Tessier-3 Clefts: Clinical Features and Staged Reconstruction.

BACKGROUND: Tessier-3 clefts are rare craniofacial malformations involving the oro-naso-orbital axis and are frequently associated with orbitolacrimal and inferomedial orbital abnormalities. Published series remain limited, and the relationship between anatomic involvement, reconstructive sequencing, and childhood operative burden remains poorly characterized. PATIENTS AND METHODS: A retrospective case series included 9 patients with Tessier-3 clefts treated at a tertiary craniofacial center between 2015 and 2024. Clinical records, operative reports, computed tomography imaging, and clinical photographs were reviewed. Orbital, lacrimal, skeletal, and periocular characteristics, reconstructive sequencing, operative burden, and follow-up outcomes were analyzed descriptively. Lacrimal drainage anomalies were present in 7 patients (77.8%), globe malposition in 5 (55.6%), and inferomedial orbital skeletal deficiency in all patients. Reconstruction followed an anatomy-driven rather than strictly age-based strategy, prioritizing early ocular and periocular protection with staged orbital, nasal, and skeletal reconstruction. Thirty-four reconstructive procedures were performed (mean, 3.8 procedures per patient), including 17 secondary procedures (mean, 1.9 per patient). Lacrimal reconstruction was required in 2 patients (22.2%) because of persistent symptomatic obstruction, and 2 patients referred after previous surgery required individualized secondary reconstruction. Structural globe preservation was achieved in all 8 patients with anatomically formed globes; the remaining patient had congenital anophthalmia. Amblyopia was documented in 5 patients (55.6%), and preoperative exposure keratopathy was present in 7 (77.8%). CONCLUSIONS: Tessier-3 clefts demonstrate substantial anatomic and reconstructive heterogeneity requiring individualized, anatomy-driven staged reconstruction. Early ocular protection, selective management of lacrimal dysfunction, and coordinated multidisciplinary care remain central to successful management.