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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 3  |  Issue : 2  |  Page : 103-106

Tessier No. 3 incomplete cleft: Nasal reconstruction using turbinate mucosal flap


1 Department of Plastic and Reconstructive Surgery, Saifee Hospital, Mumbai, MaharashtraDepartment of Plastic and Reconstructive Surgery, Saifee Hospital, Mumbai, Maharashtra, India
2 Department of Dental Surgery, Saifee Hospital, Mumbai, Maharashtra, India
3 Department of General Surgery, Saifee Hospital, Mumbai, Maharashtra, India

Date of Web Publication2-Aug-2016

Correspondence Address:
Abbas Asgharali Mistry
Department of Plastic and Reconstructive Surgery, Saifee Hospital, No. 15/17, Maharshi Karve Road, Opposite Charni Road Railway Station, Mumbai - 400 004, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-2125.187526

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  Abstract 

Facial clefts are extremely rare congenital deformities, especially Type 3. In 1976, Tessier classified the clefts between 0 and 14 based on the central facial landmarks. The Tessier type 3 facial cleft, also called a nasoocular or a nasomaxillary cleft, results from the disruption of the lateral nasal and maxillary processes. It is characterized by inferior displacement of the medial canthus, superior displacement of the alar base, cleft lip and palate, coloboma of lower eyelids, nasolacrimal abnormalities, cleft of the inferomedial orbital wall, and teleorbitism. Although the literature is replete with classification and morbid anatomy of such cases, surgical management is still a challenge. In this article, we report a Tessier No. 3 incomplete cleft, wherein the turbinate mucosal flap was used for the nasal lining in reconstruction of the nose. Probably, this is the first time that the turbinate mucosal flap is used for reconstruction in Tessier No. 3 cleft.

Keywords: Nasal reconstruction, Tessier type 3 cleft, turbinate mucosa flap


How to cite this article:
Mistry AA, Qayyumi B, Mistry TA, Kardile C. Tessier No. 3 incomplete cleft: Nasal reconstruction using turbinate mucosal flap. J Cleft Lip Palate Craniofac Anomal 2016;3:103-6

How to cite this URL:
Mistry AA, Qayyumi B, Mistry TA, Kardile C. Tessier No. 3 incomplete cleft: Nasal reconstruction using turbinate mucosal flap. J Cleft Lip Palate Craniofac Anomal [serial online] 2016 [cited 2022 Jul 6];3:103-6. Available from: https://www.jclpca.org/text.asp?2016/3/2/103/187526


  Introduction Top


Tessier type 3 clefts are grouped under rare craniofacial clefts. [1],[2] The occurrence of rare craniofacial clefts is reported in 0.7-5.4 out of 1000 cases of cleft lip and palate. [3]

Mishra and Purwar [3] have divided the whole defect into three different segments, namely, eyelid, lip, and nasomalar components. This case only had the eyelid and nasomalar components involved. The lip and the palate were normal. Surgical management of such cases becomes more challenging as the classical surgical plan and markings are not standardized which are based on previous reports focused on a single case.

Instead of using the traditional cheek skin flap which is a turned over flap from the edge of the defect for the inner lining of the nose, we have used the nasal turbinate mucosal flap which is probably used for the first time in this type of cleft.


  Case report Top


A father brought his 12-year-old daughter with Tessier type 3 incomplete cleft of the left side. Financial constraint and multiple visits to various doctors had dejected him. He was uncooperative and refused any further investigation.
Figure 1: Preoperative Tessier cleft 3 showing canthal dislocation and deficiency nasomalar region

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As is evident from [Figure 1], there was a cleft in the lower half of the lateral wall of the nose with severe ectropion of the lower eyelid with medial canthal dislocation. There was a gross shortage of tissue in the nasomalar region with exposed turbinate. The lip segment was intact.

The surgical correction described in the literature is basically advancement and/or rotation of cheek flap, interdigitating with the nasal skin for the outer lining of the nose with rotation of the remnant of the nasal ala, [4] at the same time adding skin to the lower eyelid as one corrects the ectropion along with canthal fixation. [5] Alar transposition flaps have also been described. [6]

However, as regards to the inner lining of the nose, it is created mainly by turning in of the cheek skin and some amount from the in-turned alar skin. [3] On close examination, it was felt that there was enough mucosa in the exposed and hypertrophied turbinate [Figure 2]. This turbinate mucosa was opened as shown in [Figure 3], which would now form the inner nasal lining. The surface defect of the nose was corrected by rotating the ala and advancing the cheek flap simultaneously correcting the ectropion [Figure 4].
Figure 2: Intraoperative: Exposed turbinate with its mucosa

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Figure 3: The turbinate mucosa (thin arrow) is unfolded to form inner lining. Releasing incision (dotted line) to advance and rotate the ala and lateral wall of the nose (thick arrow)

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Figure 4: Immediate postoperative showing the flaps in place

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The results were equivocal, but the father was happy. The child was regularly brought for follow-up for 2 years [Figure 5], [Figure 6], and [Figure 7]. During this period, our repeated request to fix the canthus and correct the alar notch fell on deaf years and the patient was lost to follow-up.
Figure 5: Late postoperative: Good cosmetic result shown postoperatively. The medial canthal area requires revision; however, patient refused the second surgery

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Figure 6: Front view late postoperative with eye closed

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Figure 7: Front view late postoperative with eye open

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  Discussion Top


Because of the low incidence of such facial clefts, there is no definite line of treatment and a plastic surgeon, who happens to get a few patients in his entire practice is unable to do total justice to the patient.

Use of nasal turbinate mucosal flap for correction of septal defects, reconstruction of the nose after tumor extirpation, [7] palatal fistulae, and excessive nasal mucosal defect in bilateral cleft lip [8],[9] has been described. However, there is no mention of its use in other rare congenital facial clefting.

For the reconstruction of the outer lining of the nose, rotation of ala with advancement and/or rotation of cheek flap interdigitating with the nasal skin are the established treatment.

However, as regards to the inner lining of the nose, it is created mainly by a turnover flap of the cheek skin from the edge of the defect. This hinged flap based on mucocutaneous junction is an additional requirement on the already deficient cheek skin in the nasomalar region. Furthermore, this flap has no definite blood supply as it is based on mucocutaneous junction. Thus, long-term results are marred due to marginal necrosis and scarring in both, the inner lining as well as the outer skin.

In contrast, the turbinate mucosal flap provides large amounts of well-vascularized mucosa. The inferior turbinate flap has a dual blood supply as nicely outlined by Burnham [10] and Padgham and Vaughan-Jones. [11] The main blood supply enters the turbinate from above, 1 cm to 1.5 cm from its posterior border, from the descending branch of the sphenopalatine artery.

No doubt, the turbinate mucosal flap had exhibited a robust vascularity at the time of surgery. The entire cheek skin then can be used for the outer lining. We could achieve a very good closure. This proves that additional tissue available for the lining of the nose will leave more skin to play with for the reconstruction of the outer deficit of the skin thus enabling better esthetic results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We would like to acknowledge Dr. Yusuf A. Mistry.

Financial support and sponsorship

Nil

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Tessier P. Anatomical classification facial, cranio-facial and latero-facial clefts. J Maxillofac Surg 1976;4:69-92.  Back to cited text no. 1
    
2.
Ranta R, Rintala A. Oblique lateral oro-ocular facial cleft. Case report. Int J Oral Maxillofac Surg 1988;17:186-9.  Back to cited text no. 2
    
3.
Mishra RK, Purwar R. Formatting the surgical management of Tessier cleft types 3 and 4. Indian J Plast Surg 2009;42 Suppl 1:S174-83.  Back to cited text no. 3
    
4.
Reddy SG, Reddy RR, Obwegeser J, Mommaerts MY. Options for the nasal repair of non-syndromic unilateral Tessier no 2 and 3 facial clefts. Indian J Plast Surg 2014;47:340-5.  Back to cited text no. 4
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5.
Giglio A, Ruschel FF, Barcellos C, Pavelecini M, Chem RC. Rotation and advancement flap of the cheek in the treatment of rare craniofacial clefts. J Craniofac Surg 2008;19:1411-5.  Back to cited text no. 5
    
6.
Cizmeci O, Kuvat SV. Tessier no 3 incomplete cleft reconstruction with alar transposition and irregular z-plasty. Plast Surg Int 2011;2011:596569.  Back to cited text no. 6
    
7.
Murakami CS, Kriet JD, Ierokomos AP. Nasal reconstruction using the inferior turbinate mucosal flap. Arch Facial Plast Surg 1999;1:97-100.  Back to cited text no. 7
    
8.
Noordhoff MS. Bilateral cleft lip reconstruction. Plast Reconstr Surg 1986;78:45-54.  Back to cited text no. 8
    
9.
Rahpeyma A, Khajehahmadi S. The last resort for reconstruction of nasal floor in difficult-to-repair alveolar cleft cases: A retrospective study. J Craniomaxillofac Surg 2014;42:995-9.  Back to cited text no. 9
    
10.
Burnham HH. An anatomical investigation of blood vessels of the lateral nasal wall and their relation to turbinates and sinuses. J Laryngol Otol 1935;50:569-93.  Back to cited text no. 10
    
11.
Padgham N, Vaughan-Jones R. Cadaver studies of the anatomy of arterial supply to the inferior turbinates. J R Soc Med 1991;84:728-30.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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