Unilateral Left-Sided Tessier Type 4 Facial Cleft in a 6-Mont-Old Infant: A Case Report with Surgical Reconstruction and Outcome
DOI:
https://doi.org/10.26911/theijmed.2026.11.2.952Abstract
Background: Cleft Tessier is the most complex classification characterized by oro-orbital malformations with a transverse defect in the mouth extending to the nose and crossing to the lower eyelids. Recent research shows a lack of optimal reconstruction techniques, both surgical methodology and procedural. This case report aims to describe the clinical presentation, surgical reconstruction methodology, and outcomes in a 6-month-old baby with a left unilateral Tessier type 4 facial cleft.
Subject and Methods: A 6-month-old female newborn appears with a congenital left unilateral facial cleft that has existed since birth. Ocular examination showed partial involvement of the lower eyelid with a risk of exposure, while the eyeball was intact. Tessier type 4 cleft arises from failure of fusion between the maxillary and lateral nasal prominences during embryogenesis.
Results: Surgical management focuses on restoring both function particularly ocular protection and oral competence and facial aesthetics. Early intervention during infancy offers advantages such as improved tissue healing, better adaptation to facial growth, and reduced psychosocial impact. The reconstruction results achieved good initial functional and esthetic outcomes. Further monitoring during the growth period is necessary to assess facial asymmetry and hyperpigmentation that may occur.
Conclusion: Infant reconstruction can yield better esthetics and function, although monitoring and follow-up actions are necessary.
Keywords:
Tessier type 4 cleft, Facial cleft reconstruction, Craniofacial surgery, Pediatric, Tessier type 4 cleft, Facial cleft reconstruction, Craniofacial surgery, PediatricReferences
Adifitrian T, Hartono HT, Garnasih AI (2023). A case report: enhancing tarsal and muscular support for ectropion correction in Tessier 3 and 5 facial cleft. J Rekonstruksi Estet. 8(2): 85–94. doi:10.20473/jre.v8i2.51050.
Assouan C, Ambroise B, de Boutray M, Labbé D, Bénateau H, Veyssiere A (2018). Tessier number 4 bilateral craniofacial cleft associated with amniotic band syndrome: 22 years of follow-up. J Stomatol Oral Maxillofac Surg. 119(3): 208–211. doi:10.10-16/j.jormas.2017.12.005.
Babai A, Irving M (2023). Orofacial clefts: genetics of cleft lip and palate. Genes (Basel). 14(8): 1603. doi:10.3390/-genes14081603.
Behunova J, Rehder H, Dobsak A, Kircher SG, Boer LL, Mueller AA, Patsch JM, Winter E, Oostra RJ, Piehslinger E, Reich KM (2025). Facial bone defects associated with lateral facial clefts Tessier type 6, 7 and 8 in syndromic neurocristopathies: a detailed micro-CT analysis on historical museum specimens. Biology (Basel). 14(7): 872. doi:10.3390/biology14070872.
Bisetty V, Pillay P, Omodan A, Madaree A, Lazarus L (2022). Tessier cleft numbers 3 and 4: presentation of soft tissue and bony deformities in a select South African population. Transl Res Anat. 29: 100223. doi:10.1016/j.tria.-2022.100223.
Bonanthaya K, Panneerselvam E, Manuel S, Kumar VV, Rai A, editors (2021). Oral and maxillofacial surgery for the clinician. Singapore: Springer Nature Singapore. doi:10.1007/978-981-15-1346-6.
Budihardja AS, Lutfianto B, Liman NP, Hiesmantjaja H, Wolff KD (2020). Rare facial cleft: surgical treatment and middle-term follow-up during charity operation. Craniomaxillofac Trauma Reconstr. 13(2): 138–142. doi:10.1177/1943387520904210.
Chahal HS, Viruni N, Patel R, Glover AT (2021). Bilateral craniofacial cleft (Tessier type 4): case report and oculoplastic reconstruction. Cleft Palate Craniofac J. 58(10): 1313–1317. doi:10.1177/1055665621989129.
Civantos AM, Shakya P, Shaye DA (2024). Atypical facial clefts: Tessier number 3 and 4 clefts. Curr Opin Otolaryngol Head Neck Surg. 32(4): 248–256. doi:10.1097/MOO.0000000000000985.
Das D, Modaboyina S, Agrawal S, Pushker N, Meel R, Bajaj MS (2022). Tessier cranio-facial clefts presenting to a tertiary eye care center in Northern India: ophthalmic features and a review of management. Indian J Ophthalmol. 70(8): 2902–2908. doi: 10.4103/ijo.IJO_86_22.
Gao JL, Rogers GF, Myseros JS, Habeshian KA (2022). Facial cleft presenting as a congenital facial papule. Pediatr Dermatol. 39(6): 990–991. doi:10.1111/pde.15059.
Hutagalung MR, Putri IL, Wahdini SI, Dachlan I, Zarasade L (2022). Tarsoconjunctival-skin flap as another option in correcting ectropion for oro-ocular cleft reconstruction: report of 2 cases. Cleft Palate Craniofac J. 59(9): 1201–1205. doi:10.1177/10556656211-036620.
James O, Sabo VY, Adamson OO, Otoghile B, Adekunle AA, Adeyemo WL, Ladeinde AL, Ogunlewe MO (2023). Presentation and management of atypical orofacial clefts: a single-institution experience for 13 year period. Cleft Palate Craniofac J. 60(2): 133–141. doi:10.1177/10556656211055012.
Kim JH, Lim SY (2024). Evaluation of long-term outcomes of transverse facial cleft repair. Cleft Palate Craniofac J. 61(3): 326–331. doi:10.1177/10556656231207205.
Kini U (2023). Genetics and orofacial clefts: a clinical perspective. Br Dent J. 235(3): 221–226. doi:10.1038/s41415-023-5994-3.
Li M, Fu S, Wang S, Cui Q, Wu Y (2024). Reconstruction of oblique facial cleft deformity with adjacent flap and nasolabial flap: a case report. Int J Surg Case Rep. 121: 109981. doi:10.1016/j.ijscr.2024.109981.
Lu J, Peng B, Wang W, Zou Y (2024). Epithelial-mesenchymal crosstalk: the scriptwriter of craniofacial morpho-genesis. Front Cell Dev Biol. 12: 1497002. doi:10.3389/fcell.2024.-1497002.
Lucangeli N, Cannistrà MS, Scopelliti D, Parisi P, Tripodi D, Barbet P, Cannistrà C (2025). Facial clefts and the trigeminal nerve: a narrative review of the literature and clinical considerations in the era of personalized medicine. J Pers Med. 15(11): 556. doi:10.3390/jpm15110556.
Omodan A, Pillay P, Lazarus L, Satyapal K, Madaree A (2022). Tessier number 3 and 4 clefts: clinical presentation and associated clefts in a South African population. Cleft Palate Craniofac J. 59(10): 1299–1305. doi:10.1177/1055-6656211036306.
Pellerin P, Tonello C, da Silva Freitas R, Tang XJ, Alonso N (2023). Tessier’s cleft number 6 revisited: a series of 26 new cases and literature review of 44. Cleft Palate Craniofac J. 60(8): 938–948. doi:10.1177/10556656221086459.
Prasetyo AT (2025). Challenges in nasal reconstruction for facial clefts Tessier 3 bilateral and Tessier 0: a staged surgical approach case report. Maxillofac Plast Reconstr Surg. 47(1): 7. doi:10.1186/s40902-025-00461-0.
Rasul MI, Fujiwara K, Ruslin M, Astuti IA, Takaichi M, Noguchi M (2025). Amniotic band syndrome with severe facial cleft: a case report. Cleft Palate Craniofac J. 62(1): 149–153. doi:10.-1177/10556656231199648.
Roohani I, Trotter C, Shakoori P, Moshal TA, Lasky S, Manasyan A, Wolfe EM, Magee WP, Hammoudeh JA (2023). Lessons learned from a single institution’s eight years of experience with early cleft lip repair. Medicina (Lithuania). 59(10): 1741. doi:10.33-90/medicina59101741.
Soedjana H, Prasetyo AT, Mayrissa TF, Andalu N (2023). Neglected case of facial cleft associated with Adam complex: soft tissue reconstruction with Abbe flap and nasal transposition — a case report. J Maxillofac Oral Surg. 22(4): 966–971. doi: 10.10-07/s12663-023-01903-w.
Taub PJ, Hazkour N (2025). Tessier facial clefts. Facial Plast Surg Clin North Am. doi:10.1016/j.fsc.2025.07.006.
Tonello C, Martins DANP, Baptista MAFB, Mondelli F, Kokitsu Nakata NM, Feitosa LB, Alonso N (2022). Tessier 3 and 4 clefts and choanal atresia: an unusual association? Cleft Palate Craniofac J. 59(10): 1228–1232. doi: 10.1177/10556656211042172.
Van Slyke AC, Burge J, Bos R, Parker G, Chong DK (2022). The anatomical subunit approach to managing Tessier numbers 3 and 4 craniofacial clefts. Plast Reconstr Surg Glob Open. 10(10): e4553. doi:10.1097/GOX.00000000000-04553.
Vibert F, Schmidt G, Löffler K, Gasiorek-Wiens A, Henrich W, Verlohren S (2024). Accuracy of prenatal detection of facial clefts and relation between facial clefts, additional malformations and chromosomal abnormalities: a large referral-center cohort. Arch Gynecol Obstet. 309(6): 1971–1980. doi:10.1007/s00404-023-07084-8.
Walsh K, Foy C (2025). Surgical repair of cleft lip: comparison of neonatal and standard timing in a systematic review. Cureus. 17(9): e92858. doi:10.7759/cureus.92858.
Wang X, Wang H, You J, Zheng R, Xu Y, Zhang X, Guo J, Fan F (2021). Morphological analysis of nose in patients of Tessier No. 0 cleft with a bifid nose in China. Front Pediatr. 9: 768176. doi:10.3389/fped.2021.768-176.
Zhang Z, Hou Z, Wang Y, Ma L, Li D (2025). Clinical manifestations of and surgical treatment strategies for Tessier No. 3 and No. 4 clefts in Chinese patients: a large retrospective case series. J Craniofac Surg. 36(6). doi:10.1097/SCS.0000000000011373.
