CLEFT LIP & PALATE RECONSTRUCTION

About Cleft Lip & Palate Reconstruction

A Cleft Lip and Palate can be a most devastating occurrence for mother, father, and child; however, it does not have to be due to well-established procedures and therapies, ranging from surgical interventions to speech therapy that can restore form and function. A team approach can add insight and recommendations at various stages. Cleft Lip and Palate formations occur in 1 out of 600 births in the United States. In some developing countries, the incidence may be as high as 1 out of 400. The defect occurs about the sixth week in embryonic development. As the various developmental components of the face begin to fuse, a non-union or breakdown occurs along the seams. As a result, the cleft forms according to the degree of non-union.

There are no known specific environmental causes of cleft formations. Many mothers are concerned that they have done something wrong to cause this defect, but clefts are rarely related to a syndrome or specific actions of the parents. Parental guilt is unwarranted. The defect occurs in a variety of combinations from complete lip/palate, partial lip/complete palate, or complete lip/partial palate. Cleft deformities are more common in males. More often, 60 percent of the time, they are located on the left side of the face. Occasionally, however, the clefts may be both on the right and the left sides. Bilateral cleftscan vary in their presentation and severity also. A complete cleft lip and palate begins in the upper lip, connecting the mouth to the nose. The bone for the teeth is called the alveolus and is also clefted. There can be missing, deformed, or extra teeth in the area. The cleft then extends onto the hard palate, which means that the mouth and the nasal passage are connected. Finally, the soft palate is divided, and this division affects speech. 

Because of the open passages in cleft palates, children with such deformities are prone to have ear infections. Subsequent hearing loss might occur if the infections are not treated. Feeding and nutrition are usually of immediate concern and education is essential. Various forms of bottles with modified nipples, oral appliances, and techniques for breast feeding infants with clefts are available and offer an adequate means for nutrition and satisfaction both to the infants and their mothers. Feeding specialists in hospital settings are able to address these concerns at the time of birth and reinforcement and support from consultants is available. Life-long care by specialists is also available to the families and cleft patients. These care-givers include hearing specialists, called audiologists, speech pathologists, speech therapists, ear, nose, and throat specialists,  plastic, oral and maxillofacial surgeons, orthodontists, pediatricians, pediatric dentists, social workers, psychologists, psychiatrists, and geneticists. To provide overall planning, the child will be examined at various times by all these people in a team setting. At times, the child may be examined by individuals, depending on the age and needs. Usually the primary surgeon will be the coordinating team member. The surgical treatment for Cleft Lip and Palate has both standard and variable aspects, depending on the needs of the patient.

Before		After
Before		After

Cleft Lip & Palate Reconstruction Treatment Schedule

Closure of the lip . . . . . . . . . . . . . . 3 months
Closure of the palate . . . . . . . . . . . . 12 months
Ear tubes placed . . . . . . . . . . . . . . . As needed
Pediatric dentist appointment . . . . . 3 years
Speech therapy . . . . . . . . . . . . . . . . 5 years
Lip and/or palate revision . . . . . . . . 5 years
Orthodontist evaluation . . . . . . . . . 6 years
Initial orthodontic treatment . . . . . . 9 years
Bone graft to cleft . . . . . . . . . . . . . . 9 1/2 years
Facial skeletal surgery . . . . . . . . . . . 14-19 years
Nasal revision . . . . . . . . . . . . . . . . . 14-19 years
Dental reconstruction . . . . . . . . . . . 14-21 years

When the child is 5 to 7 years old, orthodontic needs should be evaluated. Bone grafting of the cleft in the tooth-bearing area, called the alveolus, is performed between ages 9 and 11, preceded by expansion of the palate to correct any cross-bite, intercepting the eruption of the upper canine tooth into the cleft. Final orthodontic treatment is completed during adolescence in conjunction with surgery, if necessary, to correct any disproportional facial growth. This surgery may involve moving the midface forward, up, and/or down. This type of facial/jaw surgery is known as Orthognathic Surgery and is recommended if he face does not grow properly.

The ordinary repair of the lip is usually performed by the age of 3 months. At this age the baby is large enough to undergo the surgery with minimal complications. The rule of tens is: 10 weeks of age, 10 pounds of weight, and a hemoglobin of 10mg/dl (blood count). First, a breathing tube is placed through the mouth to breathe for the baby during the general anesthesia. The surgery lasts 1 1/2 to 2 hours including the preparation time. A variety of methods is available to surgically close the lip. The main goals of all methods are to approximate the muscles, align the vermillion (the red part of the lips where lipstick is applied), establish the symmetry of the nose, and create the philtrum (cupid’s bow). Sutures are placed on the skin surface in the lip muscles and in the mucosa in the mouth. Only the sutures on the skin need to be removed, the others will dissolve.

The baby can resume feeding either from the breast or the bottle soon after surgery. Because of the baby’s small size, he or she will need to stay in the hospital overnight to make sure feeding is adequate.

Preparing For Cleft Lip & Palate Reconstruction

At least 1 month prior to surgery
Stop smoking at least 1 month prior to your procedure. Smoking reduces circulation to the skin, impedes healing, and can lead to major postoperative complications.

2 weeks prior to surgery
Stop all medications that can thin the blood 2 weeks prior to surgery. These include drugs such as Aspirin, Coumadin, Lovenox, Ibuprofen, Vitamin E, and multiple herbal preparations. These medications may cause bleeding during and after surgery. Please see the warning about blood thinning medications on our website for a list of drugs that must be stopped.

1 week prior to surgery
Report any sign of a cold or infection that appear the week prior to your surgery. You may need to postpone your procedure to avoid unnecessary complications. Make sure you fill all of your prescriptions provided to you by our doctors prior to your surgery day; this will make the transition from the surgery center to your home as smooth as possible.

The day before surgery
Do not eat or drink anything after midnight before your surgery. This includes water, ice, or hard candy. The only exception is that you may take your blood pressure or heart medication with a sip of water the morning of surgery.

The day of surgery
Plan to wear loose fitting clothes to the procedure.

Do not wear jewelry or bring valuables with you on the day of surgery.
You may wash your surgical site with regular soap the day before and morning of surgery.
You must arrange to have a responsible adult drive you home after your procedure

After the surgery
The lip will be swollen and tender. A small amount of oozing of blood will be present along the incision line.

You may resume feeding either by bottle or by breast the day following surgery. A special feeding nipple and/or technique may continue to be necessary.

If no tape or bandage is placed over the surgical site, it should be cleansed twice each day with a 50:50 mixture of hydrogen peroxide and water using a cotton-tipped applicator.

After each cleaning, antibiotic ointment, such as Neosporin, should be applied to the surgical site.

Sutures are removed in 5 days, and the incision is taped with a skin glue to keep it from spreading apart.

Your first follow-up visit will be 1 week after surgery. Your surgeon will then see you at appropriate intervals after this to monitor your progress.

Call your surgeon immediately if you experience any of the following: excessive pain, bleeding, redness at the incision site, or fever over 101° F.

All Surgery Carries Some Uncertainty & Risk.

The complications for lip repair include severe asymmetry, eye socket deformities, scarring, infection, bleeding, and stitch abscesses. Typically, some residual asymmetry may last for the first 6 months. Revision will usually be necessary in the future.