Midface Rotation Advancement: Repairing of Tessier No. 3 and No. 4 Craniofacial Clefts with Facial Unit & Muscle Repositioning

Background: The Tessier No. 3 and No. 4 craniofacial clefts are rare congenital facial clefts. The accepted surgical correction of the soft tissue defect is by the use of interdigitating skin flaps along the line of the facial cleft. However, this kind of repair frequently results in unsightly facial scars, skin patches of different colors along the line of the repair, and an unnatural facial expression. Based on these clinical difficulties, we have developed our technique using the midface rotation-advancement concept to repair the Tessier No.3 and No.4 craniofacial cleft.

Methods: This is a retrospective study of patients (n = 14) who had underwent surgical repair of Tessier No. 3 and No.4 over a 35 years period (1976- 2010) at the craniofacial center in Chang Gung Memorial Hospital. It can be divided into two groups: first group of patients consists of 5 patients operated by the Z-plasty principles and second group of 9 patients operated by the rotation-advancement technique; six of them have Tessier No. 3 clefts and three patients have Tessier No.4 clefts. Seven of those nine patients were primary cases while the other two cases were secondary or tertiary revisions.

Results: None of the patients in the first group had a satisfactory result in terms of scar quality, color matching or natural facial expression. The cases in the second group that were surgically treated with midface rotation advancement technique, though their medial canthus and alar base might not be well repositioned, still had much better result in their scar and facial expression.

Conclusions: The mid-face rotation advancement technique avoided the significant scarring with poor skin color matching and unnatural facial expressions associated with the interdigitating skin flaps technique. This technique is applicable to either the primary repair or secondary revision of the No.3 and No. 4 craniofacial clefts.