elevated and in this manner closes the eyelid defect. External ear reconstruction is usually done when the individual is at least eight years old. Sometimes, the external auditory canal or middle ear can also be treated. The optimal age for the maxillomandibular reconstruction is controversial; as of 2004, this classification has been used: Type I (mild) and Type IIa (moderate) 13–16 years Type IIb (moderate to severe malformation) at skeletal maturity Type III (severe) 6–10 years When the teeth are cutting, the teeth should be under supervision of an orthodontist to make sure no abnormalities occur. If abnormalities like dislocation or an overgrowth of teeth are seen, appropriate action can be undertaken as soon as possible. Orthognathic treatments usually take place after the age of 16 years; at this point, all teeth are in place and the jaw and dentition are mature. Whenever OSAS is detected, the level of obstruction is determined through endoscopy of the upper airways. Mandibular advancement can be an effective way to improve both breathing and æsthetics, while a genioplasty only restores the profile. If a nose reconstruction is necessary, it is usually performed after the orthognathic surgery and after the age of 18 years. The contour of the facial soft tissues generally requires correction at a later age, because of the facial skeletal maturity. The use of microsurgical methods, like the free flap transfer, has improved the correction of facial soft tissue contours. Another technique to improve the facial soft tissue contours is lipofilling. For instance, lipofilling is used to reconstruct the eyelids. Hearing loss Hearing loss in Treacher Collins syndrome is caused by deformed structures in the outer and middle ear. The hearing loss is generally bilateral with a conductive loss of about 50–70 dB. Even in cases with normal auricles and open external auditory canals, the ossicular chain is often malformed. Attempts to surgically reconstruct the external auditory canal and improve hearing in children with TCS have not yielded positive results. Auditory rehabilitation with bone-anchored hearing aids (BAHAs) or a conventional bone conduction aid has proven preferable to surgical reconstruction. Psychiatric The disorder can be associated with a number of psychological symptoms, including anxiety, depression, social phobia, and distress about body image. People who have this disorder may also experience discrimination, bullying, and name calling, especially when young. A multi-disciplinary team and parental support should include these issues. Epidemiology TCS occurs in about