A male patient with Tessier No. 4 cleft (unilateral left) presented at 20 days of age. The cleft defect beginning between the cupid bow and oral commissure extended to the ipsilateral orbital floor, skirting the nose and lacrimal duct while passing through the cheek medial to the infraorbital nerve. With the lesser segment disposed 16 mm transversely, the wide gap included an absence of orbital floor and lower eyelid. A deficient midfacial platform caused a severe inferior globe dystopia, superiorly displaced left ala base, and severe vertical shortening between ala-canthus and ala-globe.
Intervention
A modified Latham device applied directional orthopedics to contract the cleft gap and with an eye part added to elevate the dystopic globe. Two different Latham devices used in succession were each applied for 4 weeks. Lastly, a removable plate further repositioned the eye. Each appliance was designed to differentially move the noncleft and cleft segments of the maxilla. Presurgical orthopedics began at 3 weeks lasted 14 weeks. Intraoperatively at 17 weeks, the inferior globe dystopia was effectively reduced, and the cleft gaps were nearly closed and aligned at the orbital floor, cheek, and the alveolus. Respecting the aesthetic units of face became possible with the soft-tissue repair yet were tight enough in the malar region to retract the lower lid.
Conclusion
The presurgical directional orthopedic and eye-globe mechanics were sufficient to enable medial canthal repositioning, sustainable correction of orbital distopia, and optimized primary soft-tissue repair. Early result suggests that surgery with presurgical orthopedics is superior to surgery alone.
Boo-ChaiK.The oblique facial cleft: a report of 2 cases and a review of 41 cases. Br J Plast Surg.1970; 23: 352–359.
6.
ChanK.T., HayesC., ShustermanS., MullikenJ.B., WillL.A.The effects of active infant orthopedics on occlusal relationships in unilateral complete cleft lip and palate. Cleft Palate Craniofac J.2003; 40: 511–517.
7.
ChenP.K., ChangF.C., ChanF.C., ChenY.R., NoordhoffM.S.Repair of Tessier no. 3 and no. 4 craniofacial clefts with facial unit and muscle repositioning bymidface rotation advancement without Z-plasties. Plast Reconstr Surg.2012; 129: 1337–1344.
8.
Da Silva FreitasR., AlonsoN., BusatoL., UedaW.K., HotaT., MedeirosS.H., KunzR.T.Oral-nasal-ocular cleft: the greatest challenge among the rare clefts. J Craniofac Surg.2010; 21: 390–395.
9.
DecW., ShetyeP.R., DavidsonE.H., GraysonB.H., BrechtL.E., CuttingC.B., WarrenS.M.Presurgical nasoalveolar molding and primary gingivoperiosteoplasty reduce the need for bone grafting in patients with bilateral clefts. J Craniofac Surg.2013; 24: 186–190.
10.
GalanteG., DadoD.V.The Tessier number 5 cleft: a report of two cases and a review of the literature. Plast Reconstr Surg.1991; 88: e131–e135.
11.
GfrererL., ShubinetsV., HoyosT., KongY., NguyenC., PietschmannP., MortonC.C., MaasR.L., LiaoE.C.Functional analysis of SPECC1L in craniofacial development and oblique facial cleft pathogenesis. Plast Reconstr Surg.2014; 134: 748–759.
12.
GraysonB.H., ShetyeP.R.Presurgical nasoalveolar moulding treatment in cleft lip and palate patients. Indian J Plast Surg.2009; 42: S56–S61.
13.
HathawayR.R., EppleyB.L., HennonD.K., NelsonC.L., SadoveA.M.Primary alveolar cleft bone grafting in unilateral cleft lip and palate: arch dimensions at age 8. J Craniofacial Surg.1999a; 10: 58–67.
14.
HathawayR.R., EppleyB.L., NelsonC.L., SadoveA.M.Primary alveolar cleft bone grafting in unilateral cleft lip and palate: craniofacial form at age 8. J Craniomaxillofac Surg.1999b; 10: 68–72.
15.
HenkelK.O., GundlachK.K.Analysis of primary gingivoperiosteoplasty in alveolar cleft repair. Part I: Facial growth. J Craniomaxillofac Surg.1997; 25: 266–269.
16.
KaraI.G., OçselH.The Tessier number 5 cleft with associated extremity anomalies. Cleft Palate Craniofac J.2001; 38: 529–532.
17.
KawamotoHKJr.. The kaleidoscopic world of rare craniofacial clefts: order out of chaos (Tessier classification). Clin Plast Surg.1976; 3: 529–572.
18.
KawamotoHJr., Praveen-KumarK.P.Atypical facial clefts. In: BentzM.L., BauerB.S., ZukerR.M., eds. Principles and Practice of Pediatric Plastic Surgery.Stanford, CT: Appleton and Lange;1998: 175–225.
19.
LathamR.A.Developmental deficiencies of the vertical and anteroposterior dimensions in the unilateral cleft lip and palate deformity. In: GeorgiadeN.G., ed. Symposium on Management of Cleft Lip and Palate and Associated Deformities.St. Louis, MO: C.V. Mosby;1974: 10–12.
20.
LathamR.A.Orthopedic advancement of the maxillary segment: a preliminary report. Cleft Palate J.1980; 17: 227–233.
21.
LaureB., PicardA., Bonin-GogaB., LetouzeA., PetraudA., GogaD.Tessier number 4 bilateral orbito-facial cleft: a 26-year follow-up. J Craniomaxillofac Surg.2010; 38: 245–247.
22.
MaedaT., OyamaA., OkamotoT., FunayamaE., FurukawaH., HayashiT., MuraoN., SatoY., YamamotoY.Combination of Tessier clefts 3 and 4: case report of a rare anomaly with 12 years' follow-up. J Craniomaxillofac Surg.2014; 42: 1985–1989.
23.
MenardR.M., MooreM.H., DavidD.J.Tissue expansion in the reconstruction of Tessier craniofacial clefts: a series of 17 patients. Plast Reconstr Surg.1999; 103: 779–786.
24.
MishraR.K., PurwarR.Formatting the surgical management of Tessier cleft types 3 and 4. Indian J Plast Surg.2009; 42(suppl): S174–S183.
25.
Ortiz-MonasterioF., Fuente Del CampoA., DimopulosA.Nasal clefts. Ann Plast Surg.1987; 18: 377–397.
RossR.B.Growth of the facial skeleton following the Malek repair for unilateral cleft lip and palate. Cleft Palate Craniofac J.1995; 32: 194–198.
28.
RubinM.S., CloustonS., AhmedM.M., M'LoweK., ShetyeP.R., BroderH.L., WarrenS.M., GraysonB.H.Assessment of presurgical clefts and predicted surgical outcome in patients treated with and without nasoalveolar molding. J Craniofac Surg.2015; 26: 71–75.
StellzigA., BasdraE.K., MuhlingJ., KomposchG.Early maxillary orthopedics in a child with an oblique facial cleft. Cleft Palate Craniofac J.1997; 24: 147–150.
TessierP.Fentes orbito-faciales no 3, 4 et 5. In: RougierJ., TessierP., HervouetF., eds. Chirurgie Plastique orbito-palpe'brale. Rapport Soc Fr Ophtalmol.Paris: Masson;1977: e223–e237.
38.
Van der MeulenJ.C.Oblique facial clefts: pathology, etiology, and reconstruction. Plast Reconstr Surg.1985; 76: 212–224.
39.
Van der MeulenJ.C.H., VaandragerJ.M.Facial clefts. World J Surg.1989; 13: 373–383.
40.
VersnelS.L., van den ElzenM.E., WolviusE.B., BiesmeijerC.S., VaandragerJ.M., van der MeulenJ.C., MathijssenI.M.Long-term results after 40 years experience with treatment of rare facial clefts: Part 1-Oblique and paramedian clefts. J Plast Reconstr Aesthet Surg.2011; 64: 1334–1343.
41.
VersnelS.L., WolviusE.B., van AdrichemL.N., van der MeulenJ.N., OngkosuwitoE.M., MathijssenI.M.Distraction assisted treatment of a unilateral complex facial cleft. Int J Oral Maxillofac Surg.2009; 38: 790–794.
42.
ZhouY.Q., JiJ., MuX.Z., ZhangR.H., WeiM., YuZ.Y.Diagnosis and classification of congenital craniofacial cleft deformities. J Craniofac Surg.2006; 17: 198–201.
