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A method of repairing the no. 3 facial cleft
British Joumal
ofPlastic
Surgery (1992), 45,44-46
A method of repairing the No. 3 facial cleft A. Madaree, W. M. M. Morris and I. C. McGibbon Sub-Department of Plastic and Reconstructive Surgery, University oj’Nata1, Wentworth Hospital, Durban, South Africa SUMMARY. A method of correction of an incomplete no. 3 facial cleft’in an infant is presented. It is compared with previously described repairs, and its advantages are outlined.
nares. B was a turn over flap, based medially, to till the gap in the nasal lining above A. C was an inferiorly based skin flap transposed onto the side of the nose above A; its donor defect was closed by undermining and medially advancing the cheek skin, and the resultant scar then lay in the paranasal sulcus. Elevation of flap D, an inferiorly-based skin flap centred over the true site of the medial canthus, and direct closure of its donor defect, brought the inferolaterally displaced medial canthus into a position corresponding to that on the normal right side, though no attempt was made to dissect out and identify the medial canthal ligament if it had been present. E was a full-thickness laterally-based flap of the lower eyelid in the,skin crease lines, advanced medially to close the coloboma defect and below which flap D was transposed, trimmed and inset. Conjunctival lining was quite adequate, and again no attempt was made to expose and to correct the underlying palpable bony depression. Finally, the upper coloboma was corrected with a pentagonal excision and direct closure. Figure 3 shows the result at 3 years without any further revisions.
Of the rare facial clefts, the Tessier No. 3 cleft (Tessier, 1976) is one of the less frequently seen, and even surgeons involved in an active Craniofacial Unit will seldom be called upon to repair such1‘a deformity. Thus, when we were referred a neonate wit+ typical No. 3 cleft, we reviewed the literature available’to us for the details of methods of repair. The ,operation we performed differs in some respects from previously presented corrections, and this report deqcribeb details of our repair and its advantages. Case report A 6-week-old male Asian
infant was referred to our department with a left sided naso-ocular cleft. The child was the mother’s first, her pregnancy had been uneventful and there was no family history of congenital abnormalities. Abnormal findings in this otherwise thriving infant were confined to the face where the typical incomplete No. 3 cleft was evident on the left side (Fig. 1). The alar base and rim were pulled up towards the eye, and the nostril was considerably enlarged; there was a coloboma of the lower eyelid between the punctum and the medial canthus, which was displaced inferiorly and laterally. In addition, there was a small coloboma of the medial upper eyelid, representing a minimal No. 11 extension of the cleft. Operative repair of the cleft was carried out when the child was 7 weeks of age, and his mass was 3.5 kg. General anaesthesia was employed with POR 8 (Ornipressin) infiltration of the incisions to minimise bleeding. The postoperative course was uneventful and now 3 years later the child remains well with normal development and a satisfactory cosmetic appearance (Fig. 3).
Discussion Though the No. 3 cleft is a well described entity in a number of publications (Tessier, 1969; Boo-Chai, 1970; Bartels et al., 1971; Wilson et al., 1972; Dey, 1973; Kawamoto et al., 1977) few papers give actual details of the methods of repair of the clefts. In a review of those where the surgical corrections were described (Tessier, 1969; Ortega and Flor, 1969; Bartels et al., 197 1; Onizuka et al., 1978; Jackson et al., 1982), it was evident that some form of Z-plasty was used by all the authors to correct the eyelid and medial canthal aspects of the cleft, but the techniques used to correct the alar and narial parts of the deformity varied. From the diagram in Onizuka’s paper (Onizuka et al., 1978) it appears that a superomedially based flap of the upper eyelid and adjacent upper nasal skin was transposed to below the eye and onto the side of the
Technique The repair we devised basically employed five local flaps, out of which two pairs utilised the Z-plasty principle to obtain lengthening in the line of the cleft, and a fifth was a turn-over flap for additional nasal lining. Initially, the coloboma in the lower lid, between the punctum and the medial canthus, was excised in a wedge; the canaliculus was absent. As depicted in Figure 2, A was a full thickness flap of the alar rim which was rotated down, so equalising the external 44
45
A Method of Repairing the No. 3 Facial Cleft
Fig. 1
/__(gjg<
e
Fig. 2
____I---
-
B
views at 7 weeks (A) AP view, (B) Left oblique view. Figure S-Operative Figure -Preoperative views i 3 years. (A) AP views, (B) Left oblique view.
design of flaps. Figure 3-Postopel rative
British Journal of Plastic Surgery
46
nose above the released alar rim; a triangular flap of cheek skin based medially was turned over for nasal lining, with the resultant donor defect scar running transversely across the cheek. Ortega and Flor (1969) released the alar rim and used a medially based turnover flap for additional nasal lining, as we did, but they utilised a short superiorly based naso-labial flap for transposition onto the side of the nose above the released alar rim ; the donor defect scar lay in the nasolabial skin crease. However, their patient was 16 years of age, and the cleft was relatively small in relation to the amount of normal nasal, cheek and lip tissues available for the repair. Bartels et al. (1971) used a composite graft from the ear above the ala, but other than a photograph of this, no other details were given of their surgical procedure. In the repair depicted in the atlas by Jackson et al., (1982) the superolateral displacement of the alar base is minimal and a small Z-plasty is described to “lengthen the short skin at the side of the nose . . .“, in combination with a Z-plasty to the medial canthus, and a modified rotationadvancement repair of the lip cleft. Tessier’s method of repair (Tessier, 1969) well known from its later reproduction in a classic textbook of paediatric plastic surgery (Tessier, 1979) also utilised a Z-plasty to the displaced medial canthus, release of the alar rim based medially, and a turnover flap for additional nasal lining, but he advanced cheek skin, based laterally, up onto the side of the nose above the released alar rim. This may tend to’tent across and so partially obliterate the paranasal sulcus. We feel that our inferiorly based transposed paranasal flap is a preferable method of filling the defect above the released alar rim, for four reasons : Its size and dimensions can be exactly planned as it corresponds to the discrepancy in the levels of the alar margins between the cleft and the normal side. Closure of the donor defect is easily achieved by undermining and medially advancing the cheek skin. The donor defect scar lies in the paranasal sulcus, and by fixing the suture line down to the deeper tissues at the margin of the pyriform aperture, the sulcus can be accentuated.
transposition of this flap above the released alar rim in combination with the Zplasty to the medial canthus ensures adequate lengthening in the line of the cleft, with the resultant scars in cosmetically acceptable positions.
4. The
References Bartels, R. J., O’Malley, J. E., Baker, J. L. and Doaglas, W. M. (1971). Naso-ocular clefts. Plastic and Reconstructive Surgery, 41, 351.
Boo-Chai, K. (1970). The oblique facial cleft. British Journal of Plnstic Surgery, 23, 352. Dey, D. L. (1973). Oblique facial clefts. Plustic and Reconstructive Surgery, 52,258.
Jackson, 1. T.4 Munro, I. R., Salyer, K. E. and Wbitaker, L. A. (1982). Maxillary surgery and repair of facial clefts. Atlas of CraniorrtaxillofaciaISurgery. St Louis, C.V. Mosby Co., p. 234. Kawamoto, H. K. Jr., Wang, K. H. aud Macomber, W. B. (1977). Rare craniofacial clefts. In Converse, J. M. (Ed.). Reconstructive Plastic Surgery. Philadelphia, W. B. Saunders, pp. 4, 116. Onizuka, T., Kato, I., Icbinose, M. and Imai, S. (1978). Naso-ocular clefts, Plastic and Reconstructive Surgery, 61, 118. Ortega, J. and Flor, E. (1969). Incomplete naso-ocular cleft. Plastic and Reconstructive Surgery, 43,630. Tessier, P. (1969). Fentes orbito-faciales verticales et obliques (colobomas) completes et frustes. Annales de Chirurgie Plastique, 14,301. Testier, P. (1976). Anatomical classification of facial, craniofacial and laterofacial clefts. Journal of Maxillo-Facial Surgery, 4,69. Tessier, P. (1979). Vertical and oblique facial clefts. In Mustard& J. C. (Ed.). Plastic surgery in infancy and childhood. 2nd Edition. Edinburgh, Churchill Livingstone. Wilson, L. F., Musgrave, R. H., Garrett, W. and Conklin, J. E. (1972). Reconstruction of oblique facial clefts. Cleft Palate Journal, 9, 109.
The Authors AntlMadaree, FCS @A), Consultant, Sub-Department of Plastic and Reconstructive Surgery, University of Natal, Wentworth Hospital, Private Bag Jacobs, 4026 Durban, South Africa. Warwick M. M. Morris, FRCS, Head, Craniofacial Unit, Pietermaritzburg; Consultant, Sub-Department of Plastic and Reconstructive Surgery, University of Natal, Wentworth Hospital. Ian C. McGibbon, FCS (SA), Consultant Plastic Surgeon, George Provincial Hospital, George, South Africa; formerly Consultant, Sub-Department of Plastic and Reconstructive Surgery, University of Natal, Wentworth Hospital. Requests for reprints to Mr A. Madaree. Paper received 27 March 1991. Accepted 4 June 1991.
ofPlastic
Surgery (1992), 45,44-46
A method of repairing the No. 3 facial cleft A. Madaree, W. M. M. Morris and I. C. McGibbon Sub-Department of Plastic and Reconstructive Surgery, University oj’Nata1, Wentworth Hospital, Durban, South Africa SUMMARY. A method of correction of an incomplete no. 3 facial cleft’in an infant is presented. It is compared with previously described repairs, and its advantages are outlined.
nares. B was a turn over flap, based medially, to till the gap in the nasal lining above A. C was an inferiorly based skin flap transposed onto the side of the nose above A; its donor defect was closed by undermining and medially advancing the cheek skin, and the resultant scar then lay in the paranasal sulcus. Elevation of flap D, an inferiorly-based skin flap centred over the true site of the medial canthus, and direct closure of its donor defect, brought the inferolaterally displaced medial canthus into a position corresponding to that on the normal right side, though no attempt was made to dissect out and identify the medial canthal ligament if it had been present. E was a full-thickness laterally-based flap of the lower eyelid in the,skin crease lines, advanced medially to close the coloboma defect and below which flap D was transposed, trimmed and inset. Conjunctival lining was quite adequate, and again no attempt was made to expose and to correct the underlying palpable bony depression. Finally, the upper coloboma was corrected with a pentagonal excision and direct closure. Figure 3 shows the result at 3 years without any further revisions.
Of the rare facial clefts, the Tessier No. 3 cleft (Tessier, 1976) is one of the less frequently seen, and even surgeons involved in an active Craniofacial Unit will seldom be called upon to repair such1‘a deformity. Thus, when we were referred a neonate wit+ typical No. 3 cleft, we reviewed the literature available’to us for the details of methods of repair. The ,operation we performed differs in some respects from previously presented corrections, and this report deqcribeb details of our repair and its advantages. Case report A 6-week-old male Asian
infant was referred to our department with a left sided naso-ocular cleft. The child was the mother’s first, her pregnancy had been uneventful and there was no family history of congenital abnormalities. Abnormal findings in this otherwise thriving infant were confined to the face where the typical incomplete No. 3 cleft was evident on the left side (Fig. 1). The alar base and rim were pulled up towards the eye, and the nostril was considerably enlarged; there was a coloboma of the lower eyelid between the punctum and the medial canthus, which was displaced inferiorly and laterally. In addition, there was a small coloboma of the medial upper eyelid, representing a minimal No. 11 extension of the cleft. Operative repair of the cleft was carried out when the child was 7 weeks of age, and his mass was 3.5 kg. General anaesthesia was employed with POR 8 (Ornipressin) infiltration of the incisions to minimise bleeding. The postoperative course was uneventful and now 3 years later the child remains well with normal development and a satisfactory cosmetic appearance (Fig. 3).
Discussion Though the No. 3 cleft is a well described entity in a number of publications (Tessier, 1969; Boo-Chai, 1970; Bartels et al., 1971; Wilson et al., 1972; Dey, 1973; Kawamoto et al., 1977) few papers give actual details of the methods of repair of the clefts. In a review of those where the surgical corrections were described (Tessier, 1969; Ortega and Flor, 1969; Bartels et al., 197 1; Onizuka et al., 1978; Jackson et al., 1982), it was evident that some form of Z-plasty was used by all the authors to correct the eyelid and medial canthal aspects of the cleft, but the techniques used to correct the alar and narial parts of the deformity varied. From the diagram in Onizuka’s paper (Onizuka et al., 1978) it appears that a superomedially based flap of the upper eyelid and adjacent upper nasal skin was transposed to below the eye and onto the side of the
Technique The repair we devised basically employed five local flaps, out of which two pairs utilised the Z-plasty principle to obtain lengthening in the line of the cleft, and a fifth was a turn-over flap for additional nasal lining. Initially, the coloboma in the lower lid, between the punctum and the medial canthus, was excised in a wedge; the canaliculus was absent. As depicted in Figure 2, A was a full thickness flap of the alar rim which was rotated down, so equalising the external 44
45
A Method of Repairing the No. 3 Facial Cleft
Fig. 1
/__(gjg<
e
Fig. 2
____I---
-
B
views at 7 weeks (A) AP view, (B) Left oblique view. Figure S-Operative Figure -Preoperative views i 3 years. (A) AP views, (B) Left oblique view.
design of flaps. Figure 3-Postopel rative
British Journal of Plastic Surgery
46
nose above the released alar rim; a triangular flap of cheek skin based medially was turned over for nasal lining, with the resultant donor defect scar running transversely across the cheek. Ortega and Flor (1969) released the alar rim and used a medially based turnover flap for additional nasal lining, as we did, but they utilised a short superiorly based naso-labial flap for transposition onto the side of the nose above the released alar rim ; the donor defect scar lay in the nasolabial skin crease. However, their patient was 16 years of age, and the cleft was relatively small in relation to the amount of normal nasal, cheek and lip tissues available for the repair. Bartels et al. (1971) used a composite graft from the ear above the ala, but other than a photograph of this, no other details were given of their surgical procedure. In the repair depicted in the atlas by Jackson et al., (1982) the superolateral displacement of the alar base is minimal and a small Z-plasty is described to “lengthen the short skin at the side of the nose . . .“, in combination with a Z-plasty to the medial canthus, and a modified rotationadvancement repair of the lip cleft. Tessier’s method of repair (Tessier, 1969) well known from its later reproduction in a classic textbook of paediatric plastic surgery (Tessier, 1979) also utilised a Z-plasty to the displaced medial canthus, release of the alar rim based medially, and a turnover flap for additional nasal lining, but he advanced cheek skin, based laterally, up onto the side of the nose above the released alar rim. This may tend to’tent across and so partially obliterate the paranasal sulcus. We feel that our inferiorly based transposed paranasal flap is a preferable method of filling the defect above the released alar rim, for four reasons : Its size and dimensions can be exactly planned as it corresponds to the discrepancy in the levels of the alar margins between the cleft and the normal side. Closure of the donor defect is easily achieved by undermining and medially advancing the cheek skin. The donor defect scar lies in the paranasal sulcus, and by fixing the suture line down to the deeper tissues at the margin of the pyriform aperture, the sulcus can be accentuated.
transposition of this flap above the released alar rim in combination with the Zplasty to the medial canthus ensures adequate lengthening in the line of the cleft, with the resultant scars in cosmetically acceptable positions.
4. The
References Bartels, R. J., O’Malley, J. E., Baker, J. L. and Doaglas, W. M. (1971). Naso-ocular clefts. Plastic and Reconstructive Surgery, 41, 351.
Boo-Chai, K. (1970). The oblique facial cleft. British Journal of Plnstic Surgery, 23, 352. Dey, D. L. (1973). Oblique facial clefts. Plustic and Reconstructive Surgery, 52,258.
Jackson, 1. T.4 Munro, I. R., Salyer, K. E. and Wbitaker, L. A. (1982). Maxillary surgery and repair of facial clefts. Atlas of CraniorrtaxillofaciaISurgery. St Louis, C.V. Mosby Co., p. 234. Kawamoto, H. K. Jr., Wang, K. H. aud Macomber, W. B. (1977). Rare craniofacial clefts. In Converse, J. M. (Ed.). Reconstructive Plastic Surgery. Philadelphia, W. B. Saunders, pp. 4, 116. Onizuka, T., Kato, I., Icbinose, M. and Imai, S. (1978). Naso-ocular clefts, Plastic and Reconstructive Surgery, 61, 118. Ortega, J. and Flor, E. (1969). Incomplete naso-ocular cleft. Plastic and Reconstructive Surgery, 43,630. Tessier, P. (1969). Fentes orbito-faciales verticales et obliques (colobomas) completes et frustes. Annales de Chirurgie Plastique, 14,301. Testier, P. (1976). Anatomical classification of facial, craniofacial and laterofacial clefts. Journal of Maxillo-Facial Surgery, 4,69. Tessier, P. (1979). Vertical and oblique facial clefts. In Mustard& J. C. (Ed.). Plastic surgery in infancy and childhood. 2nd Edition. Edinburgh, Churchill Livingstone. Wilson, L. F., Musgrave, R. H., Garrett, W. and Conklin, J. E. (1972). Reconstruction of oblique facial clefts. Cleft Palate Journal, 9, 109.
The Authors AntlMadaree, FCS @A), Consultant, Sub-Department of Plastic and Reconstructive Surgery, University of Natal, Wentworth Hospital, Private Bag Jacobs, 4026 Durban, South Africa. Warwick M. M. Morris, FRCS, Head, Craniofacial Unit, Pietermaritzburg; Consultant, Sub-Department of Plastic and Reconstructive Surgery, University of Natal, Wentworth Hospital. Ian C. McGibbon, FCS (SA), Consultant Plastic Surgeon, George Provincial Hospital, George, South Africa; formerly Consultant, Sub-Department of Plastic and Reconstructive Surgery, University of Natal, Wentworth Hospital. Requests for reprints to Mr A. Madaree. Paper received 27 March 1991. Accepted 4 June 1991.