially expressed genes were obtained, including 381 upregulated genes and 106 downregulated genes. Ten Hub genes were calculated using Cytoscape software, including TTN, TNNI1, TNNT3, TPM2, TPM1, TPM3, MYH8, MYH3, TMOD3, and MYL3. The TOMD3 gene was the most likely to be associated with malformations, but further validation and functional experiments are needed to prove it.

The length of the middle and posterior skull base of Tessier No.0 clefts with nose deformity patient was longer than that of the normal people. At the same time, the sphenoid-occipital joint closed earlier, accompanied by upward displacement of the sella turcica. Age subgroup analysis showed that most of the skull base deformities began at 2 years old and mainly affected the development of the nasal bone and the posterior cranial fossa. By analyzing the diameter of nasopharynx and respiratory tract, it was found that its development did not affect the patient's breathing.

A total of 33 patients were included in the study. The average age of the patients was 8.79 ± 5.59 years, and the average follow-up time was 5.5 years (5 months to 10 years). For the mild deformity patients, we primarily used local skin flap with silicone or costal cartilage rhinoplasty. With regard to the severe deformity patients, it is difficult to repair local skin flap due to involving multiple nasal subunits. Thus, we adopted nasal reconstruction using an expanded forehead flap for covering with costal cartilage as a framework. During follow-up, 28 patients (84.85%) had satisfactory outcomes, four patients (12.12%) had partially satisfactory results, and one patient (3.03%) had an unsatisfactory outcome.

It was observed that males exhibited a significantly larger nasofrontal angle, and female patients showed a relatively larger nasofacial angle. The medial canthus and nose width index, nasal tip protrusion and nasal width index, and nasal width and ala length index were both significant in males and females. For the method of forehead expansion flap and costal cartilage transplantation, it could better improve the nasal facial angle and is better in shaping the nasal height and less flaring of the alar bases. By comparison, the method of local flaps and silicone prosthesis implantation can better improve the columella length and nasal tip protrusion.

Conclusion

   Through the morphological analysis of Tessier No. 0 cleft with nose deformity patients, it can be seen that the length of the middle and posterior skull base increased during their development, and there may be late closure of the sphenoid-occipital junction and saddle displacement. In addition, we adopted different surgical strategies for patients with different degrees of deformity, which improved the defects of patients to the greatest extent, and the results were also satisfied. The measurement of the face has also improved our understanding of the deformity and the surgical methods. Regrettably, this study failed to find the variant gene locus in the second generations sequencing that led to the inconsistent phenotypes of the three pairs of identical twins with Tessier No. 0 cleft with nose deformity. In addition, it was found that the expression of LncRNAs and mRNAs were significantly different between normal skin tissues and abnormal tissues. They may affect the development of face through some signal pathways.