Primary cleft lip repair (cheiloplasty)

The goals of primary cleft lip repair involve reconstruction of the normal anatomy and function of the lip, correction of the nasal deformity, and construction of the floor of the nose and proper alignment of the maxillary segments (gum-line).

Clefts vary in severity from partial unilateral (one side) cleft to complete bilateral (both sides).

Surgery of the lip will be performed at approximately 4-6 months of age. The child must be healthy and gaining weight. The guideline followed is that children must weigh ten pounds before the surgery will be done. Bilateral lip repair may be done as one surgical procedure or may require a second procedure at least 8 weeks after the first surgery. Myringotomies and tubes may be inserted into the ears at the time of surgery if needed. A preoperative work-up must occur within 30 days of surgery. Hemoglobin and hematocrit levels will be checked prior to surgery and home care instructions will be discussed. Generally, the child will spend one night in the hospital following surgery. They will need to be drinking enough to remain hydrated to be discharged to home. They will return for a follow-up appointment 7-10 days after surgery for removal of sutures if needed. Additional appointments will be made with the cleft surgeon 4-6 weeks after surgery. At this time palate surgery will be discussed, if needed and a procedure date scheduled.

Cleft palate repair (palatoplasty)

Cleft palate repair is of concern to plastic surgeons, speech pathologists, otolaryngologists and orthodontists with respect to the timing of the operation, the type of palatoplasty to be considered and the effect of the repair on speech, facial growth and eustachian tube function. The objective of this procedure is to close the palatal defect and create an adequately functioning velopharyngeal mechanism for normal speech production.

Surgery of the palate generally occurs between 9-15 months of age. It is done at this time in an effort to provide the child with the best physiological mechanisms for language and speech development. A preoperative work-up with hemoglobin and hematocrit levels must occur within 30 days of surgery. Most children spend 1 or 2 nights in the hospital following surgery. They will return for a follow-up appointment 3-4 weeks after surgery. A visit with the cleft surgeon and other members of the cleft team should occur 3-6 months later.

Other surgeries/procedures

Further surgery may be done to 1) correct speech problems not resolved with speech therapy, 2) improve the appearance of the nose or lip area, and 3) provide support for the teeth where the gum ridge is affected. These may include:

Z-plasty or pharyngeal flap

Some children may have hypernasal speech despite closure of the palate. Z-plasty may be done to lengthen the soft palate and decrease nasal escape of speech sounds. A pharyngeal flap involves raising a flap of tissue from the back wall of the throat and attaching it to the soft palate. The flap blocks some of the air that used to leak out the nose.

The purpose of the z-plasty or pharyngeal flap procedures is to decrease the hypernasality and nasal emissions evident in speech. Nasal emission and nasality generally occur because a person can not consistently close the opening between the oral and nasal cavity. In such instances there is air coming out the nose when talking rapidly or during conversational speech. Nasality and nasal emission of air can be observed by either plugging up the nose while talking or placing a mirror under the nostrils underneath the nose. Small amounts of air can either be seen or felt coming out the nose.

This condition generally occurs because of a physical limitation rather than a learned behavior and may be due to a short or immobile palate, deep pharynx, adenoid shrinkage, submucous cleft palate, neurological disorder, or a combination of the above.

Although no surgical procedure can be guaranteed, we estimate that at least 80% of the patients improve their speech. Generally, the patient will stay in the hospital for 1 or 2 nights, and will be on a liquid diet followed by a soft diet for approximately 3 weeks after the this procedure. Often the patient will have a stiff neck and have discomfort when swallowing for a few days following surgery.

Initially after the surgery it may sound like the person has a slight cold when speaking. Likewise, after the surgery snoring may occur and breathing through the mouth is common.

These procedures are usually performed between 4-6 years of age prior to entering school.

Fistula repair

After the palatoplasty is performed the tissues may heal in such a way that there is still an abnormal opening, called a fistula. This opening may allow food to move from the oral to the nasal cavity when eating. It may also allow more air to pass out of the nose during speech. If there are problems with either eating or speech the fistula will most likely be closed when another procedure is to be done.

Alveolar bone graft

Alveolar cleft repair is a secondary cleft procedure performed when there is insufficient bone in the area of the alveolar (gum-line) defect. Surgical repair of the defect involves taking bone marrow from the patient’s hip and grafting it into the cleft defect in the bony ridge. This procedure offers several advantages:

  • Provides bone support for the permanent teeth. 
  • Provides stability of the bony segments of the upper jaw. 
  • Assists in closing oral/nasal fistulas that may be present. The improved bone support for the permanent teeth will enable the orthodontist to align individual teeth in the cleft area. The increased stability of the bony segments will help the prosthodontist to replace any missing teeth.

The graft procedure is done after the baby teeth are lost, but before the child’s lateral incisors or eye teeth erupt. Dental x-rays help in deciding when to do the bone graft. Many children are around 5 to 9 years of age, but dental status, not the child’s age, will be the deciding factor.

Maxillary distraction osteogenesis

In children that have a Class 3 malocclusion (the bottom jaw protrudes out beyond the top jaw), distraction osteogenesis may be done to deal with the alignment process. The procedure involves surgically freeing the upper jaw (LeFort l osteotomy) and then moving it slowing forward over a period of 4-6 weeks. As the upper jaw is moved forward, new bone is made to create a solid jaw. This movement is achieved by wearing a rigid external device called a halo, with wires attached to a mouth appliance. By turning screws on the device daily the tension is adjusted which allows the jaw to move forward.

Once the amount of forward movement that is desired has been obtained, the device is left in place for an additional 2-3 weeks. After the device is removed nighttime headgear is worn for a 4-6 week time period.

The process allows for treatment at an earlier age, versus waiting until patients have reached skeletal maturity (typically 14-17 years of age). There also appears to be a benefit in regard to the long-term outcomes.

Lip and/or nasal revision (cleft rhinoplasty)

Lip and/or nasal revision may be done at any age to improve the contour or shape of the lip and nose. Revisions are usually done when the child or parent expresses a desire to proceed. To decrease the number of revisions a child may have, it is often suggested to delay treatment until facial growth is complete typically around sixteen years of age or older. When revisions are done sooner, normal growth may alter how the lip or nose look and create the need for more repairs.