Evolving Surgical Techniques for Tessier Clefts Number 3 and 4

Tessier cleft types 3 and 4 are exceptionally rare even within the ambit of rare craniofacial clefts, with very few reported cases worldwide, particularly in the bilateral forms. This rarity combined with the absence of standardized management guidelines poses significant technical challenges for plastic surgeons and suboptimal surgery can leave patients with substantial facial deformity and stigma. In this study, the authors have presented the management guidelines for the repair of these clefts and have discussed some of the cases in detail. The senior author has operated on 15 clefts in 11 patients (4 bilateral). The strategy employed includes components of the techniques described by Longaker and colleagues and Giglio and colleagues. This includes rotation and advancement of lateral cheek flaps and use of naso-jugal flaps. This modified technique incorporates the use of a nasojugal flap for lower eyelid reconstruction, a cheek rotation flap tocover the medial cheeek defect, closure of alveolar cleft with the use of mucoperiosteal flaps and repair of the lip by principles described by Millard. These modifications keep the scars along the facial esthetic units thus achieving better esthetic outcomes. The authors have utilised this technique for both type 3 and 4 clefts with the addition of a glabellar flap in some cases of Tessier No. 3 clefts. Most of these cases were operated on before 6 months of age and the average follow-up time was 28 months after surgery. Conclusion: Management of craniofacial clefts has evolved. Due to the rarity of craniofacial clefts, surgical development in this regard is slow and complex. The authors invite the plastic surgery fraternity to apply their technique in the repair of these clefts and recommend giving feedback by conducting further studies to assess this technique's feasibility, versatility, and cosmetic outcome.