M. Muraoka Æ T. Harada Æ I. Hayashi Æ N. Sasaki
Fourteen-year follow-up of a Tessier number 4 cleft
Received: 26 March 2004 / Accepted: 12 August 2004 / Published online: 11 May 2005
Ó Springer-Verlag 2005
Abstract A 3-month-old girl of Japanese parents pre-
sented with a left oblique facial cleft (Tessier number 4
cleft). It extended from the area lateral to the Cupid’s
bow, through the cheek on the lateral side of the ala nasi,
to the medial side of the lacrimal punctum of the lower
eyelid. As a result, the left lower eyelid was split, resulting
in marked ectropion. There was another cleft present on
the medial side of the left upper eyelid. The left ala nasi
was normal morphologically but was raised upwards.
The cleft extended into the secondary palate. The nasal
septum was preserved, and left choanal atresia was
present. CT examination revealed hypoplasia of the left
maxillary bone and sinus. A total of seven operations was
performed during the 14-year follow-up period; the end
result was satisfactory. Artiﬁcial bone (apatite ceramics)
was implanted on the anterior wall of the maxilla, when
the child was aged 6 years, and to the orbital ﬂoor when
she was 13. CT examination (at 13 years) revealed that
the artiﬁcial bone implanted at age 6 was correctly ori-
ented and had fused to the anterior wall of the maxilla
and zygoma. Resorption had been minimal.
Keywords Long-term follow-up Æ Tessier number 4
cleft Æ Oblique facial cleft
Tessier devised a classiﬁcation of craniofacial clefts that
combined the preoperative clinical ﬁndings with the
anatomical deformities found during surgery . Ob-
lique facial clefts are divided into Tessier number 4 and 5
clefts, and both are very rare. Resnick and Kawamoto
reported eight cases and noted that fewer than 50 Tessier
number 4 clefts had been reported . One bilateral case
was reported . Only one long-term follow-up study
has been published , thus no widely accepted thera-
peutic policy has been established for this anomaly. Not
only surgical treatment but also maxillary orthopedics is
required at diﬀerent times during the course of the pa-
tient’s development .
A report of a case of Tessier number 4 cleft is pre-
sented. A total of seven operations was performed dur-
ing a 14-year follow-up period.
A 3-month-old girl of Japanese parents was referred to
our clinic with a left oblique facial cleft (Fig. 1). Her
general condition was normal, and her family history
included nothing of note.
The cleft extended from the area lateral to the Cu-
pid’s bow; it passed through the cheek on the lateral side
of the ala nasi, to the medial side of the lacrimal punc-
tum of the lower eyelid. As a result, the left lower eyelid
was split and showed marked ectropion. Another cleft
was also seen on the medial side of the left upper eyelid.
Left anophthalmos was present. The left ala nasi was
normal morphologically but was raised upwards. The
cleft extended to the secondary palate as a cleft palate.
The nasal septum was preserved, and left choanal atresia
was present. CT examination revealed hypoplasia of the
left maxillary bone and sinus, compared to the unaf-
fected side (Fig. 2).
The patient underwent the following seven operations
over 14 years for correction of the deformity.
Operation 1 at 4 months: The left oblique facial cleft
was closed by a multiple Z-plasty (Fig. 3). However,
ectropion of the lower eyelid due to scar contracture was
observed 9 months after surgery (Fig. 4).
M. Muraoka (&) Æ T. Harada Æ I. Hayashi Æ N. Sasaki
Department of Plastic and Reconstructive Surgery,
Osaka City University Graduate School of Medicine,
Asahi 1-4-3, Abeno, 545-8585 Osaka, Japan
Eur J Plast Surg (2005) 27: 387–390