Return to Tour Zambia: URGENT Bilateral Cleft Face





Susan S

Posted on Tuesday, January 16, 2007 - 05:33 pm:   


Submitted by Goran J, Zambia

This is a 14-months-old child with Tessier III cleft face, bilateral.

Scheduled for surgery on Thursday.
Any suggestions or warnings would be welcome.

Goran J, Lusaka, Zambia

Gary F (MA, US)

Posted on Tuesday, January 16, 2007 - 05:45 pm:   


good luck! i've forwarded this to our craniofacial surgeon, janice l and hopefully she will respond

Amy W (CA, US)

Posted on Tuesday, January 16, 2007 - 10:40 pm:   


Dear Goran- You may want to approach this as a soft tissue cleft and a boney cleft. You can address the underlying boney defect at a later age But at this age you should plan to close the soft tissue cleft. I approach these Like a bilateral cleft lip and close the lip with a Modified Manchester closure. Then I close the cleft along the nasolabial fold in multiple layers making sure to approximate mucosa muscle and skin. I would then wait until the child is older-8-10 at the minimum to close the boney cleft with bone graft. You will need to suspend the medial canthus to the medial orbital wall and place a stent into the lacrimal duct if you can find it. If you cannot find the duct then anatomic approximation with a medial canthopexy of the lid will close the defect and correct the ectropion. Good luck!

Goran J (Zambia)

Posted on Tuesday, January 16, 2007 - 11:15 pm:   


Thanks Amy,

Will let you know how it ended. I was suggested that I should use Mustardee flaps bilat. to close the defect? Apparently Done by Dutch Surgeon 2 years ago in Amsterdam. There is no literature about bilat. Tessier III.
Will send pictures on Thursday.


Puneet P


Posted on Wednesday, January 17, 2007 - 12:40 am:   


Hi Goran,
I think this case is almost similar to Tessier cleft 4 . Generally the tissue is available but what you need is wide mobilisation and the right markings . Afterwards , everything fits like jigsaw puzzle . What I recommend is do one side first and go for the other side after 3 months. Please see the attatchment for markings and this case had excellent results , if you want I can post pre and post also
Dr. Puneet P
Tessier Cleft$

Goran J (Zambia)

Posted on Wednesday, January 17, 2007 - 04:31 am:   


Thanks Punit,
I appreciate your photo.Please send me postop pict. if you have.I have one article with unilateral Cleft but not for bilat.


Gary F (MA, US)

Posted on Wednesday, January 17, 2007 - 06:24 am:   


Dear Goran:
I am the CFC surgeon at UMass that Gary talked about. I'm using his entry codes because I can't find mine right off the bat. Anyway, I agree with preparing family for one side at a time. I think modified Mustarde flaps are going to be more applicable to your case than the Tessier 4 markings outlined as the medial canthal distortion in your case doesn't exist - just quite severe colobomas. The key unfortunately is the modified part as the lower eyelids and nasolabial area are going to be your biggest challenge - you can actually repair the bilateral cleft part by your simplest mode possible. One 'off the cuff' idea - after you mark out the columella, if vascularity permits, use the elements lateral to that to swing into the maxillary area - providing more soft tissue.
Good luck
Janice L

Goran J (Zambia)

Posted on Wednesday, January 17, 2007 - 08:45 am:   


I will do my best. If there is oxygen in OT tomorrow I will operate and send immediate postop. pictures. I am still more of a doing it bilaterally at the same time. Closing bil. cleft as well as the face using bilat. Mustardee flap.


Kevin H (TX, US)

Posted on Wednesday, January 17, 2007 - 12:30 pm:   


Dear Goran,
I agree with Dr. Lalikos about your markings. I can't see on the AP photo, but you may have some lateral nasal tissue that you can use as a superiorly-based flap and rotate it into the lower eyelid. The use of the excess lateral prolabial tissue for the maxilla is a good idea as well. Doing both sides at the same time shouldn't be an issue. I had a similar case recently (posted below). Good luck!

Kevin H

Kevin H (TX, US)

Posted on Wednesday, January 17, 2007 - 12:42 pm:   


Here is the photo
craniofacial cleft

Goran J (Zambia)

Posted on Wednesday, January 17, 2007 - 01:40 pm:   


Thanks for the photos Dr. H.
I think that I will have enough tissue in the prolabium to use to move it to nasolabial fold and higher towards eyelids.
I hope I will manage to operate the child tomorrow.


Puneet P (India)

Posted on Thursday, January 18, 2007 - 12:02 am:   


Hi . Here are the pre and post op photos
Puneet P
Tessier4  pre


tessier4 post

Pius A (Ghana)

Posted on Sunday, January 21, 2007 - 09:45 am:   


I agree that you consider the problem as a bilateral cleft lip and follow the same principles of bilateral lip repair. Thus you repair the defect lips at the same OP. This should be possible. I am looking for the photos of a bilateral cleft lip I did some time ago. I will send you the photos as soon I get the time.
Good luck, Goran.

Goran J (Zambia)

Posted on Wednesday, January 24, 2007 - 11:34 am:   


Here are photos. It took almost 3 hours but I think it was worth it. Hope postop period goes well.

Regards to all and thanks for your support.

Postop 1




postop 3



Paul R (MO, US)

Posted on Wednesday, January 24, 2007 - 02:35 pm:   


Dear Goran,

That looks beautiful. You do excellent work! Congrats and best wishes.


Paul R
St. Louis, MO

Janice L (MA, US)

Posted on Wednesday, January 24, 2007 - 05:00 pm:   


Kudos to you -
And it ONLY took 3 hours.
Big long distance high five.

Janice L
Worcester, MA

Puneet P (India)

Posted on Thursday, January 25, 2007 - 12:29 am:   


Great job, Goran .

Kevin H (TX, US)

Posted on Thursday, January 25, 2007 - 10:17 am:   


Dear Goran,
Beautiful work! Did you rotate any of the extra prolabial soft tissue?

Kevin H
Corpus Christi, TX

Goran J (Zambia)

Posted on Thursday, January 25, 2007 - 11:20 am:   


Thanks you all for your kind words. Credit also goes to my assistant, anaesthesiologists, scrub nurses and paediatritian and to all of you that contributed and did everything possible preoperatively that things go well.
To Dr. Hopkins, yes I used a bit on both side. I will take new photos tomorrow. Child was OK today but a bit swallen so I thought it would be better to take new photos tomorrow after some of the swelling goes down

Albert P (Ghana)

Posted on Thursday, January 25, 2007 - 12:39 pm:   


Excellent result. Well done Goran

Goran J (Zambia)

Posted on Friday, January 26, 2007 - 12:46 pm:   


Hi everyone.
Just to send first update on the child.
He is OK, Eating and behaving normal (only cries when he sees me!!!).
Here is also first follow up photo taken today.
follow up 1

Goran J (Zambia)

Posted on Thursday, February 01, 2007 - 02:37 pm:   


Dear Colleagues,
I discharged little one today.
Here are his final pictures.
Thank you all once again for your support.

Final pict. 1


Final w.v.


Finla lat.