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

Abstract

Background: 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.

Atypical facial clefts: Tessier number 3 and 4 clefts

“…A summary of data from studies that included patients with Tessier number 3 and 4 clefts is displayed in Table 1[6,7,16–20,21 ▪ ]. Both are among the rarest of atypical clefts, with Tessier number 3 slightly less common, and both associated with other types of facial clefts.…”

“…The management of facial clefts has evolved over the past few decades, with a shift towards a subunit-based approach to repair. A study by Van Slyke et al [21 ▪ ] aimed to outline a consistent surgical approach based on the following principles: ‘(1) Incisions planned within anatomical subunits; (2) skin discrepancies dealt with through the creation of triangular flaps on the side of skin excess; (3) posterior lamella eyelid reconstruction as required; and (4) large bilaminar cheek rotation flap to reposition the underlying musculature and allow tension-free skin closure’. Building off of previously published methods, the authors incorporate anthropometrics, identifying the side of the cleft that needs to be elongated and designing incisions accordingly.…”

A Case Report: Enhancing Tarsal and Muscular Support for Ectropion Correction in Tessier 3 and 5 Facial Cleft

“…For Tessier 3 cleft, the initial incision is made within the supra-alar crease, and the triangular shape is crafted utilizing the surplus skin along the lateral margin of the cleft. 3,27 The surgical treatment of these cases poses a significant challenge due to the rarity of these anomalies and the absence of established standard care guidelines. 28 Additionally, the traditional management approach entails intricate markings that can be challenging for surgeons to memorize, discouraging many from attempting the surgery.…”