Numerous transverse facial cleft repair techniques and designs have been described; however, a complication of surgical reconstruction is scar formation with brown discoloration. This study investigated the histological basis of the darker white lip at the cleft margin, its role in postoperative brown discoloration, and the potential esthetic benefits of extending the excision. In this retrospective analysis, patients with transverse facial cleft were divided into limited and extended excision groups. Histological assessment of melanin pigment was performed using Fontana-Masson staining, and postoperative buccal scars were evaluated from photographs using the Stony Brook Scar Evaluation Scale. The Mann-Whitney U test was used for statistical analysis. We divided 16 Japanese patients (4 boys and 12 girls) into limited (n = 9) and extended excision groups (n = 7). The cleft length was 8.6 ± 2.1 and 8.9 ± 3.3 mm in the limited and extended excision groups, respectively, with unilateral/bilateral laterality being 9/0 and 6/1, respectively. Initial surgeries for both groups were performed at 11.4 ± 8.4 and 8.3 ± 7.7 months, and scar evaluations were based on photographs obtained at 47.8 ± 13.5 and 27.1 ± 14.2 months, respectively. Histology showed increased melanin in the darker area of the white lip at the cleft margin, with markedly reduced pigment density in the normal-toned area. The extended excision group had less colored scar than the limited excision group (p < 0.05). Incorporating pericleft pigmentation excision into surgical design may reduce postoperative periscar hyperpigmentation and improve esthetic outcomes for several years.

Given its rarity, there are few large-number studies regarding Tessier 7 clefts. A review and classification of 81 Tessier 7 patients who presented to our craniofacial center was performed. The most common Tessier 7 clefts were middle positioned, followed by agenetic, superiorly rotated, and inferiorly rotated clefts, respectively. A total of 77/81 patients had simple macrostomia and 4/81 patients had macrostomia with muscle diastasis. The most common associated anomalies were craniofacial microsomia, skin tags, and ear anomalies occurring in 80%, 71%, and 37% of patients, respectively. In this cohort, the most common subsequent procedures performed in our center were orthognathic surgery (15), fat grafting (11), and facial contouring (7). This information can assist clinicians in patient assessment, family counseling, and refining surgical planning. In this work, we compared our results to other centers by performing a meta-analysis and found we had a higher rate of left-sided clefts, craniofacial microsomia, and simple macrostomia. Our rates of bilaterality and gender distribution were similar to that of other centers. A review of 766 Tessier 7 presentations across 34 recent studies demonstrated unilateral clefts in 84.3% and bilateral clefts in 15.7% overall. Up to 62% of black African patients had bilateral Tessier 7 presentations. There was also increased rates of associated craniofacial microsomia in ethnically Chinese population groups. Overall review of 766 patients demonstrated more right-sided clefts than left, and a slight female preponderance.

Tessier no. 3 and no. 4 clefts are rare and difficult-to-treat orbitofacial malformations. The aim of the present study is to describe the clinical manifestations of these rare clefts observed in 21 patients treated with surgery over the past 15 years. The clinical data of all patients with Tessier no. 3 and no. 4 clefts treated between 2009 and 2024 by a single senior surgeon were reviewed. The patient's demographic data and associated clinical findings, including eyelid, lacrimal system, and eyeball anomalies, were recorded. The reconstruction methods used for each patient were noted and evaluated retrospectively. This study included 21 eyes of 21 patients with Tessier no. 3 and no. 4 clefts who underwent plastic surgery. Eight males and thirteen females were identified, and the age at initial treatment ranged from 1 to 20 years. A lower eyelid coloboma was observed in most patients (14 patients); 12 of whom presented with medial canthus dystopia. Seven patients presented with isolated medial canthus dystopia. Thirteen patients had lacrimal system anomalies. Microphthalmia and ipsilateral anophthalmia were detected in 5 and 3 patients, respectively. Satisfactory esthetic and functional outcomes were achieved in all patients owing to the use of traditional techniques and techniques modified by the authors. The clinical manifestations of Tessier no. 3 and no. 4 facial clefts vary, thus treatment plans and techniques must be personalized to meet the needs for each patient.

This case report presents the rare association of Tessier number 4 and 5 facial clefts with a palatal cleft in a 4-month-old infant, encountered during a humanitarian mission in Sabou, Burkina Faso. The patient, born with bilateral facial clefts and right anophthalmia, was planned for a 2-step surgical approach. The first surgery addressed the facial clefts, including a modified unilateral cleft lip repair and Z-plasty techniques for the left Tessier number 5 cleft. The second surgery, palatoplasty will be performed in the next mission. Follow-up assessments showed excellent outcomes, including improved facial aesthetics and ocular protection. The etiology of Tessier clefts remains uncertain, with multiple contributing factors such as genetic predisposition, craniofacial embryogenesis, and environmental influences. This case highlights the challenges of managing complex craniofacial deformities in resource-limited settings and underscores the importance of humanitarian missions in providing life-changing care to patients with limited access to specialized treatments.

Craniofacial clefts are extremely rare. In 1976, Paul Tessier developed a comprehensive numerical classification system to categorize craniofacial clefts based on precise anatomic location. In order to comprehend craniofacial cleft development, it is crucial to understand embryologic development of the face. Craniofacial clefts can be classified into 4 main categories: oral-nasal (number 0-3), oral-ocular (number 4-6), lateral face (number 7-9), and cranial (number 10-14). Treatment goals include restoring oral competence and function, achieving nasal symmetry, establishing separation of anatomically distinct cavities, addressing orbital asymmetries, hypotelorism, or hypertelorism, and reconstructing cranial defects caused from encephaloceles.