Cleft Lip & Palate
This website is intended to provide you with general information only. This information is not a substitute for advice from your Specialist Plastic Surgeon and does not contain all the known facts about this procedure or every possible side effect of surgery. It is important that you speak to your surgeon before deciding to undergo surgery. If you are not sure about the benefits, risks and limitations of treatment, or anything else relating to your procedure, ask your surgeon to explain.
What is a cleft lip or palate
Cleft lip and cleft palate are facial and oral deformities that occur very early in pregnancy, while the baby is developing inside the mother’s womb. Clefts results when there is not enough tissue in the mouth or lip area, and the tissue that is available does not join together properly.
A cleft lip is a physical split or separation of the two sides of the upper lip and appears as a narrow opening or gap in the skin of the upper lip. This separation often extends beyond the base of the nose and includes the bones of the upper jaw and/or upper gum.
A cleft palate is a split or opening in the roof of the mouth. A cleft palate can involve the hard palate (the bony front portion of the roof of the mouth), and/or the soft palate (the soft back portion of the roof of the mouth).
Cleft lip and cleft palate can occur on one or both sides of the mouth. As the lip and the palate develop separately, there may be a cleft lip without a cleft palate, a cleft palate without a cleft lip, or both together.
Who Gets Cleft Lip and Cleft Palate?
,Cleft lip, with or without cleft palate, affects one in 550 live babies annually, and is the fourth most common birth defect in Pakistan. Compared with girls, twice as many boys have a cleft lip, both with and without a cleft palate. But compared with boys, twice as many girls have cleft palate without a cleft lip.
What Causes a Cleft Lip and Cleft Palate?
In most cases, the cause of cleft lip and cleft palate is unknown. So far these conditions cannot be prevented. Most scientists believe clefts are due to a combination of genetic and environmental factors. There appears to be a greater chance of clefts in a newborn if a sibling, parent, or relative has had the cleft.
Another potential cause may be related to a medication taken by the mother during her pregnancy. Some drugs may cause cleft lip and cleft palate. Among them: anti-seizure/anticonvulsant drugs, acne drugs containing Accutane, and methotrexate, a drug commonly used for treating cancer,arthritis, and psoriasis.
Cleft lip and cleft palate may also occur as a result of exposure to viruses or chemicals while the fetus is developing in the womb. Xray of Pelvis taken during first or early second month may lead to Cleft Lip or Palate and other abnormalities.In other situations, cleft lip and cleft palate may be part of another medical condition.
How Are Cleft Lip and Cleft Palate Diagnosed?
As cleft lip or palate cause very obvious physical changes, a cleft lip or cleft palate is easy to diagnose. Prenatal ultrasound by an expert Ultra-sonologist can sometimes determine if a cleft exists in an unborn child. If the cleft has not been detected in an ultrasound prior to the baby’s birth, a physical exam of the mouth, nose, and palate confirms the presence of cleft lip or cleft palate. However it may be difficult to diagnose Submucous cleft palate at birth.Sometimes diagnostic tests may be conducted to determine or rule out the presence of other abnormalities.
What Problems Are Associated With Cleft Lip and/or Palate
Eating problems. With a separation or opening in the palate, food and liquids can pass from the mouth back through the nose. Fortunately, specially designed baby bottles and nipples that help keep fluids flowing downward toward the stomach are available. Children with a cleft palate may wear a Palatal obturator to eat properly and ensure that they are receiving adequate nutrition until surgical treatment is provided.
Ear infections/hearing loss.Children with cleft palate are at increased risk of ear infections since they are more prone to fluid build-up in the middle ear. If left untreated, ear infections can cause hearing damage.
Speech problems. Children with cleft palate or cleft lip may also have trouble in speaking. The voice may take on a nasal sound, and the speech may be difficult to understand. Not all children have these problems and surgery may fix these problems entirely for many. For others, a special doctor, called speech pathologist, will work with the child to resolve speech difficulties.
Dental Problems. Children with clefts are more prone to have larger than average number of cavities and often have missing, extra, malformed, or displaced teeth requiring dental and orthodontic treatments. In addition, children with complete cleft palate often have an alveolar ridge defect. The alveolus is the bony upper gum that contains teeth. A defect in the alveolus can (1) displace, tip, or rotate permanent teeth, (2) prevent permanent teeth from appearing, and (3) prevent the alveolar ridge from forming. These problems can usually be repaired through alveolar bone grafting surgery.
Who Treats Children With Cleft Lip and/or Palate?
Due to the number of oral health and medical problems associated with a cleft lip or cleft palate, a team of doctors and other specialists is usually involved in the care of these children. Members of a cleft lip and palate team typically include:
Plastic surgeon to evaluate and perform necessary surgeries on the lip and/or palate, to reposition segments of the upper jaw when needed, to improve function and appearance and to repair the cleft of the gum
An ENT Surgeon to evaluate hearing problems and consider treatment options for hearing problems
An Orthodontist to perform routine dental care and straighten and reposition teeth
A Prosthodontist to make artificial teeth and dental appliances to improve the appearance and to meet functional requirements for eating and speaking
A Speech pathologist and Speech Therapist to assess speech problems and to work with the child to improve speech
An Audiologist to assess and monitor hearing problems
A nurse coordinator to provide ongoing supervision of the child’s health
A Social worker/Psychologist to support the family and assess any adjustment problems
A Geneticist to help parents and adult patients understand the chances of having more children with these conditions
The team members work together under the leadership of Plastic Surgeon to develop a plan of care to meet the individual needs of each patient. Treatment usually begins in infancy and often continues through early adulthood.What’s the Treatment for Cleft Lip and Cleft Palate?A cleft lip(unilateral or wide bilateral) may require one or two surgeries depending on the extent of the repair needed. The initial surgery is usually performed at three months of age, provided the patient has good weight and optimum Hemoglobin level.
Repair of a cleft palate may require one or multiple surgeries over the course of 18years. The first surgery to repair the palate usually occurs when the baby is between 9 and 12 months old. The initial surgery creates a functional palate to have a better speech and reduces the chances that fluid will develop in the middle ears..
Children with a complete cleft palate may also need a bone graft when they are about 8-9 years old to fill in the upper gum line so that it can support permanent teeth and stabilize the upper jaw. About 20% of children with a repaired cleft palate may require further surgeries to improve their speech.Once the permanent teeth grow in, braces are often needed to straighten the teeth.Additional surgeries may be performed to improve the appearance of the lip and nose, close openings between the mouth and nose or between underside of the lip and nose, help breathing, and stabilize and realign the jaw at the age of 16-20 years.
Final repairs of the scars left by the initial surgery will probably not be performed until adolescence, when the facial structure is more fully developed..
What Surgery can do?
Surgery can repair most clefts so that the child’s appearance and speech develop normally. However, children born with a cleft lip or palate may need the skills of other medical professionals to correct the associated problems.
For that reason, parents should seek the help of an expert cleft lip and palate team as early as possible. Dr. Fayyaz has formed a very competent team to help the parents to plan for their cleft child’s care from birth, or even before.
What Is the Outcome for Children With Cleft Lip and/or Cleft Palate?
Although treatment for a cleft lip and/or cleft palate may extend over several years and require one, two or multiple surgeries depending upon the severity of the cleft, most children affected by this condition can achieve normal appearance and speech.
Dental Care for Children With Cleft Lips and/or Palates
Generally, the preventive and restorative dental care needs of children with clefts are the same as for other children. However, children with cleft lip and cleft palate may have special problems related to missing, malformed, or mal-positioned teeth that require close monitoring.
Early dental care. Like other children, children born with cleft lip and cleft palate require proper cleaning, good nutrition, and fluoride treatment in order to have healthy teeth. Appropriate cleaning with a small, soft-bristled toothbrush should begin as soon as teeth erupt. If a soft children’s toothbrush will not adequately clean the teeth because of the modified shape of the mouth and teeth, a toothette may be recommended by your dentist. A toothette is a soft, mouthwash-containing sponge on a handle that’s used to swab teeth. Many dentists recommend that the first dental visit be scheduled at about 1 year of age or even earlier if there are special dental problems. Routine dental care can begin around 1 year of age.
Orthodontic care. A first orthodontic appointment may be scheduled before the child has any teeth. The purpose of this appointment is to assess facial growth, especially jaw development. After teeth erupt, an orthodontist can further assess a child’s short and long-term dental needs. After the permanent teeth erupt, orthodontic treatment can be applied to align the teeth.
Prosthodontic care. A prosthodontist is a member of the cleft palate team. He or she may make a dental bridge to replace missing teeth or make special appliances called “speech bulbs” or “palatal lifts” to help close the nose from the mouth so that speech becomes better or more normal. The prosthodontist coordinates treatment with the plastic surgeon and the speech pathologist.
What are the potential risks and complications?
Modern surgery is generally safe but may have some potential risks and complications. In cleft lip surgery, the most common problem is asymmetry, where one side of the mouth and nose does not match the other side, or there may be a notch at the lip border. In cleft palate surgery, the goal is to close the opening in the roof of the mouth so the child can eat normally and learn to speak properly. Occasionally, poor healing in the palate or poor speech may require a second operation.
What do I need to do before surgery?
At your initial consultation, Prof. Fayyaz will share the details of the procedure with you, the type of anaesthesia to be used, possible risks and complications, recovery, costs, and the results you can expect. He will also answer any questions you may have about feeding your baby, by breast or by bottle, both before and after the surgery.
What do I need to do after surgery?
After the surgery, your child will probably feel some soreness and pain. Our staff will prescribe pain medication to relieve any discomfort.
It is normal for your child to be restless for a while after surgery. During this period, your child may not eat or drink as much as usual. If this is the case, an intravenous line will be used to maintain fluid levels. We will advise you on how to feed your child during the first few weeks after surgery. It is crucial that you follow the advice on feeding to allow the palate to heal properly.
Elbow restraints may be necessary for a few days to prevent your baby from rubbing the stitched area. We usually do not use any dressing fro Cleft Lip repair. sutures are removed after one week by our staff member.
Will there be scarring?
Scars are an inevitable part of any invasive surgery. We will do our utmost effort to minimise scarring and to keep your scars as inconspicuous as possible. It is normal for the surgical scar to appear to get bigger and more red for a few weeks after surgery. This will gradually fade, although the scar will never totally disappear. However in some patients, the scar may get hypertrophy( raised above the surface) due to exaggerated reaction to scar formation. In that case vigorous massage for 6 months may be needed to get it settled.
Support for parents
Having a child with a cleft lip or palate who requires surgery can be emotionally difficult. Parents need to be supported, particularly in the first few days when feeding is difficult and many of the questions remain unanswered. Parents can call our representative for any support needed. Please remember that cleft Lip & Palate will be repaired in time and cleft-affected children can go on to lead normal and happy lives. +Your child is in the hands of experienced doctors We care for more than 3,000 children every year with cleft lip and/or palate. This is the highest number by any one team in the whole world Children come here from all over the Pakistan to have surgery for cleft lip and palate from Prof. Fayyaz. We perform more surgeries for this condition than any other centre in the region including Pakistan and India.
Our approach means fewer surgeries, we start treatment early to provide comprehensive support and to reduce the need for surgeries as your child grows up.
For children with wide clefts we can reshape the gums, lip and nose in the months before surgery by using Naso-Alveolar Molding (NAM). Pre-surgery molding may decrease the number of surgeries. We provide the treatment that is right for your child at the right time. If an ultrasound during pregnancy indicates that your baby has cleft lip or cleft palate, we help you understand treatment options that will be possible after birth. We teach you ways to feed your baby so they thrive adequately to gain good weight. We can guide the family more about how prenatal counselling can help you prepare to care for your child.
As your child grows, we help with feeding and measure their growth. We recommend regular check-up for their hearing and assess their speech and language development. We do surgeries to fix your child’s cleft at the right time. At school age and into young adulthood, we use orthodontic treatments to correct your child’s bite if needed.
+Support for your whole family
Families face many challenges when their child has cleft lip or cleft palate. We take time to explain your child’s condition and answer all your questions.
We help you fully understand your treatment options and make choices that are right for your family. All through the years, our staff members help your child and your family to cope with the cleft associated problems. We put you in touch with resources in your community. As your child matures, we include them in decisions about their medical care. Our experts work together and with you and your family’s doctor to coordinate your child’s care. Our team meets regularly to discuss complex patient cases and decide on the best care plan. We innovate to improve treatments and your child’s quality of life
Road Map for Cleft Patient:-
It is based on the evidence about what is most effective. This gives doctors a blueprint for delivering the best possible care and makes it easier to improve that care.
We have an active research team working to understand more about what causes clefts, ways to prevent it and how to ensure the best outcomes for children born with clefts. We are working closely with Department of Genetics,University of Health Sciences, Lahore
How to feed your Cleft kid?
Why do babies with clefts have problems with feeding? Cleft Patients have trouble with feeding because cleft changes how parts of the mouth are formed and how they work and fit together. Normally, a baby pulls the nipple into their mouth and makes a seal with the lips around the nipple. When the baby sucks and swallows, the back of the roof of their mouth (soft palate) rises up and closes off the mouth from the nose. This creates suction and holds the breast or bottle nipple in the mouth, and the baby sucks to draw out milk. Cleft lip makes it hard for babies to make a good seal around the nipple. Cleft palate makes it hard to create suction because the mouth cannot be closed off from the nose. Feeding and nutrition help so your child thrives tarting soon after birth, we regularly check your child’s weight and growth. Parents often need help with feeding if their baby has a cleft.
Cleft lip makes it hard for the baby to make a seal with their lips around the nipple. Most often, babies with cleft lip can be fed by breast or regular bottle. We can give you tips on how to hold your baby for better feeding.
With a cleft palate, the baby cannot get enough suction to suck milk out of the breast or regular bottle. When they suck, the roof of their mouth does not close off the mouth from the nose. Babies with cleft palate usually need special bottles and nipples. We can help you understand the different types. We will teach you feeding techniques so your baby eats enough to grow and thrive.
How do I feed my baby with cleft lip?
Babies with only cleft lip can usually be fed by breast or regular bottle. Our nurses and infant-feeding specialists can help you make sure your baby gets a tight seal around the nipple.
Breast-feeding
During breast-feeding, the soft breast tissue often will fill the opening in the lip and/or gum line. This seals off the mouth and lets your baby create enough suction. Sometimes it helps to hold a finger across the cleft while your baby feeds. Swallowing noises and normal weight gain are signs that breast-feeding is going well. If your baby is “noisy” with feeding, making clicking or kissing noises, they may not have enough suction.
Bottle-feeding
If you bottle-feed your baby, feeding may work better using special bottles or nipples with a wider base. When starting a feeding, hold your baby in a slightly upright position. Touch the baby’s lower lip with the nipple. When the baby latches on, direct the nipple slightly downwards. Try to keep the nipple in the centre of the baby’s mouth. Do not let it slip up into the cleft. How do I feed my baby with cleft palate?Babies with cleft palate usually need special bottles and techniques to feed well, whether or not they have cleft lip. It is rarely possible to breast-feed or use a regular bottle.
With cleft palate, a baby cannot create suction to get milk out of the breast or bottle. A baby who is put to the breast may look like they are latching on and sucking well. But they are using up energy and getting little or no milk. If you planned to breast-feed, we encourage you to express your milk and feed your baby using a special bottle. Breast milk is considered the most ideal food for all babies. There are added benefits for babies with cleft palate, such as fewer middle ear infections.
Often, mothers who were looking forward to breast-feeding feel great sadness at the loss of this experience. We encourage you to acknowledge this loss and seek support. We can help with feeding techniques to help you maintain closeness with your baby. What kind of bottle should I use for feeding with cleft palate? There are 4 types of bottles for feeding babies with clefts:
Cleft Lip/Palate Nurser by Mead Johnson
SpecialNeeds Feeder by Medela
Pigeon feeder with one-way valve
Dr. Brown’s Specialty Feeding System with one-way valve The Pigeon nipple with one-way valve can be used with any bottle. The Cleft Palate Foundation website has a video on feeding your baby and information on how to order supplies online. Cleft Lip/Palate Nurser by Mead Johnson The Cleft Lip/Palate Nurser by Mead Johnson is a low-cost, soft, squeezable bottle. We suggest that you replace the long yellow nipple that comes with the bottle. Use any shorter, softer nipple. Before using the bottle for the first time, put some water in it and practice squeezing the liquid out of the nipple. This will help you get a feel for how firmly you need to squeeze. When you squeeze the bottle, the liquid should flow easily but not too fast.
As your baby begins to suck, squeeze the bottle with a firm, steady pressure to the count of “squ-e-e-ze-2, 3.” Relax your squeeze on the 2, 3 count. This pauses the flow of milk. You should only squeeze when your baby is sucking. Watch your baby closely and listen for swallowing sounds.
If your baby pauses to breathe, you should pause also. If your baby is getting milk out of the bottle, you should see air bubbles in the milk.
If you forget to stop squeezing the bottle when your baby pauses, your baby may cough and sputter. Just take the nipple out of the baby’s mouth for a moment and let them settle. Then continue feeding.
Most parents quickly learn to adjust squeezing to their baby’s sucking rhythm.
SpecialNeeds Feeder
The SpecialNeeds Feeder by Medela has a one-way valve that keeps milk in the nipple. It does not require suction. This bottle used to be called the Haberman feeder. Sometimes babies can get milk from this feeder themselves by pushing the nipple against their gum line. The nipple is soft-sided. For many babies, it works best for the parent to squeeze the bottle to match their baby’s rhythm of sucking and swallowing.
There is a “Y” cut in the nipple. Turning the nipple in the baby’s mouth changes the orientation of the “Y” cut in the baby’s mouth. This varies the rate of flow. The nipple has 3 lines that indicate which flow rate is in effect. Dr. Brown’s Specialty Feeding System with one-way valve feeding system You can buy Dr. Brown’s Specialty Feeding System with one-way valve through Amazon or the Dr. Brown’s website.
Dr. Brown’s Specialty Feeding System uses a bottle with a one-way valve at the base of the nipple to keep the nipple full of milk. It does not require suction. When the baby bites or compresses the nipple, milk flows into their mouth and not back into the bottle. The one-way valve ensures that there is always milk in the nipple. The baby controls the rate of the feeding.
Pigeon feeder
The Pigeon feeder has a nipple with a one-way valve. The nipple can be used with any bottle. The nipple comes in 2 sizes. The smaller size has a slower flow. It is best for newborns. The larger, faster-flowing nipple works well for babies 6 weeks and older. The Pigeon nipple with one-way valve works by compression only. No squeezing is needed. A plastic one-way valve that fits into the nipple keeps milk in the nipple. Place the valve with the flat side toward the tip of the nipple. When your baby begins to suck, milk flows easily. Your baby controls the flow of milk. The nipple has a firm side that goes against your baby’s gum line and a softer side that goes on their tongue.
A small notch near the rim of the nipple serves as an air vent. This notch should be under your baby’s nose when feeding. This puts the nipple correctly in your baby’s mouth. Tightening the nipple slows the flow of milk. Loosening it makes the flow faster. If the nipple collapses, loosen and retighten it.
How do I care for the bottles and nipples?
All of these bottles and nipples can be hand washed in hot soapy water. Rinse and allow to air dry. Do not boil the bottles or parts. Do not wash them in the dishwasher or put them in a microwave. They may soften and start to leak. How do I express breast milk for my baby? If you want to express breast milk for your baby, we recommend a hospital-grade electric breast pump with a double pumping system. Large hospitals have pumps for mothers to use in the hospital.
At first, pump at least 8 times in 24 hours, including at least once during the night. After several weeks of frequent pumping, most mothers make enough milk by pumping about 6 times a day. Tips for pumping breast milk (PDF). How much should my baby eat? Newborn babies begin with frequent feedings of very small amounts of milk (1 ounce or less). Over time, they increase the amount they can take.
By 2 weeks of age, a baby needs at least 2 to 2.5 ounces of milk per pound of weight each day. For example, a 3-week old baby who weighs 9 pounds should have at least 18 to 22.5 ounces of breast milk or formula in 24 hours. A feeding session should take no longer than 30 minutes. If it takes longer, your baby is working too hard and burning calories needed for growth. We recommend weighing babies weekly until they show a normal rate of growth. Usually this happens in 4 to 6 weeks.
How often does my baby need to eat?
During the first month of life, a baby will feed 8 to 12 times per day — every 2 to 3 hours. A baby this young usually feeds at least 2 times during the night. At 2 to 4 months, a baby will feed 6 to 8 times per day — every 3 to 4 hours. How will I know if my baby is gaining enough weight? A baby usually loses weight the first week of life. The loss is usually 5% to 10% of their body weight. Your baby should regain this weight by 2 weeks old.
At first, we expect your baby to gain 5 to 7 ounces per week. At 4 to 6 months old, the rate of weight gain slows. Your baby should gain about 3.5 to 4.5 ounces per week. What if my baby is not gaining enough weight? Sometimes babies with cleft lip and palate have difficulties taking enough breast milk or formula to grow. Ask your child doctor for advice. They can give you an approved recipe for adding formula powder to breast milk or regular formula. This gives your baby extra calories, protein and vitamins. We can help you in any such problem.
What about starting solid foods?
Babies with clefts can start solid foods at the same age as other babies. Most often, this is at 4 to 6 months. Experiment to find the right consistency for solids. It needs to be just right so your baby can eat without the food coming out their nose. This is not harmful to your baby. Sneezing will usually clear the food out of the nose. Most babies learn quickly to get the food down their throats rather than out their noses.
Can my baby drink from a cup?
Cup feeding can also be started at the usual age, 8 to 12 months. Cups with plain lids can help limit spills. Do not use spill-proof cups with valves. These require that baby create suction to get any fluid. Genetic Tests can help in the diagnosis The doctor may suggest doing genetic tests to tell whether your child’s cleft lip and palate are part of a condition that causes other signs or symptoms. Examples are Van der Woude syndrome, 22q11.2 deletion syndrome, Pierre Robin sequence, Stickler syndrome and Treacher Collins syndrome. More than 40% of children with cleft palate but without cleft lip have it as part of a syndrome.
For many babies, the syndrome is caused by a new genetic change that was not inherited from the mother or father. But sometimes a parent has an abnormal gene that is passed on to their child. There is a greater chance of having a child with cleft if a parent or other child has a cleft lip and/or palate. Your doctor or our genetic counsellors can talk with you about the likelihood for your family.
We recommend genetic counselling before your child reaches age 21 so they understand the chance of cleft in any children they may have.
Taping and nasoalveolar molding to improve results of surgery
For children with wide clefts of Lip & Palate, we reshape the gums, lip and nose by using taping or nasoalveolar molding (NAM) before cleft lip surgery. The goal of molding is to make the gap in the gums and lip smaller before your baby’s cleft lip surgery. It also lifts and shapes the nose. A better result with the first surgery could mean fewer surgeries later in childhood. In the months before surgery, your baby wears a custom-made molding plate that fits on the gum line.
The plastic plate gently directs the growth of the baby’s gums. Every 1 to 2 weeks, our orthodontist adjusts the molding plate. Over time, the cleft gets smaller. After the cleft has narrowed, a small post may be added to the molding plate and put into your baby’s nostril. The orthodontist slowly adjusts the post to shape the nose cartilage, lift up the nose and open the nostril. Hearing evaluation and ear tubes
Audiologist will be needed to examine the hearing status of the cleft patient. If there are concerns, an ear, nose and throat doctor (otolaryngologist) will see your child. Most children with cleft palate have fluid buildup behind the ear drum. This can make it harder to hear. If this is a problem for your child, we recommend inserting small plastic tubes in the ear drum. This keeps the middle ear clear of fluid. It is often done at the same time as surgery to fix cleft palate.
Surgery of Cleft Lip
+Surgery for cleft palate
+Speech development
Our Speech Therapist will regularly check your child’s speech ability and how their language is developing. We can help even before your child’s cleft palate is repaired, as early as 9 months. Cleft palate affects the muscles needed for normal speech. Your child may have trouble making correct speech sounds, even after the cleft is repaired. Some children with repaired cleft palate have a condition called velopharyngeal dysfunction (VPD). Often, speech therapy helps children develop more normal speech patterns.However if in spite of repeated attempts with speech therapy, there is no benefit to the speech.
Then sometimes a custom-made speech appliance called an obturator can be helpful to improve the speech. It looks like a dental retainer with a small bulb at the back.
but some children will benefit only from further surgery after cleft palate repair. This is likely if your child has a type of VPD called velopharyngeal insufficiency. Plastic surgeon and speech pathologist will work together to recommend what is best for your child. Our orthodontists are a key part of the team.
Your child is likely to need orthodontic treatment to align teeth if their cleft affects the gum line (the hard palate) or the back of the roof of the mouth (soft palate). We coordinate dental and orthodontic needs with other treatments to get the best results.
Orthodontic treatment helps prepare your child if they need surgery for a cleft in the part of the jaw that holds the teeth. The surgery is called alveolar bone graft. At 12 to 18 years, your child has final orthodontic treatment to correct their bite and align their teeth. For some children, this will include surgery on the jaws.
+Alveolar bone graft for upper jaw clefts Many children with cleft lip and cleft palate also have a cleft in the bone of the upper jaw that holds the teeth. This bone is called the alveolus (al-vee-OH-liss). An alveolar bone graft is a surgery to fill the gap in that bone. Your child will probably need orthodontic treatment for several months to prepare for surgery.
During an alveolar bone graft, the surgeon opens the gum tissue to show the gap in the bone. Spongy bone taken from inside the hip bone is put into the gap. Next, the surgeon puts gum tissue back over the bone graft and stitches are placed. The cut in the hip is also stitched closed. After surgery, the bone graft in the upper jaw will become hard and strong bone. This surgery is done when your child is 8 to 9 years. Most often, surgery takes 2 hours. Your child will stay in the hospital 1 to days.
+Rhinoplasty for clefts affecting the nose
Many of the surgeons do not repair the nose during Cleft Lip Repair and say that Nose will be repaired at the age of 16-18 8years. However Prof. GQ Fayyaz always elevates the Nose during Lip Repair. This elevation will save your child from the teasing by peers in the school. But some children need more surgery as they get older.
A child with a cleft may have problems with breathing because the inside of their nose has not formed right. A deviated septum is one example. Most often, surgery to correct breathing issues and improve symmetry happens during the late teen years. Sometimes a small nose surgery (rhinoplasty) will be considered during school age. We will work with you to decide when and how best to proceed. +Jaw surgery to line up the teeth in young adults As children near adulthood, some will need jaw surgery to properly align their teeth.
Children with clefts have a greater chance of having their upper jaw grow less than their lower jaw. Your child may have an underbite or abnormal bite (malocclusion). Most often, we recommend Le Fort I maxillary advancement surgery to correct it. Some children also need surgery for a lower jaw that has not formed correctly (mandible advancement).
Better Ways to Treat and Prevent Cleft Lip and Palate
Our Craniofacial team works to find better ways to treat clefts and improve our patients’ quality of life. We listen to families to better address your needs. We have a research team working to understand more about the causes of this condition, prevention and how to ensure the best outcomes for children born with clefts..
Words you should know
Cleft: A birth defect where the two halves of the palate and/or the lip don’t fuse properly, leaving an open space
General anaesthesia: Drugs and/or gases used during an operation to relieve pain and alter consciousness
Local anaesthesia: A drug injected directly to the site of an incision during an operation to relieve pain and produce vasoconstriction
Sutures: Stitches used by surgeons to hold skin and tissue together
Demographics
Cleft lip is the second most common embryonic (congenital) deformity. (Club foot is the most common congenital deformity.) Cleft lip occurs in approximately one in 750–1,000 live births. The highest incidence exists in North American Indians and Japanese (approximately one in 350 births). African Americans and Africans represent the lowest incidence of cleft lip deformity (approximately one in 1,500 births). There is a higher frequency of clefts in certain populations of Scandinavia and Middle European countries.
Cleft lip occurs more commonly in males, while cleft palate is more likely to occur in females. Cleft lip alone (without cleft palate) occurs in approximately 20% of cases across both genders. The majority of cases—80%—have both cleft lip and cleft palate. A unilateral cleft lip, commonly occurring on the left side, is more common than a bilateral cleft lip.
Potential causes
Most cases of cleft lip have no known cause. However, there is a strong genetic correlation. Other single gene defects that are associated with cleft lip include: Van der Woude syndrome, Opitz Syndrome, Aarskog syndrome, Fryns syndrome, Waardenburg syndrome, and Coffin-Siris syndrome. Approximately 5% of cleft conditions are associated with a genetic syndrome. Most of these syndromes do not include mental retardation. Facial cleft has been implicated with maternal exposure to environmental causes, such as rubella or medications that can harm the developing embryo. These medications include steroids, antiseizure drugs, vitamin A,
oral anti-acne medications (such as Acutane) taken during the first three months of pregnancy. Cleft lip is also associated with fetal alcohol syndrome and maternal diabetes. Risk of cleft lip increases with paternal age, especially over 30 years at the time of conception. Generally, the risk is higher when both parents are over 30 years of age. However, most cases seem to be isolated within the family with no obvious causation.
When the affected child has unilateral cleft lip and palate, the risk for subsequent children increases to 4.2%. Advances in high resolution ultrasonography (prenatal ultrasound exam) have made it possible to detect facial abnormalities in the developing embryo (in utero).
Developmental anatomy
Important structures of the embryo’s mouth form at four to seven weeks of gestation. Development during this period entails migration and fusion of mesenchymal cells with facial structures. If this migration and fusion is interrupted (usually by a combination of genetic and environmental factors), a cleft can develop along the lip. The type of cleft varies with the embryonic stage when its development occurred.
There are several types of cleft lip, ranging from a small groove on the border of the upper lip to a larger deformity that extends into the floor of the nostril and part of the maxilla (upper jawbone).
Unilateral cleft lip results from failure of the maxillary prominence on the affected side to fuse with medial nasal prominences. The result is called a persistant labial groove. The cells of the lip become stretched and the tissues in the persistent groove break down, resulting in a lip that is divided into medial (middle) and lateral (side) portions. In some cases, a bridge of tissue (simonart band) joins together the two incomplete lip portions.
Bilateral cleft lip occurs in a fashion similar to the unilateral cleft. Patients with bilateral cleft lip may have varying degrees of deformity on each side of the defect. An anatomical structure (Pre-maxillary segment) projects to the front and hangs unattached. Defects associated with bilateral cleft lip are particularly problematic due to discontinuity of the muscle fibers of the orbicularis oris (primary muscle of the lip.) This deformity can result in closure of the mouth and pursing of the lip.
Classification
In addition to classification as unilateral or bilateral, cleft lips are further classified as complete or incomplete. A complete cleft involves the entire lip, and typically the alveolar arch. An incomplete cleft involves only part of the lip. The Iowa system (which also classifies cleft palate) classifies cleft lip in five groups:
Group I—clefts of the lip only
Group II—clefts of palate only
Group III—clefts of lip, alveolus, and palate
Group IV—clefts of lip and alveolus
Group V—miscellaneous
Another widely accepted cleft lip classification is based on recommendations of the American Cleft Palate Association. This classification divides cleft lip into unilateral or bilateral (right, left or extent) in thirds—(i.e., one-third, two-thirds, three-thirds), or median cleft lip, the extent of which is also measured in thirds.
Advantages of the MS Noordhoff rotation advancement technique (include:
It is the most common procedure (i.e., surgeons more familiar with it).
The technique is adaptable and flexible.
It permits construction of a normal-looking Cupid’s bow.
A minimal amount of tissue is discarded.
The suture line is camouflaged.
There is no notch in the Vermilion.
Cupid’s bow is a critical part of the repair, making it very important to accurately determine the high point of Cupid’s bow on the lateral lip.
Aftercare
The postoperative focus is on ensuring proper nutrition, as well as lip care and monitoring the activity level. Breast milk or full-strength formula is encouraged immediately after surgery or shortly thereafter. Lip care for patients with sutures should include gentle cleansing of suture lines with cotton swabs.
Liberal application of topical antibiotic ointment several times a day for 10 days is recommended. There will be some scar contracture, redness, and firmness of the area for four to six weeks after surgery. Parents should gently massage the area, and avoid sunlight until the scar heals.
The patient’s activities may be limited. Some surgeons use elbow immobilizers to minimize the risk of accidental injury to the lip. Immobilizers should be removed several times a day in a supervised setting, allowing the child to move the restricted limb(s). Interaction between the orthodontist and surgeon as part of the treatment team begins in the neonatal period, and continues through the phases of mixed dentition.
Risks
There may be excessive scarring and contraction of the lips. Two types of scars, hypertrophic or keloid, may develop. Hypertrophic scars appear as raised and red areas that usually flatten, fade in color, and soften within a few months. Keloids form as a result of the accelerated growth of tissue in response to the surgery or trauma to the area. The keloid can cause itching and a burning sensation. Scratching must be avoided because it can lead to healing problems. Some patients require minimal revision surgery, but in most cases, the initial redness and contracture is part of the normal healing process.
Normal results
Ideal surgical results for cleft lip include symmetrically shaped nostrils, and lips that appear as natural as possible and have a functional muscle. Many characteristics of the natural lip can be achieved; however, the outcome ultimately depends on a number of factors, including the skill of the surgeon, accurate pre-surgery markings, alignment of bones within the affected area, uncomplicated healing of the initial repair, and the effect of normal growth on the repaired lip. Additional surgical correction to reconstruct nasal symmetry is sometimes necessary.
Morbidity and mortality rates
Generally, cleft lip repair is well-tolerated in healthy infants. There are no major health problems associated with this reconstructive surgery. Depending on the results, it may be necessary to perform additional operations to achieve desired functional and cosmetic outcomes.
Alternatives
There are no alternatives for this surgery. Obvious deformity and impairments of speech, hearing, eating, and breathing occur as a direct result of the malformation. These issues can not be corrected without surgery.
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
A plastic and reconstructive surgeon performs the procedure in a hospital equipped with a surgical department. Plastic surgeons typically have five years of training in general
Many plastic surgeons who operate on cleft lip (or palate) patients have received additional surgical training in Cranio-Facial plastic surgery. However, completion of a surgical training program does not guarantee clinical expertise, and parents should seek surgeons who having both training and experience in Cleft Surgery
QUESTIONS TO ASK THE DOCTOR
How many cleft palate surgeries has the surgeon performed?
How is nutrition managed after surgery?
What lip care will be required after surgery?
How much activity will be allowed, and will the patient be immobilized following the surgery?
How much follow-up is required?
What cosmetic and functional results are expected?
How long is the surgical procedure?