title: Tessier no. 4 facial cleft: evolution of surgical treatment in a large series of patients.
abstract: BACKGROUND
  : Tessier no. 4 facial cleft is a rare, complex, and challenging craniofacial malformation. The present article aims to describe different clinical features evidenced in 21 cases of this malformation, discussing a 20-year experience with and evolution of its surgical treatment.
  
  
  METHODS
  : Some demographic data, clinical features, and reconstructive results were evaluated retrospectively. These patients have been evaluated and treated in three specialized Brazilian craniofacial centers. Nineteen were already operated on, with a mean follow-up of 3.5 years (range, 1 to 20 years).
  
  
  RESULTS
  : Sex distribution showed a male prevalence (2:1). The average age of initial treatment was 5.4 years. Four cases were affected on the right side of the face, seven on the left, and 10 bilaterally. Six patients had other rare associated facial clefts, including nos. 5 (three patients), 7, 9, and 10. Cleft upper lip was evidenced in all patients, and maxillary hypoplasia was present in five and maxilla cleft in eight. Lower eyelid coloboma was seen in almost every case (19 patients); 10 of these had medial canthus dystopia. Four patients had amniotic bands in the limbs. Surgical repair was individualized to each patient. Surgical experience gained with these patients allowed the authors to develop some technical modifications, which have improved aesthetic results, camouflaging scars into natural folds and anatomical units, without compromising functional outcomes.
  
  
  CONCLUSIONS
  : The great majority of Tessier no. 4 facial clefts can be appropriately treated using local flaps. Classic techniques are extremely useful, but long-term results could be improved if the technical modifications described were adopted.
authors.affiliation: Curitiba and São Paulo, Brazil From the Craniofacial Surgery Unit, Department of Plastic Surgery, São Paulo University; Plastic and Reconstructive Surgery Unit, Federal University of Paraná; and the Assistance Center for Cleft Lip and Palate.
authors.forename: Nivaldo
authors.initials: N
authors.lastname: Alonso
authors.forename: Renato da Silva
authors.initials: RDS
authors.lastname: Freitas
authors.forename: Gilvani Azor
authors.initials: GA
authors.lastname: de Oliveira E Cruz
authors.forename: Dov
authors.initials: D
authors.lastname: Goldenberg
authors.forename: Andre Ricardo
authors.initials: AR
authors.lastname: Dall'Oglio Tolazzi
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D002971:Cleft Lip / Q000453:epidemiology / Q000473:pathology / Q000601:surgery*; D003103:Coloboma / Q000473:pathology / Q000601:surgery*; D005143:Eyelids / Q000002:abnormalities / Q000601:surgery; D005145:Face / Q000002:abnormalities* / Q000601:surgery*; D005147:Facial Bones / Q000002:abnormalities / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D017678:Sex Distribution; D013524:Surgical Flaps