This document discusses the management of craniofacial clefts. It begins by stating that craniofacial clefts are rare birth defects affecting the bones and soft tissues of the face. It then outlines the goals of treatment, which include early soft tissue repair to minimize scarring, reconstruction of orbital floors when needed, and restoring orbicularis oris continuity. The document presents guidelines for surgical correction of different types of craniofacial clefts and results from managing 33 patients in the author's setting. It concludes by thanking the reader.
2. rare congenital conditions
incidence 1.43 to 4.84
/100,000 live births
•Monasterio FO, Taylor JA. Major craniofacial clefts: case series and treatment philosophy. PlastReconstrSurg 2008; 122(2): 534-43.
•Stricker M.Craniofacial Malformations.London: Churchill Livingstone; 1990, p 317-23.
•Kawamoto HK Jr. The kaleidoscopic world of rare craniofacial clefts: order out of chaos (Tessier classification).ClinPlast Surg. 1976 Oct;3(4):529-72.
3. abnormal ossification in or
between the ossification
centers, preventing the
normal adjacent soft tissues
to develop normally.
•Vermey-Keers C, Mazolla RF, van-der-Meulen JC, Stricker M. Cerebrocraniofacialand craniofacial
malformations: an embryological analysis. Cleft Palate J 1983;20(2):128-45.
Pathophysiology
4. Standardization of the surgical
procedures is difficult:
numerous variations of the soft
tissue/skeletal deformities
presenting in different
combinations and severity
Surgical correction problems
•Vermey-Keers C, Mazolla RF, van-der-Meulen JC, Stricker M. Cerebrocraniofacialand craniofacial malformations: an
embryological analysis. Cleft Palate J 1983;20(2):128-45.
5. good aesthetic/ functional
outcome by minimizing
scaring and reducing time of
treatment
•Resnick JI, Kawamoto HK. Rare craniofacial clefts: Tessier no. 4 Clefts. PlastReconstr Surg1990;85(6):850-2.
goals of treatment:
6. Early soft tissues repair (3-6 months)
scars along the skin tension lines
Closing soft tissue defects with advancement
flaps/z-plasties
Orbicularis-oris continuity
Orbital contents containment by
reconstruction of orbital floor where
required
•Resnick JI, Kawamoto HK. Rare craniofacial clefts: Tessier no. 4 Clefts. PlastReconstr Surg1990;85(6):850-2.
guidelines for surgical correction
7. early reconstruction of
maxillary extrophy with bone
grafts is controversial due to
the concern of normal
growth failure
•Resnick JI, Kawamoto HK. Rare craniofacial clefts: Tessier no. 4 Clefts. PlastReconstr Surg1990;85(6):850-2.
12. Cleft excision and closure
Long upper lip/redundancy was
corrected with peri-alar cresent shape
excision
Bifid nose was corrected with excision
and closure
Septum duplication correction at
definitive rhinoplasty
Tessier Cleft “0”: 11
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24. Nasal deformity of these clefts was
corrected by alar rotation/dorsal
transposition flaps.
In one case, only alar rotation
sufficed the reconstruction.
•Rashid M, Islam ZU, Tamimy MS, Haq EU, Aman S, Aslam A.Cleft Palate–Craniofacial Journal 2009;46(6):674-80.
Tessier Cleft 1 and 2:
6
1
25.
26.
27.
28.
29.
30.
31.
32. Tessier Cleft 4:
four components:
upper lip cleft, cheek deformity,
lower lid defect and nasal rotational
deformity,
4 8
33. Problem:
No muscle in medial lip segment
correction:
Removal & Unilateral/bilateral lip repair
as applicable
Millard’s type for unilateral
Mullikan’s for bilateral
Tessier Cleft 4: 4 Upper lip cleft:
34. Problem:
Horizontal and vertical soft tissue deficiency
Guidelines
• Cheek advancement
• Closure as Weber Ferguson/avoid cheek scars
• Vertical/horizontal flap lengthening by Z-plasties
at nasolabial/pre-auricular area
• Medial cheek segment: utilized for lid closure/de-
epithelized to augment the cheek soft tissue
Tessier Cleft 4: 4 Cheek:
35. Lid/cheek junction incison + lateral
canthotomy for release & medial advancement
of lateral lid segment
Medial canthopexy + lower lid canaliculus
reconstructed by adding a stent (mini-Monoka)
Correction of down –slanting medial canthus
addition of V-releasing incision and
repositioned in a horizontal incision
Tessier Cleft 4: 4 Lower lid:
36.
37. nose is usually rotated upwards
Corrected as de-rotation flap with a
back-cut /alar fixation at a lower
position with periosteum
Tessier Cleft 4: 4 Nose:
46. Mark commissures ,
Reciprocating the normal side
commissure to Cupid’s bow
height on cleft side
Redundant lip resection and
layered closure
Tessier Cleft 5: 5 lip
47. Excised as pentagon and
closed in layers
Tessier Cleft 5: 5 Lower lid coloboma
48. marked and de-epithelialized
skin margins undermining from soft tissues
Soft tissue overlapping over the de-
epithelized cleft for filling
Z-plasties at the nasolabial/lid cheek junction
to lengthen/rearrange scars
Cleft palate was closed at 8 to 12 months
Tessier Cleft 5: 5 Cheek cleft
66. excision/layered closure
leaving 1 cm of mucosa with the bone for
maintaining sulcus integrity/water tight closure
In one case
Incomplete cleft of the mandibular &
glosso-labiochelesis
Tongue release from the lip and mouth floor
/repaired by primary closure
Tessier Cleft 30: 7