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A Novel Single-Staged Technique for the Treatment of Soft Tissue in a Tessier No. 4 Cleft
Donald J. Harvey, MD1, Hiteswar Sarma, MCh2, Gregory E. Lakin, MD1.
1University Hospitals Case Medical Center, Cleveland, OH, USA, 2Guwahati Comprehensive Cleft Care Center, Guwahati, India.

Purpose: Tessier No. 4 clefts are extremely rare and cause significant morbidity. These clefts are complex and require a fundamental understanding of cleft classification and repair techniques. We describe a new technique for reconstructing the buccal sulcus and palpebral conjunctiva in a single-staged procedure.
Methods: We present a novel single-staged technique for repair of the soft tissue Tessier cleft No. 4. We also present a case report of a unilateral right-sided rare Tessier No. 4 cleft in a 14-year-old female with the cleft extending from the lip to the orbit with noted dystopia and microphthalmia. The technique involves preserving the soft tissue within the cleft to provide both buccal sulcus and lower lid orbital conjunctival lining, a Mustarde cheek advancement flap, an anatomical subunit lip repair, a dorsal nasal Rieger flap for ala repositioning, and a lateral nasal flag flap to reconstruct the upper cheek and lower lid.
Results: The single-staged soft tissue closure had no complications within the perioperative period. Additional procedures to address the periorbital tissues may be required.
Conclusion: This novel single-staged technique for the treatment of the soft tissue within the Tessier No. 4 cleft provides excellent results for a complex problem. This technique provides reconstruction for both the buccal sulcus and lower lid palpebral conjunctiva using turnover flaps from the normally discarded excess soft tissue within the wide cleft. An additional benefit to the turnover conjunctival flap is creation of a deeper fornix to aid with placement of an orbital prosthesis.


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