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Dissection of nasomalar component in a case of B/L Tessier cleft type-4. Note the lateral lacrimal duct (going towards & ending in the blind maxillary sinus) and medial lacrimal duct going towards the lateral nasal wall
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Figure 0016: Dissection of nasomalar component in a case of B/L Tessier cleft type-4. Note the lateral lacrimal duct (going towards & ending in the blind maxillary sinus) and medial lacrimal duct going towards the lateral nasal wall

Mentions: The inferior punctum (critical in drainage of lacrimal secretion) is continued as a separate “lateral lacrimal duct” into this blind maxillary sinus. Due to clefting, this duct never gets a chance to unite with its medial counterpart or to drain into the lateral wall of nose [Figure 5b], thereby obstructing free flow of lacrimal secretions. This understanding of morbid anatomy is critical in surgically uniting this “lateral lacrimal duct” with the “medial lacrimal duct,” or directly implanting it into the lateral nasal wall to facilitate proper drainage of lacrimal secretion.

Formatting the surgical management of Tessier cleft types 3 and 4

Mishra RK, Purwar R - Indian J Plast Surg (2009)

Bottom Line: Any person skilled in the plastic surgical art would appreciate that individual management of the aforesaid demarcated areas is easy as compared to the surgery of the entire craniofacial cleft, that too with the contemporary approach.We have evaluated this formatting technique with a 'split approach' in seven cases and found the results more convincing compared to those of classical methods.We invite the surgical fraternity to validate the surgical formatting in their settings and provide us with feedback on the same to consolidate these results.

Affiliation: Plastic Surgery Unit, Sushrut Institute of Plastic Surgery, 29, Shahmeena Road, Lucknow-3, U.P, India.

ABSTRACT
Tessier cleft types 3 and 4 are rare entities even among what are considered other rare craniofacial clefts. Very few cases have been reported worldwide, especially in the bilateral form. In the absence of any well-laid guidelines for management of such rare cases, plastic surgeons operate on such cases due to the inherent complexities in technique. To overcome this problem and provide a ground rule for surgical management of such cases, we propose an easier format with a 'split approach' of the affected areas. In our proposed formatting, we have divided the affected areas of the cleft into three components: 1. Lid component; 2. Lip component; and 3. Nasomalar component. Any person skilled in the plastic surgical art would appreciate that individual management of the aforesaid demarcated areas is easy as compared to the surgery of the entire craniofacial cleft, that too with the contemporary approach. We have evaluated this formatting technique with a 'split approach' in seven cases and found the results more convincing compared to those of classical methods. We invite the surgical fraternity to validate the surgical formatting in their settings and provide us with feedback on the same to consolidate these results.

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