Anthropometrically-Based Surgical Technique for Tessier 3 Cleft Reconstruction

Abstract

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.

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

“…4 Recently, Morgan and colleagues have suggested that a repair based on anthropometrics of the deformity is needed to mask the stigma of the Tessier 3 cleft; they present a case report to demonstrate this. 5 Still, despite the literature, little is found to help technically guide the surgeon. Hence, we present a step-by-step description to managing these complex patients using principles learned from the anatomical subunit cleft lip repair.…”

“…Our series builds off of these previously published concepts. [2][3][4][5] In addition, we have incorporated the use of triangles and opening incisions seen in the anatomical subunit repair of cleft lips. 10 With wide subperiosteal undermining and bilaminar dissection, we postulate that incisions can be closed along anatomic subunits and the use of flaps outside the ones described are not necessary.…”

“…Various groups have published their treatment philosophy and approach to atypical facial clefts. [2][3][4][5][6][7][8][9] Monasterio and Taylor presented a large series of 495 major craniofacial clefts, in which they applied their revised treatment philosophy to 280 of these patients. 2 By the generous use of tissue expanders, placement of scars within anatomic boundaries, and symmetrically reconstructing facial landmarks with tissue of like color and texture, the authors have been able to reduce their incidence of facial asymmetry and visible scars post repair.…”

“…[2][3][4][5][6][7][8][9] Surgical treatment with direct closure, local rotation flaps, use of tissue expansion, and Z-plasties have been proposed to manage these defects. [2][3][4][5][6][7][8][9] Although many craniofacial units have used these principles of treatment with reported success, a clear surgical plan and concise description of their operative technique is lacking. This is in contrast to the literature on cleft lip repair, where the operative plan has been well documented.…”

“…Many approaches have been described for treating atypical facial clefts. 2–9 Surgical treatment with direct closure, local rotation flaps, use of tissue expansion, and Z-plasties have been proposed to manage these defects. 2–9 Although many craniofacial units have used these principles of treatment with reported success, a clear surgical plan and concise description of their operative technique is lacking.…”