Correcting Abnormal Development
Cleft lip repair and cleft palate repair are types of surgery used to correct this abnormal development and are meant to restore function to the lips and mouth along with producing a more normal appearance.
Cleft lip repair usually leaves a small scar on the lip under the nose. At 9-12 months of age, a cleft palate usually can be repaired. Plastic surgeons connect the muscles of the soft palate and rearrange the tissues to close the cleft. This surgery requires general anesthesia and a short hospital stay for recovery.
Cleft lip and cleft palate repair is surgery to fix birth defects of the upper lip and palate (roof of the mouth).
Recovering from a surgical procedure is never easy, but because cleft lip and cleft palate repairs are performed on your child when they are as young as three months old, there are many special considerations to be aware of during the recovery phase.
Cleft lip and cleft palate repairs are done as two separate procedures. Cleft lip repair is usually performed on children at 3 months of age, while cleft palate repair is performed at 9 to 12 months.
A cleft lip is a birth defect:
- A cleft lip may be just a small notch in the lip. It may also be a complete split in the lip that goes all the way to the base of the nose.
- A cleft palate can be on one or both sides of the roof of the mouth. It may go the full length of the palate.
- Your child may have one or both of these conditions at birth.
Most times, cleft lip repair is done when the child is 3 to 6 months old.
For cleft lip surgery, your child will have general anesthesia (asleep and not feeling pain). The surgeon will trim the tissues and sew the lip together. The stitches will be very small so that the scar is as small as possible. Most of the stitches will be absorbed into the tissue as the scar heals, so they will not have to be removed later.
Most times, cleft palate repair is done when the child is older, between 9 months and 1 year old. This allows the palate to change as the baby grows. Doing the repair when the child is this age will help prevent further speech problems as the child develops.
In cleft palate repair, your child will have general anesthesia (asleep and not feeling pain). Tissue from the roof of the mouth may be moved over to cover the soft palate. Sometimes a child will need more than one surgery to close the palate.
During these procedures, the surgeon may also need to repair the tip of your child’s nose. This surgery is called rhinoplasty.
Early intervention by a team of specialists is needed to evaluate and manage your child’s treatment and development in cases of cleft lip and/or cleft palate. The team will work together to deﬁne a course of treatment, including feeding recommendations, surgical repair of the cleft, speech rehabilitation and dental restoration. These specialists may include a:
- Plastic surgeon
- Pediatric dentist
- Otolaryngologist (ear, nose and throat specialist)
- Lactation Specialist
- Occupational therapist
- Auditory or hearing specialist
- Speech-language pathologist
- Genetic counselor
- Social worker
It is important to know that at the earliest stages feeding, growth, and development will be the most important priorities for your child’s cleft-related care. Specialized bottles, or more rarely, feeding tubes, may be necessary to help your child eat well. Often, when a cleft palate is involved, the infant will not be able to feed at the breast like other infants due to problems with creating oral suction.
Surgery to repair a cleft of the lip or palate is highly individualized. Surgery is intended to close the cleft defect, but also to help your child ability to function and grow normally. Cleft lip repair, also called cheiloplasty, includes reconstruction of the lip to create a more normal appearance, namely:
- Closure of the cleft resulting in a scar located within or near the typical features of the upper lip
- Formation of a cupid’s bow (the curves along the center of the upper lip)
- Establishing adequate distance between the upper lip and nose
Clefts of the upper lip typically affect the shape of the nose and additional procedures may be recommended to:
- Restore nasal symmetry and nostril shape
- Straighten and create adequate length for the columella (the tissue that separates the nostrils)
Because the palate creates the ﬂoor of the nasal cavity and is responsible for allowing normal speech, considerations in repairing a cleft palate include:
- Separating the mouth and nasal tissues by closing the defect along its length
- Re-establishing soft palate muscle function to promote normal speech
- Recreating normal relation of the soft palate to the auditory canal and Eustachian tube to allow for normal hearing
- Promoting as much as possible the normal growth and development of the upper jaw and teeth
- Repairing, when appropriate, any defects in the gumline to allow for permanent tooth eruption
The success and safety of your child’s cleft procedure starts during your consultation with a plastic surgeon.
During your child’s cleft surgery consultation be prepared to discuss:
- Your concerns and an evaluation of your child’s condition
- Options available for cleft lip and/or cleft palate repair
- Likely outcomes of surgery and the potential risks and complications associated with the procedure
- A recommended course of treatment
Be candid about your concerns for your child and your plastic surgeon’s ability to meet his or her special needs. The success of your child’s procedure, safety and overall satisfaction requires that you:
- Honestly share your concerns
- Fully disclose your child’s health history including current medications, vitamins and herbal supplements
- Commit to precisely following all of your plastic surgeon’s instructions
Prior to your child’s surgery, your plastic surgeon will discuss with you:
- Pre-surgical considerations, diagnostic testing and medications
- Day-of-surgery instructions and medications
- Specific information related to the use of anesthesia
- Postoperative care and follow-up
Your plastic surgeon will also discuss where your child’s procedure will be performed. Initial cleft lip and cleft palate repair is generally performed in a hospital setting and most commonly requires overnight admission.
Step 1 – Anesthesia
Medications are administered for your child’s comfort during the surgical procedures. The choices include intravenous sedation and general anesthesia. Your doctor will recommend the best choice for your child.
Step 2 – The incision
The goal of cleft lip surgery is to close the separation in the lip and to provide a more normal function, structure and appearance to the upper lip. Incisions are made on either side of the cleft to create ﬂaps of skin, muscle and intraoral tissue that are then drawn together and stitched to close the cleft and recreate typical lip and nose anatomy.
The repair of a cleft palate requires careful repositioning of tissue and muscles to close the cleft and rebuild the roof of the mouth. Incisions are made on either side of the cleft and specialized ﬂap techniques are used to reposition the tissues of the hard and soft palate. This will include repositioning of the soft palate muscles used in speech. The repair is then stitched closed, generally along the midline of the roof of the mouth, providing enough length of the palate to allow for normal feeding, speech development and continued growth throughout life.
Step 3 – Closing the incisions
Once the cleft lip and/or cleft palate has been repaired, the incisions can be closed with removable or absorbable sutures.
Step 4 – See the results
The resulting external scars of a cleft repair are generally positioned in the normal contours of the upper lip and nose. Over time, these will fade and your child’s ability to grow and function normally will continue to improve.
Parents generally request the specific “care path” for their child so that expectations for cleft lip and cleft palate repair plastic surgery can be defined. These treatment protocols vary between centers and among surgeons; there is no absolute right or wrong. Nevertheless, we believe that any protocol should deliver a clear vision of care from infancy to adulthood.
Many parents are very concerned about the presence of scars. Unfortunately, all cleft lip repairs leave visible scars. Every effort is made to keep scars to a minimum and to place scars so that they are easily concealed.
Secondary (or “redo”) surgeries at any stage may be necessary. Our occurrence of secondary surgery is less than 5%.
The goal after surgery is to protect the new repair and stitches. For this reason there will be some changes in the child’s feeding, positioning, and activity for a short time. Remember, these are only temporary!
Infants will not be able to suck on a nipple/bottle or pacifier for 10 days after surgery. A syringe with a short piece of soft rubber tubing will be used for feeding. Older children may drink from a cup. It is helpful if the child has practiced drinking from the syringe before surgery. As soon as the infant awakes from anesthesia and acts hungry they may be offered a feeding of clear liquid (Pedialyte, sugar water, apple juice). When this is tolerated, they may resume their regular formula. Infants who have already begun cereal or baby foods may be offered diluted feedings with the syringe. Older children will be on a blenderized diet that pours easily from a cup.
There may be some discomfort as the child swallows so they may not drink much the first evening. This is why IV fluids are continued until their drinking improves. Pain medicine will also be given to relieve distress.
A child who has had a cleft lip repair should be positioned on their side or back to keep them from rubbing their face in the bed. A child with only a cleft palate repair may sleep on their stomach.
It is important to keep the stitches clean and without crusting. Parents are shown how to clean the suture line and apply ointment while in the hospital. This will continue until the stitches are removed about a week later.
It is important to keep the child from hurting the incision or putting hands or toys in their mouth. For this reason they will wear arm restraints which keep them from bending their elbows. These are also used for 10 days after surgery.
Children usually spend one night in the hospital and are discharged when they begin to drink an adequate amount of fluids. Parents are encouraged to stay with their child and participate in their care. Chair beds are available in the rooms for overnight sleeping.
The main risks with these procedures are damage to the incision and infection.
If your child has any of the following warning signs at any point during their recovery, contact their doctor immediately:
- Pain that isn’t relieved by prescribed or recommended medication
- Temperature over 100.4 degrees & fever
- Diarrhea or vomiting
- Drainage fluids that smell bad or look like pus
- Bleeding from incisions or from the nose or mouth in the case of cleft palate repair
- Any injury sustained to the child’s repaired lip or palate
- Failure of the child to drink adequate fluids
- Difficulty waking the child or excessive sleepiness
- Irregular healing of scars including shortening, thickening or overgrowth
- Residual irregularities and asymmetries in the lip or nose
- Anesthesia risks
- Respiratory problems after surgery
- Allergies to tape, suture materials and glues, topical preparations or injected agents
- Damage to deeper structures—such as nerves, blood vessels, muscles and auditory canal can occur and may be temporary or permanent
- Possibility of revisional surgery
Use this checklist as a guide during your child’s cleft repair surgery consultation:
- Are you certified by the American Board of Plastic Surgery?
- Are you a member of the American Society of Plastic Surgeons?
- Were you specially trained in the field of plastic surgery?
- Do you have hospital privileges to perform this procedure? If so, at which hospitals?
- Is the office-based surgical facility accredited by a nationally- or state-recognized accrediting agency, or is it state-licensed or Medicare-certified?
- How many procedures of this type have you performed?
- Is my child a good candidate for this procedure?
- What will be expected to get the best results?
- Where and how will you perform my child’s procedure?
- What shape, size, surface texturing, incision site and placement site are recommended for my child?
- How long of a recovery period can we expect, and what kind of help will my child need during my recovery?
- What are the risks and complications associated with this procedure?
- How are complications handled?
- What are my options if I am dissatisfied with the outcome of my child’s cleft surgery?
- Do you have before-and-after photos I can look at for each procedure and what are reasonable results?
A passage in the ear.
Cleft lip repair surgery.
The incomplete formation of the upper lip.
The incomplete formation of the roof of the mouth.
A separation of the upper lip and/or the roof of the mouth.
Tissue that separates the nostrils.
Drugs and/or gases used during an operation to relieve pain and alter consciousness.
Inside the mouth.
Sedatives administered by injection into a vein to help you relax.