Facial cleft is a rare congenital anomaly with incidence between 1.43 and 4.85 per 100 000 live birth.¹ Treatment of rare facial cleft is complex, and the evaluation of its long-term results is challenging because of the low incidence. In comparison to cleft lip and palate abnormalities, the operation technique for the repair facial cleft is currently not well established because high variants and low incidence may occur in facial cleft cases

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Tessier's classification is a clinical descriptive system of clefts rather than a system based on the involved structures or embryologic origin. The clefts are numbered from 0 to 14 in a counterclockwise fashion around the orbit. The value of Tessier's classification is the fact that it encourages the physician to look for malformations along the entire cleft direction.³ Each cleft path, the combination of 2 clefts, adds up to a value of 14.²

The embryologic basis of these clefts is linked to failed fusion between the maxillary and medial nasal prominences. This failure results in clefts that compromise facial aesthetics and function, including feeding, breathing, and vision. Because of this, management must be individualized and involve a multidisciplinary team, often over multiple surgical stages.

A 8 months old male child, resident of Jaspura, Bharatpur presented with Chief Complaints of Unusual shape and symmetry of face noted by parents since birth, inability to suck while breastfeeding, and frequent episodes of cough and cold. History of Presenting Complaints were midface deformity, h/o taking top feeds with the help of a dropper till 2.5 months f/b feeding with bottles with modified nipples. Also had1-2 episodes of common cold every month along with sneezing, irritability, watering of eyes, difficulty in sleep-got relieved bt treatment on opd basis. The baby didn’t need hospitalization in 8 month, had no associated other limb /STERNAL anomalies or associated any abnormal movements, also had no difficulty in breathing neither had h/o seizures/ear discharge. Findings over face: frontal flattening, increased interpupillary distance, widening of root of nose, enlarged and deviated nasal septum, absent nasal sill, absent floor of nose, tip of nose and prolabiumseparated, superiorly displaced premaxilla, visible nasal turbinates, bilateral cleft in lip, cleft in palate, normal tongue were seen. Personal History : The baby was the 1st born male child in family had a normal vaginal delivery at full term with birth weight of 3.5kg in a primary health care facility. Baby had normal bladder and bowel habits, sleep and appetite. Also developmental milestones achieved as per age except for speech. Immunization History : The baby had complete as per age group. Peri-Natal History : G1P0T0P0A0L0 The age of mother at conception is 21yr had no h/o any consanguinity, no h/o radiation exposure to mother, no h/o any teratogenic drug intake, no h/o any addiction, no h/o any significant illness in mother during all three trimesters. Mother had h/o three antenatal visits with USG for fetal well being done at 3 and 6 months of gestation and 1 week before expected date of delivery elsewhere. Family History: parents and grand parents found normal. General Physical Examination : On admission Child is conscious and active with good cry, fairly nourished, No evidence of pallor , cyanosis, icterus , clubbing , edema , lymphadenopathy, Wt at 8mon 12 days, length and head circumference- all>50th centile. Vitals : Pulse- 110/min, SpO2 - 99% on room air Local Examination Baby had prominent forehead, increased intercanthal distance ( 7cm ), Hypertelorism, widening of glabella, deformed tip of nose and nasal septum, absent nasal sill and floor, bilateral cleft lip, cleft palate also seen. Other Systemic Examination Cardio-Vascular System- S1,S2 heard, no murmurs heard Respiratory System- bilateral air entry equal, no added sounds Gastro-Intestinal System -soft abdomen, no palpable organomegaly Musculo-Skeletal System - moving all limbs, no visible bony deformity Genito-Urinary System-normal structure and function Nervous System-conscious, active with good cry Provisional diagnosis: Based on all examinations the probable diagnosis was Congenital facial cleft. DIFFERENTIAL Diagnosis / Syndromes with associated anomalies • Treacher Collins syndrome • Goldenhar syndrome • Peiffer’s syndrome • Carpenter’s syndrome • Muenke syndrome • Van Der Woude syndrome 3D CT FACE Wide cleft between bony orbits, maxillary bones and ethmoid elements with cleft extending to sphenoid posteriorly. The ossification of frontal bone appears deficient, median cleft nose, premaxilla, upper lip and palate, bilateral hypertelorism were seen. FINAL DIAGNOSIS: this was a case of Craniofacial cleft(Tessier cleft type1 and 13) with Paramedian cleft had a incidence-1.4-4.9 per 1lakh, may present unilateral or bilateral, and is sporadic. SURGICAL PLAN Following surgeries were done: Cranio-facial cleft - facial bipartition hypertelorism - correction by bringing both orbits together Bilateral Cleft lip - lip repair Cleft Palate - Repair of cleft Nasal distorted shape and asymmetry - Corrective Rhinoplasty Surgical Management FACIAL BIPARTITION WITH BILATERAL CLEFT LIP REPAIR Investigations: Lab investigations: Parameters Result Value WBC 14900/micL Hb 13.5 gm/dl Platelet 1,58,000/micL PT-INR 17.5 sec – 1.4 RBS 89.0 mg/dl Na/K/Cl 136/3.8/116 mmol/L SGOT/SGPT 36 / 35 U/L Se Creatinine 0.2mg/dl HIV/HBsAg/Anti-HCV Negative X-Ray Chest P/A View : Normal study 2-D Echocardiography : Normal cardiac structure and function, USG CHEST : Minimal free fluid in right pleural space SURGICAL PLAN : 1. Cranial Vault + Orbital + Mid face(Nose and lip)Correction 2. Cleft Palate Repair 3. Corrective Rhinoplasty OPERATIVE MANAGEMENT I Surgery: Cranial cleft + Orbital Correction+ nasal and bilateral cleft lip repair (Facial bipartition+ lip repair) Fig. 1 Bicoronal Incision & Flaps raised Fig . 2 Frontal Craniotomy + Supraorbital Bandeau Fig 3. DISSECTION OF ORBITAL CONTENTS Fig 4. MEDIALIZATION OF ORBIT Fig 5. REPLACING BONE FRAGMENTS AND FIXATION Fig 6. CORRECTION OF NASAL DEFORMITY Fig 7. CORRECTION OF CLEFT LIP DEFORMITY Fig : 8. CLOSURE OF INCISION POST-OPERATIVELY for postoperative care Patient was shifted to PICU and sedation & elective mechanical ventilation was advised for 24 hours (airway & tongue edema). Following surgery anti convulsant prophylaxis (Inj.Levetiracetam 85 mg 12 hrly i.v) and antibiotics (Inj.Meropenem +Inj. Vancomycin) were given. Post Op Course Day 0 SIMV-VC Mode ,throat pack in situ Day 1 1 Unit PRBC transfusion. Day 2 throat pack removed Day 3 CPAP trial given followed by extubation, on HFNC Day 4 Sedation stopped, feed started by orogastric tube Day 8 patient shifted to ward (Parents sensitized for proper follow up & for next surgery) POST-OP X-RAY Comparative Photographs Pre-Op Post –op Fig :9 pre op and post op comparative photographs After 3 months of first surgery correction of Cleft Palate will be done and then corrective Rhinoplasty will be done. Literature Craniofacial cleft (Tessier cleft type1 and 13)3 Paramedian cleft with Incidence-1.4-4.9 per 1lakh.4 It May present unilateral or bilateral. It is Sporadic in nature.5 Embryology of face Fig : 11 Failure of fusion of different processes cause cleft formation6 Fig 12FACIAL BIPARTITION- STANDARD MODALITY OF TREATMENT7

Most people consider cleft deformity as  God’s curse and live with it, as they assume it untreatable. Early surgical intervention is required. Better instrumentation/anesthesia/ICU care have improved surgical results  and With proper counselling and public awareness, we can improve the quality of life of these patients.

1.Wolfe A. Foreword: how our surgical universe has become “orbito-centric”? Lessons learned from Paul Tessier. Ann Chir Plast Esthet. 1995;40(1):9–10. 

2. Bensaghir H, Ben Driss C, Fejjal N. Tessier type 3 facial clefts: A case report and literature review. Int J Surg Case Rep. 2025 Sep;134:111818. doi: 10.1016/j.ijscr.2025.111818. Epub 2025 Aug 14. PMID: 40818407; PMCID: PMC12392671.
3. da Silva Freitas R., Alonso N., Busato L., et al. Oral-nasal-ocular cleft: the greatest challenge among the rare clefts. J. Craniofac. Surg. 2010;21(2):390–395.
4. Tessier P. Anatomical classification of facial, cranio-facial, and latero-facial clefts. J. Maxillofac. Surg. 1976;4(2):69–92.
5. Grayson B.H., Santiago P.E., et al. Presurgical nasoalveolar molding in infants with cleft lip and palate. Cleft Palate Craniofac. J. 1999;36(6):486–498. 
6. Mulliken J.B., Burvin R., Farkas L.G. Repair of bilateral complete cleft lip: intraoperative nasolabial anthropometry. Plast. Reconstr. Surg. 2001;107(2):307–314.
7. Kwon T.G. Accuracy and reliability of three-dimensional computer-assisted planning for orthognathic surgery. Maxillofac. Plast. Reconstr. Surg. 2018;40:14