Formatting the surgical management of Tessier cleft types 3 and 4

Atypical facial clefts: Tessier number 3 and 4 clefts

PURPOSE OF REVIEW

Tessier number 3 and 4 clefts result from failed fusion of facial processes during embryogenesis, and cause functional, psychosocial, and cosmetic morbidity. Given their rarity and heterogeneity, they present a unique challenge to the reconstructive surgeon, with limited literature for guidance. The purpose of this update is to summarize Tessier number 3 and 4 clefts with a focus on recent literature and expert opinion.

RECENT FINDINGS

The incidence of atypical facial clefts has been estimated between 1.4 and 4.9 per 100 000 live births. Several retrospective chart reviews have been published in recent years; however, the epidemiologic data remains limited. Surgical management must be individualized and guided by classic reconstructive principles. The goal of surgery is to return the three soft tissue components (lip, nasomalar, and eyelid) to their proper anatomical location.

SUMMARY

Tessier number 3 and 4 clefts are rare, demonstrate a wide spectrum of clinical presentation, and remain challenging to gain a breadth of experience for any single surgeon. They are classified based on their location along well defined anatomical axes. Component repair is performed with attention to the lip, nasomalar, and eyelid regions to restore facial symmetry and function.

Presentation and Management of Atypical Orofacial Clefts: A Single-Institution Experience for 13 Year Period

This study reviews the craniofacial clefts that presented at a Nigerian tertiary health facility, highlighting our experience with the pattern of presentation and surgical care of these patients.

A retrospective review of the smile train database and medical records of all individuals who had been diagnosed with any of the Tessier craniofacial clefts and managed between 1st January 2007 and 31st December 2020 was done. The data were presented as numbers and percentages of cases.

The cleft clinic of a tertiary health facility and a major cleft referral center in South-West Nigeria.

Forty-five patients with craniofacial clefts were managed over the study period. 15.6% had associated syndromes, 2.2% had a family history of similar craniofacial cleft and 11% had a history of a possible teratogen. There were 21 (46.7%) middle clefts, 14(31.1%) lateral clefts and 10(22.2%) oblique clefts. The most common type of cleft was Tessier 0 while the Tessier 6 was the least common type. The median age at surgery was 10 months for male and 5months for female subjects, 15.3% complication rate was found in this study. Four patients had revision surgeries to correct residual deformities in this study.

The diverse presentations and occurrence of the rare craniofacial clefts present complex aesthetic and functional problems that require individualized often multidisciplinary care. The execution of a properly planned treatment will reduce complications and the need for revision surgeries.

Facial cleft presenting as a congenital facial papule

Tessier number 3 craniofacial clefts are a rare congenital deformity of the oronasoocular region with variable severity, most often with serious impacts on appearance and function due to involvement of the bone and soft tissue. However, they can occasionally manifest mildly as a skin-colored congenital facial papule present with subtle anatomic anomalies and signs of deeper involvement, such as crusting and oozing. Recognizing that a congenital facial papule, including non-midline lesions, may be the presenting sign of an underlying developmental anomaly is important to avoid missing the diagnosis of a more extensive underlying congenital defect. We present a rare case of a forme fruste variant of a Tessier number 3 craniofacial cleft to raise awareness of its presentation and advise initial management in hopes of improving outcomes.

Management of Tessier Type 3 Cleft With a Novel Reverse Palatal Expander

ABSTRACT

The purpose of this clinical report is to present the novel management of a type Tessier 3 cleft which was treated using a palatal expander in reverse fashion to reapproximate the craniofacial skeleton allowing for closure of the palate and soft tissue of the cleft. Reapproximation of the bony component of the cleft was achieved without osteotomies and allowed for easier and earlier realignment of the bony and soft tissue components of the cleft. To our knowledge, this is the first use of reverse palatal expansion in the treatment of type 3 Tessier cleft. Reverse palatal expansion made management of this cleft more straightforward and should be considered as a useful adjunct in the management of wide facial clefts.

Bilateral Craniofacial Cleft (Tessier Type 4): Case Report and Oculoplastic Reconstruction

Bilateral Tessier type 4 craniofacial clefts are extremely rare and disfiguring malformations with vision-threatening ramifications. To date, there is no consensus in the literature with respect to the ideal surgical technique and management of these patients. Emergent eyelid reconstruction and additional procedures may be required to protect the cornea and avoid further ophthalmic and surgical complications. We present our experience and challenges of managing a case of bilateral Tessier type 4 clefting with an emphasis on oculoplastic considerations.

Distribution, side involvement, phenotype and associated anomalies of Korean patients with craniofacial clefts from single university hospitalbased data obtained during 1998-2018

Objective

To investigate the distribution, side involvement, phenotype, and associated anomalies of Korean patients with craniofacial clefts (CFC).

Methods

The samples consisted of 38 CFC patients, who were treated at Seoul National University Dental Hospital during 1998-2018. The Tessier cleft type, sex, side involvement, phenotype, and associated anomalies were investigated using nonparametric statistical analysis.

Results

The three most common types were #7 cleft, followed by #0 cleft and #14 cleft. There was no difference between the frequency of male and female. Patients with #0 cleft exhibited nasal deformity, bony defect, and missing teeth in the premaxilla, midline cleft lip, and eye problems. A patient with #3 cleft (unilateral type) exhibited bilateral cleft lip and alveolus. All patients with #4 cleft were the bilateral type, including a combination of #3 and #4 clefts, and had multiple missing teeth. A patient with #5 cleft (unilateral type) had a posterior openbite. In patients with #7 cleft, the unilateral type was more prevalent than the bilateral type (87.0% vs. 13.0%, p < 0.001). Sixteen patients showed hemifacial microsomia (HFM), Goldenhar syndrome, and unilateral cleft lip and palate (UCLP). There was a significant match in the side involvement of #7 cleft and HFM (87.5%, p < 0.01). Patients with #14 cleft had plagiocephaly, UCLP, or hyperterorbitism. A patient with #30 cleft exhibited tongue tie and missing tooth.

Conclusions

Due to the diverse associated craniofacial anomalies in patients with CFC, a multidisciplinary approach involving a well-experienced cooperative team is mandatory for these patients.

Distribution, side involvement, phenotype and associated anomalies of Korean patients with craniofacial clefts from single university hospitalbased data obtained during 1998-2018

OBJECTIVE

To investigate the distribution, side involvement, phenotype, and associated anomalies of Korean patients with craniofacial clefts (CFC).

METHODS

The samples consisted of 38 CFC patients, who were treated at Seoul National University Dental Hospital during 1998-2018. The Tessier cleft type, sex, side involvement, phenotype, and associated anomalies were investigated using nonparametric statistical analysis.

RESULTS

The three most common types were #7 cleft, followed by #0 cleft and #14 cleft. There was no difference between the frequency of male and female. Patients with #0 cleft exhibited nasal deformity, bony defect, and missing teeth in the premaxilla, midline cleft lip, and eye problems. A patient with #3 cleft (unilateral type) exhibited bilateral cleft lip and alveolus. All patients with #4 cleft were the bilateral type, including a combination of #3 and #4 clefts, and had multiple missing teeth. A patient with #5 cleft (unilateral type) had a posterior openbite. In patients with #7 cleft, the unilateral type was more prevalent than the bilateral type (87.0% vs. 13.0%, p < 0.001). Sixteen patients showed hemifacial microsomia (HFM), Goldenhar syndrome, and unilateral cleft lip and palate (UCLP). There was a significant match in the side involvement of #7 cleft and HFM (87.5%, p < 0.01). Patients with #14 cleft had plagiocephaly, UCLP, or hyperterorbitism. A patient with #30 cleft exhibited tongue tie and missing tooth.

CONCLUSIONS

Due to the diverse associated craniofacial anomalies in patients with CFC, a multidisciplinary approach involving a well-experienced cooperative team is mandatory for these patients.

A Rare Case of a Combination of Tessier Cleft 0 and 3 in a 4-Year-Old Child-A Case Report

Description and successful management of a patient with Tessier no. 0 and 3 facial cleft is being presented. Appropriate evaluation was done to rule out the presence of median cleft face syndrome. Lip cleft was repaired by straight line technique with staggering at the vermilion border. Nasal cleft was reconstructed by a transposition flap and the flap taken from the upper lip after correction of the midline cleft. Satisfactory outcome was achieved for this singular deformity by conforming to the basic tenets of plastic surgery.

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.

Prevalence of Rare Craniofacial Clefts

BACKGROUND

Craniofacial clefts are extremely rare congenital malformations that have adverse functional, psychosocial, and aesthetic effects on patients' life. Although the exact incidence is unclear, it is estimated between 1.4 and 4.9 per 100,000 live births. Prevalence of the rare craniofacial clefts is imprecise due to the paucity of literature as well as their etiologies.

METHODS

All the patients with rare craniofacial clefts during 10 years in a plastic surgery tertiary referral hospital were included, and Tessier craniofacial clefting classification was used for classifying the clefts.

RESULTS

Of 964 patients with craniofacial clefts, 80 (8.29%) patients were identified with rare craniofacial clefts. There were 39 (48.7%) males and 41 (51.3%) females. Family history was determined positive in 30 (37.5%) patients. Tessier number 0 (58.7%) was the most common cleft in the authors' study. Tessier numbers 8, 13, and 30 were the rarest clefts. There was no patient with Clefts numbers 5, 6, or 9. Maternal smoking during pregnancy was observed in 1 (1.3%) of the women and 3 of the women had used drugs, 1 of them used the dexamethasone tablets and 2 of them could not remember name of the used drug.

CONCLUSIONS

Tessier number 0 was the most common cleft and Tessier numbers 8, 13, and 30 were the rarest types. The precise etiology of rare craniofacial clefts remained undetermined in this study. Women should be educated about the risk factors and subsequent ways of preventing from these risk factors.

A Novel Single-Staged Technique for the Treatment of Soft Tissue in an Oblique Facial Cleft

INTRODUCTION

Oblique facial clefts are extremely rare and cause significant morbidity. Treatment of these clefts is complex and requires a fundamental understanding of cleft classification and techniques used for treatment of clefts.

METHODS

We describe a novel single-staged technique to repair the Tessier no. 4 soft tissue cleft and reconstruct the buccal sulcus and bilaminar lower eyelid by preserving normally excised tissue combined with standard procedures. We also present a case report demonstrating the technique in an adolescent female. The procedure incorporates turnover flaps from soft tissue preservation within the cleft, a Mustarde cheek advancement flap, an anatomical subunit lip repair, a dorsal nasal Rieger flap for ala repositioning, and a lateral nasal flag flap.

RESULTS

The single-staged soft tissue repair eliminated the Tessier no. 4 cleft while simultaneously reconstructing the bilaminar lower eyelid and buccal lining. Our patient had no complications within the perioperative period.

CONCLUSIONS

This novel single-staged technique for the treatment of the soft tissue Tessier no. 4 cleft not only repairs the cleft but also reconstructs the buccal sulcus and bilaminar lower eyelid with turnover flaps preserved from the normally discarded excess soft tissue within the cleft. The novel repair allows for the creation of a deeper fornix to aid with placement of an orbital prosthesis and is ideal for use in underserved or remote locations.

Anthropometrically-Based Surgical Technique for Tessier 3 Cleft Reconstruction

Craniofacial clefts are rare entities, with an incidence reported as 1.43 to 4.85 per 100,000 births. The Tessier number 3 cleft, the most medial of the oblique clefts, can manifest as clefting of the lip between the canine and lateral incisors, colobomas of the nasal ala and lower eyelid, and inferior displacement of the medial canthus-frequently disrupting the lacrimal system with extreme variability in expressivity (Eppley).Literature on cleft lip repair is extensive and has evolved to incorporate anthropometric techniques, based on identifiable landmarks and anthropometric measurements that are compared with contralateral unaffected anatomy or population means and tracked over time to assess impact on growth. Recent focus has been placed on "subunit" repair that repairs "like with like." These approaches have resulted in a remarkable reproducibility of methods and outcomes.Facial cleft surgery publications are sparse due to the rarity of the disorders, and consensus has yet to develop on standardized landmarks, reference measurements, and principles of repair. The authors describe a method of correcting incomplete unilateral Tessier 3 cleft based on the principles described above. Intraoperative photographs, including secondary revisions, as well as immediate and long-term postoperative results are presented.

Serial Presurgical Orthopedics for Eye Repositioning and Optimization of Soft-Tissue Repair in an Infant With Tessier No. 4 Cleft

OBJECTIVE

A male patient with Tessier No. 4 cleft (unilateral left) presented at 20 days of age. The cleft defect beginning between the cupid bow and oral commissure extended to the ipsilateral orbital floor, skirting the nose and lacrimal duct while passing through the cheek medial to the infraorbital nerve. With the lesser segment disposed 16 mm transversely, the wide gap included an absence of orbital floor and lower eyelid. A deficient midfacial platform caused a severe inferior globe dystopia, superiorly displaced left ala base, and severe vertical shortening between ala-canthus and ala-globe.

INTERVENTION

A modified Latham device applied directional orthopedics to contract the cleft gap and with an eye part added to elevate the dystopic globe. Two different Latham devices used in succession were each applied for 4 weeks. Lastly, a removable plate further repositioned the eye. Each appliance was designed to differentially move the noncleft and cleft segments of the maxilla. Presurgical orthopedics began at 3 weeks lasted 14 weeks. Intraoperatively at 17 weeks, the inferior globe dystopia was effectively reduced, and the cleft gaps were nearly closed and aligned at the orbital floor, cheek, and the alveolus. Respecting the aesthetic units of face became possible with the soft-tissue repair yet were tight enough in the malar region to retract the lower lid.

CONCLUSION

The presurgical directional orthopedic and eye-globe mechanics were sufficient to enable medial canthal repositioning, sustainable correction of orbital distopia, and optimized primary soft-tissue repair. Early result suggests that surgery with presurgical orthopedics is superior to surgery alone.

Options for the nasal repair of non-syndromic unilateral Tessier no. 2 and 3 facial clefts

Background:

Non-syndromic Tessier no. 2 and 3 facial clefts primarily affect the nasal complex. The anatomy of such clefts is such that the ala of the nose has a cleft. Repairing the ala presents some challenges to the surgeon, especially to correct the shape and missing tissue. Various techniques have been considered to repair these cleft defects.

Aim:

We present two surgical options to repair such facial clefts.

Materials and Methods:

A nasal dorsum rotational flap was used to treat patients with Tessier no. 2 clefts. This is a local flap that uses tissue from the dorsal surface of the nose. The advantage of this flap design is that it helps move the displaced ala of a Tessier no. 2 cleft into its normal position. A forehead-eyelid-nasal transposition flap design was used to treat patients with Tessier no. 3 clefts. This flap design includes three prongs that are rotated downward. A forehead flap is rotated into the area above the eyelid, the flap from above the eyelid is rotated to infra-orbital area and the flap from the infraorbital area that includes the free nasal ala of the cleft is rotated into place.

Results and Conclusions:

These two flap designs show good results and can be used to augment the treatment options for repairing Tessier no. 2 and 3 facial clefts.

Correction of Unilateral Nostril Hypoplasia with Z-Plasty in a Child

Unilateral nostril hypoplasia is an extremely rare congenital malformation of unknown etiology, and only a few cases have been reported in literature. Owing to variability and complexity of the deformity, surgical correction of unilateral nostril hypoplasia represents one of the most significant reconstructive challenges to reconstructive plastic surgeons. We report a 7-year-old Vietnamese child with nasal and periocular deformity resembling a craniofacial cleft. Grossly, the right nostril was patent but with alar rim deformity, and the left nostril was not readily identifiable. A dystopic medial canthus was present on the left side as well. Closer inspection and palpation of the left side of nose revealed a patency through the soft tissue and underlying bony structure, Thus, a new alar rim were reconstructed with an irregularly shaped Z-plasty to create patency on the involved side. Simulatneously, a second Z-plasty was performed to address the medial canthal deformity. Postoperative appearance and function was sastisfactory at one-year follow up visit. In the treatment of patients with nostril hypoplasia, a careful preoperative physical examination is a prerequisite, and Z-plasty can be a valuable option for surgical correction.

A bilateral tessier number 4 and 5 facial cleft and surgical strategy: a case report

INTRODUCTION

Tessier facial cleft is among the rarest facial clefts reported in literatures and there are many issues arguing about its multidisciplinary repairing techniques. Tessier number 4 and 5 are extremely rare facial anomalies. There are few literatures describing these clefts and their surgical modalities. Number 5 Tessier cleft begins medial to oral commissure in the upper lip and extends superiorly as a groove through the cheek and ends at the middle third of lower eyelid. Bonny involvement consists of alveolar ridge, maxillary bone lateral to infra orbital foramen and orbits lower rim and floor. Number 4 Tessier facial cleft begins between cupid bow and oral commissure; skirting the nose and pass through cheek and lateral to lacrimal duct. Bonny involvement consists of alveolar ridge, maxillary bone medial to infra orbital foramen and orbital rim and floor.

CASE REPORT

This paper represents a patient with bilateral number 4 and 5 Tessier cleft lip with unilateral complete cleft palate and surgical approach on her.

CONCLUSION

We recommended early repair using autogenously tissues and minimal discarding healthy tissues as possible.

Severe bilateral Tessier 3 clefts in a Uighur girl: the significance and surgical repair

The Tessier 3 cleft is one of the rarest congenital craniofacial clefts, which often extends through the upper lip, the alar groove and the medial canthus. Only a few cases have been reported. There is no standardized method for the surgical treatment for this condition in the literature, and to obtain an acceptable outcome is difficult. A Uighur girl with severe bilateral Tessier 3 clefts and associated orofacial deformities is described here, and a novel protocol for clefts of this severity and rarity is presented. This study focuses particularly on describing the surgical procedures and techniques. Further treatments required for the cleft-associated deformities during later growth and developmental stages are also discussed in detail.

Tessier 3 cleft with bilateral anophthalmia: case report and surgical treatment

Tessier clefts type 3 and 4 are rare. In this paper the authors report on the management of a wide Tessier 3 cleft. There is no standardized protocol or timing of the surgical procedures in this rare disfiguring condition. Generally speaking, the aim is to preserve the function of important anatomical structures (e.g., a seeing eye.) and reconstruct, as best as possible, harmonic facial features. The authors present a "step by step" solution of the malformation pointing out the limitations of the surgical procedures they used and the goals they wanted to obtain. Despite of the uniqueness and the complexity of the pathology, the authors think they obtained reasonable results both in term of function and aesthetics, permitting the patient to be accepted in the social environment.

Tessier no. 3 incomplete cleft reconstruction with alar transposition and irregular z-plasty

Facial clefts are extremely rare congenital deformities and there are only a few technique reports for surgical reconstruction of clefts in the literature. In this article, we report a Tessier no. 3 incomplete cleft reconstruction with alar transposition and irregular Z-plasty in a 2-year old female patient.