Surgical Strategies Early Bone Grafting in Tessier Number 4 Cleft: A Case Report Alper Sari, MD Reha Yavuzer, MD Selahattin Özmen, MD Serhan Tuncer, MD Osman Latifoglu, MD Ankara, Turkey Rare craniofacial clefts have an incidence of at least 1 per 100,000 live births. A Tessier number 4 cleft is one of the most rare craniofacial clefts, with less than 50 cases being reported in the literature. Both soft and bony tissue abnormalities take place in the cleft morphology, so not only clinical examination of the maxillofacial region but a detailed radiologi- cal workup is needed to assess clearly the nature of the clefts. A patient with a Tessier number 4 cleft is presented, whose bony defect was obliterated with autogenous iliac bone graft chips and soft tissue reconstruction was performed with multiple Z- plasty flaps. Postoperative clinical and radiological results demonstrate fine healing and good cosme- sis. Although controversy still exists about the treatment of facial clefts with early bone grafts, ad- vantages of performing both bony and soft tissue reconstructions in a single session make this treat- ment a good alternative with satisfactory clinical and radiological results. Key Words: Craniofacial cleft, Tessier cleft, bone grafts G reat controversy existed in naming rare craniofacial clefts until 1976; at that time and based on his personal experience, Tessier 1 classified them with a numbering system ranging from 0 to 14. Although the Tessier classification brought ease in naming the clefts and resolved the misunderstandings in communication among clinicians, controversy still exists in treatment options and their timing. Major discussions are about the potential inhibitory effects, efficacy, and timing of bone grafting. This controversial issue regarding early bone grafting even exists with the more com- monly seen cleft lip and palate. In the literature, both opponents and proponents of early bone grafting ex- ist. Number 4 cleft is one of the most rare classifi- cations among the Tessier clefts, and less than 50 cases have been reported in the literature, with the largest series being reported by Tessier himself and Kawamoto and his colleagues. 1–3 Van der Meulen and his colleagues 4–6 classified these clefts on a more embryological basis, and instead of the term cleft, they used the term dysplasia. In these series, they pre- sented the so-called Tessier number 4 cleft as medial maxillary dysplasia. We present a case of unilateral Tessier number 4 cleft in an 8-month-old infant, including its clinical presentation and preferred treatment. CASE REPORT A n 8-month-old male infant presented with a left- sided cleft lip that continued as an ascending groove on his cheek in an oblique direction (Fig 1). The cleft was located more laterally than the typical cleft lip, midway between the oral commissure and the philtral column. The cleft also caused separation of the maxillary alveolar arch. The nasal ala was not involved but was slightly superiorly rotated. The medial canthus was slightly lowered, but no clefting of the lower eyelid was detected. The computed to- mography examination revealed that the alveolar cleft was ascending to the anterior maxillary wall but not reaching the orbital rim. The patient was diag- nosed as having a unilateral Tessier number 4 cleft with partial expression. His systemic physical exami- nation and past medical history were otherwise nor- mal, as was his family history. From the Department of Plastic and Reconstructive Surgery, Gazi University, Medical Faculty, Ankara, Turkey. Address correspondence to Dr Yavuzer, Baris Sitesi 87, Sokak Number 24, 06530 M. Kemal Mah, Ankara, Turkey; e-mail: ryavuzer@hotmail.com 406