Surgical Management of Uncorrected Adult Bilateral Tessier No. 4 Clefts: A 2-Stage Reconstruction Using a Bipaddled ALT Free Flap and Z-Plasty

BACKGROUND: Bilateral Tessier No. 4 clefts are rare craniofacial anomalies involving the lip, maxilla, and lower eyelids. In adults, untreated cases lead to severe midface hypoplasia and cicatricial ectropion, posing significant reconstructive challenges beyond local tissue rearrangement. METHODS: A 22-year-old male with untreated bilateral Tessier No. 4 clefts underwent staged reconstruction. A bipaddled anterolateral thigh (ALT) free flap, based on 2 perforators, was used for midface augmentation and lower eyelid coverage. Secondary refinement at 2 months used Z-plasty to repair lip clefts and restore orbicularis oris continuity. RESULTS: The flap survived completely without complications. At 20 months, the patient showed improved facial symmetry with complete resolution of ectropion and epiphora. Midface volume was maintained, and oral function and aesthetics were restored. CONCLUSIONS: A staged approach combining microsurgical free tissue transfer and local flap refinement provides a reliable solution for complex craniofacial reconstruction, especially in congenital deformities.