Serial Presurgical Orthopedics for Eye Repositioning and Optimization of Soft-Tissue Repair in an Infant With Tessier No. 4 Cleft.

OBJECTIVE: 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.

Tessier No. 3 and No. 4 clefts: Sequential treatment in infancy by pre-surgical orthopedic skeletal contraction, comprehensive reconstruction, and novel surgical lengthening of the ala base-canthal distance.

BACKGROUND: Repair of facial clefts implies wide tissue mobilization with multi-stage surgical treatment. Authors propose pre-surgical orthopedic correction for naso-oro-ocular clefts and a novel surgical option for Tessier No. 3 cleft. METHODS: Two male infants, a Tessier No. 3 cleft (age 7 months) and another Tessier No. 4 (age 3 months), were treated with a modified orthopedic Latham device with additional septo-premaxillary molding and observed to age four years. Tessier No. 3 orthopedic measurements were obtained by image corrected cephalometric analysis. Subsequent repair included tissue expansion on Tessier No. 4 and naso-frontal Rieger flap combined with myocutaneous upper lid flap on Tessier No. 3. RESULTS: Orthopedic movements ranged from 18.5 mm in bi-planar to 33 mm in oblique analyses. Tissue margins became aligned with platform normalization. Tissue expansion on Tessier No. 4 improved distances from ala base-lower lid and subalar base-lip. The naso-frontal flap combined with myocutaneous upper lid flap on Tessier No. 3 had similar achievement, but also sufficiently lengthened ala base-canthal distance. CONCLUSIONS: Repairs were facilitated by pre-surgical orthopedic correction. The naso-frontal flap combined with an upper lid myocutaneous flap seems viable as a single-stage option to lengthen ala base-canthal distance to advance repair achievement in unilateral Tessier No. 3.

Changes in nose symmetry in unilateral cleft lip and palate treated by differing pre-surgical assistance: An objective assessment of primary repair.

BACKGROUND: Residual deformity of the nose, not lip, continues to be the greater challenge in UCCLP rehabilitation. Platform distortions often re-emerge following primary reconstruction revealing the stereotypical cleft-nose. Nasal alveolar molding reduces nose asymmetry. However, this study applies directional mechanics to the underlying platform distortions and soft tissue nose, introducing a novel device addressing the distorted septo-premaxillary junction. METHODS: Retrospective assessment of 47 UCCLP patients by 2-dimensional photographic analysis with 24 subjects treated by dento-maxillary advancement (DMA) and nasal septum button-head pin (NSBP), 17 having nasal molding (NM), compared to 23 subjects without nose treatment, 16 with DMA and 7 with passive plates. Measurements were assessed by t tests, ≤ 05 confidence. RESULTS: Frontal view: nose-treatment sample achieved ideal ala-bases vertical symmetry (p = 0.00065 & 0.00073); significantly improved ala-rims "slump" angle (p = 0.0071). Both samples had nose positioning within the facial frame like non-cleft population. Sub-nasal view: significant differences were for columella angle (p = 0.0015), nares "offset" (p = 0.002), and columella symmetry (p = 0.022) with nose-treatment achieving near ideal columella symmetry score (0.92) vs. (0.81). CONCLUSIONS: NM and the novel NSBP procedures integrated with the platform correction effect of the DMA successfully treated at three distorted anatomic-levels native to UCCLP to improve nasal aesthetics.