American Association of Plastic Surgeons

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Etiology of Tessier Clefts: A Developmental Perspective
Christopher M. Runyan, MD, PhD1, Jesse A. Taylor, MD2, Lisa R. David, MD, Mba1.
1Wake Forest Baptist Medical Center, Winston Salem, NC, USA, 2University of Pennsylvania, Philadelphia, PA, USA.

Purpose: Complex craniofacial clefts are relatively rare anomalies of development, and involve multiple craniofacial structures including the lips, nose, cheeks, orbits and brow. In 1973 Tessier described a system of classification based upon cleft location and involvement of the underlying bone. Critics of Tessier's classification argue that it inappropriately groups primary clefts of the skin with "false clefts", which arise secondary to underlying bony defects, and that it does not always correspond to defects in embryonic fusion planes. This study seeks to reconcile Tessier's classification with what is known of craniofacial development.
Methods: A literature review was performed examining classification schemata of complex facial clefts and the current state of understanding of craniofacial development.
Results: "Primary clefts" (Tessier 0, 1, 2, 3, 7, 30) correspond with failure of fusion of the nasal, maxillary and mandibular processes, all known planes of fusion. Problematic "secondary clefts" (Tessier 4, 5, 6, 8-14) have been proposed to form because of underlying bony deficits. New data reveals that the maxilla and frontal bones are both formed by multiple ossification centers. The seams predicted to exist between these centers perfectly correspond with the locations of secondary clefts. This proposal is supported by the high incidence of concomitant clefting amongst adjacent secondary cleft sites (eg. 4-5, 13-14), as an ossification center error would influence both flanking seams.
Conclusions: This is the first comprehensive description of a developmental basis for Tessier clefts. All such clefts correlate with either cutaneous or bony embryonic fusion planes.


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