Cleft Lip and Palate defects are congenital deformities with a variety of causes. They can be genetic or environmental. Orofacial clefts can be diagnosed during pregnancy by a routine ultrasound. They can also be diagnosed after the baby is born. If cleft lip or cleft palate are diagnosed, one should visit a craniofacial surgeon as soon as possible. This can help confirm that the baby is healthy and also what type of procedures they can anticipate once the baby is born.
If it is an isolated cleft lip, then the only procedure the baby will need is at 3 months old to have a cleft lip repair. Usually if there is some involvement of the nose, they may need an additional secondary procedure such as a rhinoplasty at around 5 years old. Potential bullying and some negative interactions in school can occur around this age.
If there is a combination with a palate, the palate must be repaired around 10 months. Specifically because we don’t want to jeopardize the growth of the hard palate. At 10 or 11 years old there could be a third procedure if there is an association with alveolar defect. The alveolar defect is part of the maxilla. In this procedure we perform a bone graft where we take some cancellous bone from the hip and we fill the gap of the bone in order for the permanent teeth to be developed.
The main problem with the cleft lip, is there a muscle called the orbicularis oris. This muscle in all cleft lip patients is not continuous. In order to repair, the surgeon must dissect and identify this muscle, detach it from the left maxillary area and suture together with normal muscle from the normal side. The other two layers that must also be repaired are the mucosa which is the pink part of the lip and then the skin. The skin must have very detailed measurements prior to avoid potential scarring and also avoid any mismatch with the vermilion border. This area which is the normally sharp demarcation between the lip and the adjacent normal skin.
There are three layers that have been defected, the skin, the muscle and the mucosa. The skin must have appropriate marking and appropriate dissection in order to allow a tension free repair. The second part is the muscle which is the most important part of the procedure because this muscle must be fully functional. If the muscle is not fully functional, the patient can have further potential problems including drooling and undesired aesthetic results. When the muscle is appropriately oriented, the mucosa will simply bring together the pink part of the lip.
The procedure is normally done under general anesthesia and patients usually can go home the same day or if they choose they can stay overnight under observation and be discharged the next day. The main goal is to make sure the patient can drink fluids before leaving the hospital. My philosophy is that babies do not need a traditional splint and they should immediately resume breastfeeding and using previous methods of feeding. We usually follow up with the patient after one month.
If the defect is large, there is a potential treatment known as nasoalveolar molding (NAM)
Nasoalveolar molding (NAM) is a nonsurgical way to reshape the gums, lip and nostrils with a plastic plate before cleft lip and palate surgery. Pre-surgery molding may decrease the number of surgeries your child needs because it makes the cleft less severe. This treatment isn’t necessary but it can help decrease the defect size.
The appropriate follow up and treatment for children with craniofacial defects and deformities especially with a cleft lip palate requires a good team consisting of a Craniofacial Surgeon, Orthodontist, ENT Surgeon, and a Nutritionist to have good results. They should be experienced in order to provide good results but also communication with the families of the patients is critical to help them understand that appropriate planning is necessary.
When the patient becomes a teenager, there is also a possibility that if they have a cleft palate can have a maxillary deficiency. This means the maxillary has not grown. In severe cases we would discuss with the Orthodontist about performing a Lefort 1 Surgery or better known as a Double Jaw Surgery. The procedure, is very safe and useful because it of its ability to position the upper jaw anywhere within three dimensions to reshape the face and improve the bite.
Insurance plans usually cover the first procedure. Unfortunately they do not always cover the secondary procedure like Rhinoplasty. We as Plastic Surgeons are working with local and state Political Action Committees to improve coverage for further craniofacial related procedures however the Cleft Lip and Palate as a primary surgery is usually covered without any issues. Medicaid patients are also eligible for this procedure as well.
