Anthropometrically-Based Surgical Technique for Tessier 3 Cleft Reconstruction

The Anatomical Subunit Approach to Managing Tessier Numbers 3 and 4 Craniofacial Clefts

Patients with atypical facial clefts are rare, and there is a paucity of literature outlining the surgical approach to managing these patients. The anatomical subunit approach to the surgical correction of the cleft lip has revolutionized cleft care. Here, we outline our approach and operative technique to treating Tessier clefts 3 and 4 using a novel technique based on the anatomical subunit approach.

Methods

All cases of Tessier facial clefts 3 and 4 between 2019 and 2021 from the senior author's practice were reviewed retrospectively. Patient demographics, clinical presentation, procedure details, and complications are reported. The senior author's technique is described in detail.

Results

Five patients underwent treatment by the senior author during the study period. One patient had bilateral Tessier 4 clefts, one patient had bilateral Tessier 3 clefts, two patients had a unilateral Tessier 4 cleft, and one patient had a unilateral Tessier 3 cleft. Two of the patients had their clefts treated as secondary procedures. The surgical complication profile was a lost nasal stent in one patient. Treatment principles of the senior author's technique are presented.

Conclusions

The anatomical subunit approach to managing atypical facial clefts provides a structured approach to a complex problem for the cleft and craniofacial surgeon. The technique of repair presented here can assist surgeons attempting to treat patients with Tessier 3 and 4 clefts.

Anatomical Classification of Tessier Craniofacial Clefts Numbers 3 and 4

BACKGROUND

Craniofacial clefts are rare occurrences with an incidence of about 1.43 to 4.85 per 100,000 live births. Understanding the skeletal deformity in these clefts is basic to any reconstructive surgery of the face. This study documented the skeletal defects present in Tessier numbers 3 and 4 using anthropometric measurements to generate a subclassification which will aim to improve the means of communication between surgeons managing this anomaly.

METHODS

Seven computed tomography scans of patients who had been treated for Tessier 3 and 4 clefts between 2003 and 2017 were analyzed. Measurements of the expected defects in each cleft was taken and compared with unaffected side as the reference. Emerging patterns of their analysis was then used to generate a subclassification for these clefts. The reliability and validity of the measurements were ensured by allowing the data to be examined by both an intra- and interobserver.

RESULTS

The presence or absence of an alveolar cleft, the emerging patterns of comparison of the measurements of the maxilla and the orbits of the cleft side and the noncleft side as well as absence of the bone were used to arrive at a subclassification system using (a), (b), (c), (M+ O+), (M- O-), and (0).

CONCLUSION

The study recommends a subclassification for Tessier clefts numbers 3 and 4 that will allow physicians anticipate the extent and the form of skeletal defects present before even seeing the patient. This can improve the communication among surgeons and team members regarding Tessier craniofacial clefts.

Scoping review of the morphology and anthropometry of Tessier craniofacial clefts numbers 3 and 4

BACKGROUND

In 2016, WHO reported a death rate of 303,000 newborns before 4 weeks of age due to congenital anomalies. Those that survive congenital anomalies may have long-term disabilities which may have significant impacts on the individual, their families, the healthcare system, and societies. Tessier craniofacial clefts numbers 3 and 4 are congenital anomalies that result in a partial or total defect of craniofacial tissues thereby seriously influencing the patient's appearance and impair normal functioning. Therefore, understanding these defects is paramount to relieving the burden caused by this disability. The objective of this review was to examine the literature on the understanding of the knowledge of morphology and anthropometry of Tessier craniofacial clefts numbers 3 and 4 so that areas yet to be fully understood by research can be mapped out for future research.

METHODS AND ANALYSIS

A scoping review for literature on patients who have Tessier craniofacial clefts numbers 3 and 4 was conducted. Relevant studies from 1976 to the present were identified. The following databases were searched for peer-reviewed literature viz., PubMed, MEDLINE, EBSCOhost, Google Scholar, and the Cochrane library. The study selection was guided by the eligibility criteria. A data table was designed to extract information from the literature. The result of this study was reported using the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA). The quality of the included studies was assessed using the Mixed Method Appraisal Tool (MMAT).

RESULT

Thirty-three studies met the inclusion criteria. The majority of the studies included were conducted in middle-income countries (54.5%) and some in high-income countries (45.5%); none was recorded from low-income countries. The total available sample size from the studies was 120 with a dominant male population of 67 (55.8%) and female 53 (44.2%). The majority (97%) of the studies reported on the knowledge of morphology while 12.1% of the included studies reported on anthropometry. Of the 33 included studies, 32 scored the highest quality (76-100%) from the quality assessment.

DISCUSSION

The findings from this review show evidence of the knowledge of morphology and the knowledge of anthropometry of Tessier craniofacial clefts numbers 3 and 4. However, these knowledges have not translated to universally recognized ways of repairing and documenting these clefts due to the sparse amount of studies on Tessier craniofacial clefts numbers 3 and 4.

Lateral Lower Lip Cleft: A Report of a Rare Craniofacial Cleft in a Child

INTRODUCTION

Craniofacial clefts are unusual. Perioral clefts that are discussed in the literature include cleft lip and cleft palate is more common. Midline mandibular and lower lip clefts are rare. Lateral lower lip cleft with only soft tissue involvement is so rare that it has not been reported until now.

CLINICAL REPORT

A 44-month-old girl with a 1-cm-length cleft on the lateral side of the lower lip 8 mm medial to the commissure in lateral one-third of the lower lip referred to the authors' clinic. Repair of the lip consisted of excision of excess mucosa, muscle repair, and 2 z plasties at the level of skin and mucosal layer.

CONCLUSION

This is the first report of a new foreseen type of Tessier clefts which may be classified as one of the clefts 15 to 29. Repair of this cleft can be done by soft tissue considerations when there are no underlying hard structure defects.