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

Abstract

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.

Fig. 1.

The anatomical subunit repair of the Tessier 3 cleft. Tissue discrepancies along the cleft margin are demonstrated, showing a deficiency of tissue along the medial margin and an excess of tissue along the lateral cleft margin (A). Extent of subperiosteal dissection demonstrated, posterior lamella reconstruction, ala derotation, nasal lining reconstruction using medial cleft tissue. Medial advancement of the deep tissues of the face hold the strength of the repair (B). Closure with the overlying skin flap laid down tension free (C).

Fig. 2.

The anatomical subunit repair of the Tessier 4 cleft. Tissue discrepancies along the cleft margin are demonstrated, showing an excess of tissue along the medial cleft margin and a deficiency of tissue along the lateral cleft margin (A). Defect above suprawhite roll demonstrated after derotation of lip, and paranasal flap design using tissue excess along medial cleft margin (B). Paranasal flap rotation and closure (C).

Fig. 3.

Modification for secondary reconstruction of the Tessier 3 cleft. Tissue origin of flaps used to create the nasal lining (A). Derotation of the ala after backcut along the alar groove (B). Reconstruction of nasal lining defect using nasal mucosa flap from nasal lining of ala (C). Reconstruction of secondary nasal lining defect using skin flap (D).

Fig. 4.

Preoperative photographs of a 10-month-old boy with a bilateral Tessier 3 cleft, complete on the right and incomplete on the left (A, B). Postoperative photographs of the same patient 2 weeks after repair (C, D).

Fig. 5.

Preoperative photograph of an 8-month-old girl with a bilateral Tessier 4 cleft, complete on the right and incomplete on the left (A). Postoperative photograph of the same patient 1 month after repair (B).

Fig. 6.

Preoperative photographs of a 14-year-old boy with a right Tessier 3 cleft that was previously repaired at another institution (A, B). Postoperative photographs of the same patient 2 months after repair (C, D).