(8) Achieving Commissural Symmetry in Patients With Tessier No. 7 Cleft: Long-Term Outcomes and Management

Abstract:

Background: Restoring facial symmetry in patients with Tessier 7 clefts may present challenges in achieving functional and aesthetic outcomes. While oral commissure reconstruction has been performed with varying degrees of success, there remains a need for comprehensive facial analysis to evaluate the symmetry of outcomes. Similarly, the rarity of this condition has resulted in limited data regarding the efficacy of current treatment paradigms. This study analyzes facial anthropometrics to compare postsurgical symmetry after commissuroplasty in children with Tessier 7 cleft over 19 years.

Methods: A retrospective review of children who underwent commissuroplasty at a major children’s hospital between 2005 and 2024 was conducted. Cohorts included preoperative and postoperative measurements within 6 months. Anthropometric measurements from frontal images (repose position) included stomion-to-chelion (Sto-Ch), chelion-to-contralateral ala (Ch-Ala), chelion-to-lateral canthus line (Ch-LC), chelion-to-menton (Ch-Men) and chelion angle deviation (Ang-Dev) (Figure 1). Symmetry ratios between the operative and non-operative sides were calculated using a range of [0.0-1.0], with 1.0 signifying ideal symmetry. For patients with bilateral Tessier 7 clefts, symmetry ratios were calculated from both sides of the face. Major revisions were defined as repeat commissuroplasty for facial asymmetry or excision of contracted scarring. Statistical analysis was performed using Student T-tests.

Results: A total of 32 patients underwent commissuroplasty for Tessier 7 of which 25 met inclusion criteria. Six patients had bilateral Tessier 7 clefts and 19 patients had unilateral Tessier 7 clefts (Right-sided: 76% vs Left-sided: 24%). All patients’ clefts were repaired with a myomucosal advancement flap commissuroplasty technique. Mean age at surgery was 13.3 ± 3.0 months. Of all patients, 48% were female, 32% had an additional Tessier cleft, and 20% were syndromic. Overall, 25% of patients required major revisional procedures. Compared to the preoperative cohort, postoperative patients demonstrated increased symmetry in 4 anthropometric measurements (Sto-Ch: 0.73 vs 0.89, P < .001; Ch-Ala: 0.84 vs 0.92, P < 0.001; Ch-LC: 0.88 vs 0.94, P = .002; Ch-Men: 0.86 vs 0.94 (P < .001). No significant difference was found between pre- and postoperative chelion angle deviation symmetry ratios (Ang-Dev: 0.51 vs 0.61, P = .139). Percent improvement was recorded across each measurement (Table 1). Mean follow-up time was 3.74 ± 6.5 years for 7 patients. Symmetry ratios from follow-up anthropometric measurements did not vary significantly from postoperative asymmetry ratios.

Conclusion: Overall, oral commissure reconstruction demonstrated improved facial symmetry in the following measurements: Sto-Ch, Ch-Ala, Ch-LC, and Ch-Men with the myomucosal advancement flap technique. However, there was no significant improvement in chelion angulation symmetry after the surgery. Postoperative symmetry did not change significantly over follow-up time. More studies are required to evaluate the most effective means of repairing these clefts to optimize long-term symmetrizing outcomes.
Figure 1. Facial AnthropometricsTable 1. Mean Symmetry Ratios (SR) Across Anthropometric Measurements