Reconstruction of Tessier no. 4 clefts revisited.

Atypical craniofacial clefts present a surgical challenge. Little is published about their treatment because of their rarity. Such is the nature of Tessier no. 4 clefts and others with shortened oculoalar and oculo-oral distances requiring multiple operative interventions. The soft-tissue abnormalities include a cleft of the lip with possible extension into the check, orbital dystopia, and globe abnormalities and a decreased oculo-oral distance. Typically, multiple local cheek and nasal flaps are used to close the soft-tissue defects, elevate the medial canthus, and protect the globe. However, this approach creates traction on the lower eyelid, suboptimal location of the scar, and poor color match between the flaps. We present two cases of Tessier no. 4 clefts and one case of a multiply clefted (Tessier nos. 1/13, 2/12, 3/11) child with the typical contracted oculoalar and oculo-oral distances. Reconstruction with a superiorly based nasolabial flap transposed 90 degrees under the eye was performed in all three as a primary procedure. This technique respects aesthetic units and places the resulting scars in less conspicuous areas on the face.