Keywords
Tessier cleft 0 - Tessier cleft 3 - facial cleft
Sir,
Congenital craniofacial clefts are malformations of the cranium and face with deficiencies
or excesses of tissue along an anatomic line based on embryologic maldevelopment.
The anatomical classification was proposed by Paul Tessier.[1] Oblique facial clefts are extremely rare congenital deformities with a reported
incidence of 0.24% of all facial clefts.[2] We present a case of combination of Tessier cleft 0 and 3 in a child.
A 4-year-old child presented to us with midline cleft of the lip and cleft of the
left nasal ala ([Fig. 1]). There was a groove in the left nasal ala with a deficiency of the lower lateral
cartilage. The nasolabial area, lower eyelid, and infraorbital regions were normal.
The columella was normal dimensionally but was slightly deviated to the right side.
There was an incomplete cleft in the midline extending to the Cupid’s bow with widened
philtrum. The distance between the philtral columns was 12 mm at the columellar end
and 20 mm in between the peaks of the Cupid’s bow. Intraorally there were two frenula
and a gap in between the upper central incisors. Slight depression was palpable in
the intact alveolus in the midline. Rest of the oral structures was normal. Computed
tomography (CT) of the craniomaxillofacial skeleton was performed to rule out median
cleft face syndrome, encephalocele, and holoprosencephaly. Patient had hypertelorism.
Based upon the clinical examination and CT scan findings, a diagnosis of Tessier No.
0 and 3 facial cleft was made. The incomplete median cleft lip was repaired first
by marking the peak of the Cupid’s bow on either sides. After keeping 2 mm medial
to the peak of the Cupid’s bow on both sides, the excess tissue was marked. A full-thickness
flap was raised from midline lip tissue islanded on the left superior labial artery
([Fig. 2)]. The tissue transferred to nose did not contain any vermillion tissue. This flap
was planned inferiorly so that skin element of the lip could be transferred to the
nasal defect and islanding possible on superior labial artery. The lip was repaired
by apposing the mucosa, orbicularis muscle, and skin in the midline. The nasal cleft
was repaired by a full-thickness transposition flap of the nasal ala which was turned
down to match the level of other side. The residual defect was covered with the flap
raised from the upper lip ([Fig. 3]). The flap was healthy and flap detachment was done on postoperative day 10. The
aesthetic outcome was well acceptable. A 6-month follow-up picture is shown in [Fig. 4].
Fig. 1 Midline cleft of the upper lip and cleft of the left nasal ala in a 4-year-old child
(preoperative picture).
Fig. 2 Schematic diagram. A full-thickness flap was raised from midline lip tissue islanded
on left superior labial artery (left). The nasal defect covered was covered with the flap raised from the midline of upper
lip (right).
Fig. 3 Incomplete median cleft lip was repaired. A full-thickness flap was raised with the
base at the upper lip and vascular supply from the superior labial artery. The nasal
cleft was repaired by a full-thickness transposition flap of the nasal ala which was
turned down to match the level of the other side (left). The residual defect was covered with the flap raised from the upper lip (right).
Fig. 4 The flap was healthy and flap detachment was done on postoperative day 10 (left). The 6-month follow-up picture (right).
A combination of Tessier cleft 0 and 3 is rare. The procedures mentioned are the nasolabial
flap,[3]
[4] forehead flap, and alar transposition flap.[5]
[6] These lead to visible scars. The idea of using the tissue from midline of the lip,
which would have been discarded anyway, has been uniquely used with no additional
scars. The limitation is the amount of tissue availability from the lip area. The
management is unique and innovative since no such reports are available in the literature.
Declaration of Patient Consent
The authors certify that they have obtained all appropriate patient consent forms.
In the form the patient(s) has/have given his/her/their consent for his/her/their
images and other clinical information to be reported in the journal. The patients
understand that their names and initials will not be published and due efforts will
be made to conceal their identity, but anonymity cannot be guaranteed.
Financial Support and Sponsorship
Nil.
