Patient 2 was remarkably similar, although her cleft was less severe and on the right side of the face.

She also had a massive hydrocephalus identified prior to birth and was delivered via planned C-section at 38 weeks. She also underwent neurological procedures before undergoing craniofacial repairs.

At 1 month of age, she underwent a lip adhesion by the Seibert technique. Of note, unrelated to the Tessier cleft, VP shunt-induced craniosynostosis developed in this patient, which ultimately necessitated total cranial vault remodeling with fronto-orbito advancement.

Upon oculoplastic examination, the team noted that Patient 2’s eyelid was lowered and rotated down.

Unlike Patient 1, there was an island of soft tissue between the oral and ocular portions of the cleft.

She had thick boney features in the prolabium that proved resistant to taping, necessitating an initial lip adhesion surgery.

Similar to Patient 1, a “top-down” approach was elected with design of a left sided, superolaterally based Reiger dorsal nasal flap with a modest back-cut.

The bilateral lip repair was performed similarly to Patient 1, with the exception of the already performed lip adhesion and still very protrusive premaxilla, which necessitated a vomer setback to better align the premaxillary segment with the lateral segments and reduce tension on the lip repair.

This lip adhesion tissue was released from the lateral lip flaps and prolabial tissue and later joined together to line the premaxilla creating a separation from the lip mucosa.

The early postoperative course for Patient 2 was complicated by a minor wound infection at the glabella region managed with local wound care in addition to mild hypertrophic scarring.