Treatment of Cleft Lip & Palate involves repair of a gap in the upper lip and/or the roof of the mouth, due to lack of fusion. The skill and experience of the plastic surgeon is critical to maximizing aesthetic and functional outcomes, while also minimizing surgery, hospital stay and long-term costs.
Approximately one in 700 children is born with a cleft lip and/or cleft palate. This condition may be associated with a number of difficulties in feeding and nutrition, dentition, facial growth, speech, and sleep or breathing. Surgical treatment is carried out over a series of years to be timed with the patient’s facial growth. Craniofacial team care is mandatory to achieve the best outcomes and will assure proper sequencing of the various surgery procedures:
A Cleft Lip may be unilateral or bilateral, complete or incomplete. The goals of cleft lip repair include re-establishment of muscle continuity and re-creation of the normal landmarks of a lip. The skin, muscles and mucous membranes are surgically moved from their abnormal positions and joined back together again. Cleft lip repair is normally performed around age 3 months.
At the Children’s Hospital of San Diego, the experienced FACESplus surgeons repair many cleft lips 1 or 2 weeks after the baby is born. These babies feed easily, gain weight quickly and become bonded to their families with minimal disruption. This early treatment approach requires the coordination of a craniofacial team and a hospital specialized in the surgery and recovery of newborns.
Normal landmarks recreated in the repair of a cleft lip include the philtrum or central dimple of the upper lip, the philtrum column or ridge on either side of the central dimple, the cupid’s bow curvature between the white and red regions of the lip, and the vermilion tubercle or pout of the central red part of the upper lip.
A Cleft Palate may be unilateral or bilateral, involve the soft palate only, soft and hard palate, and extend thru the gum where teeth will eventually erupt. The goals of cleft palate repair include re-establishment of muscle continuity in the soft palate, and re-approximation of the palate lining across the cleft. The palate lining is shifted from the sides to the center and stitched together. The bare areas left on the sides heal in spontaneously.
Cleft palate repair is normally performed around age 6 to 9 months, in time for speech development.
When present a cleft through the gum, or alveolar process, may also be closed at this time. However a bone graft may be required around age 6 to 8 years to anchor the eruption of a permanent tooth. Many children will require speech therapy and, occasionally, a surgical pharyngoplasty, to correct nasal speech. The timing of these surgeries for tooth eruption and speech is coordinated by the Cleft Palate Team at the San Diego Children’s Hospital.
Children with cleft palates may have problems with hearing, speech, and teeth eruption. Cleft palate team members, in addition to plastic surgeons, include audiologists, ear specialists, speech pathologists and therapists, dentists, orthodontists, and oral surgeons.
Cleft Nasal Deformity
A Cleft Nasal Deformity is typically associated with cleft lip and palate. The affected side of the nose is widened and flattened due to displacement of the nasal cartilages. The goals of cleft nasal surgery are to re-establish normal nasal tip projection, alignment of the nares, and position of the nasal base. To supplement the cartilages of the nasal tip, a cartilage graft may be required. The FACESplus surgeons are very experienced with nasal surgery and utilize the latest in techniques and technologies. Cleft nasal surgery is usually performed at age 4 to 5 years, prior to starting school. Because growth may not take place in a normal fashion, revisions of the nasal surgery may be required in the adolescent and teen years.
Children with cleft nasal deformity typically have difficulty nasal breathing due to the deviation of the nasal septum. This can be readily corrected at the time of the cleft nasal surgery.
Cleft Maxillary Hypoplasia
Cleft Maxillary Hypoplasia is an undergrowth of the maxilla, or upper jaw, that occasionally occurs in children with cleft lip and palate. It is more common when the cleft is bilateral. As the child’s face grows, the upper jaw is unable to keep up with normal growth of the lower jaw and the upper teeth become abnormally positioned behind the lower jaw teeth. Using principles of orthognathic surgery, the maxilla can be predictably brought forward, thus not only normalizing the relationship of the jaws, but also normalizing the relationships of the lips to each other and to the nose.
Surgery to correct cleft maxillary hypoplasia is normally performed in the teen years after jaw growth is completed. When severe, the deformity is treated earlier to avoid psychosocial harm. The newer techniques of distraction are occasionally indicated in the correction of cleft maxillary hypoplasia and the FACESplus craniofacial surgeons working together with oral surgeons have an extensive experience.
Prior to surgical reposition of the upper jaw it is important that the teeth be prepared for proper alignment and occlusion. Planning and treatment by an orthodontist is required before and after orthognathic surgery of the maxilla.