Cleft Lip and Cleft Palate Repair

Description  ( Overview)

Cleft lip and cleft palate are birth defects that occur when a baby’s lip or mouth do not form properly during pregnancy. Together, these birth def ects commonly are called “orofacial clefts”.

The lip forms between the fourth and seventh weeks of pregnancy. As a baby develops during pregnancy, body tissue and special cells from each side of the head grow toward the center of the face and join together to make the face. This joining of tissue forms the facial features, like the lips and mouth. A cleft lip happens if the tissue that makes up the lip does not join completely before birth. This results in an opening in the upper lip. The opening in the lip can be a small slit or it can be a large opening that goes through the lip into the nose. A cleft lip can be on one or both sides of the lip or in the middle of the lip, which occurs very rarely. Children with a cleft lip also can have a cleft palate.

What is Cleft Palate?

The roof of the mouth (palate) is formed between the sixth and ninth weeks of pregnancy. A cleft palate happens if the tissue that makes up the roof of the mouth does not join together completely during pregnancy. For some babies, both the front and back parts of the palate are open. For other babies, only part of the palate is open.

Children with a cleft lip with or without a cleft palate or a cleft palate alone often have problems with feeding and speaking clearly and can have ear infections. They also might have hearing problems and problems with their teeth.

Why  Cleft Lip And Cleft Palate  Repair   Is  Reguired ?

Children with cleft lip with or without cleft palate face a variety of challenges, depending on the type and severity of the cleft.

• Difficulty feeding. One of the most immediate concerns after birth is feeding. While most babies with cleft lip can breast-feed, a cleft palate may make sucking difficult.
• Ear infections and hearing loss. Babies with cleft palate are especially at risk of developing middle ear fluid and hearing loss.
• Dental problems. If the cleft extends through the upper gum, tooth development may be affected.
• Speech difficulties. Because the palate is used in forming sounds, the development of normal speech can be affected by a cleft palate. Speech may sound too nasal.
• Challenges of coping with a medical condition. Children with clefts may face social, emotional and behavioral problems due to differences in appearance and the stress of intensive medical care.

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. Most clefts can be repaired through specialized plastic surgery techniques and will help to improve your child’s ability to eat, speak, hear and breathe.

Why  Iran Is Suitable For  Cleft Lip And Cleft Palate  Repair ?

Patient Eligibility \ Who Can Have Cleft Lip And Cleft Palate  Repair?

A cleft lip and cleft palate are usually noticed at birth, and your doctor may start coordinating care at that time. If your baby has signs and symptoms of a submucous cleft palate, make an appointment with your child’s doctor.

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:

The timing of the cleft repairs depends on the individual circumstances of your child.

• Cleft lip repairs are typically performed between 2 and 6 months of age depending on your child’s health status and local cleft team protocols.
• Cleft palate repairs are generally performed after cleft lip repair in a separate surgery when the child is between 9 to 18 months of age depending on health status and local cleft team protocols.
• Cleft lip and/or palate repair may be delayed in order to treat other, more life-threatening problems that may be present such as a heart or lung disorder.
• Depending on the severity of the cleft, pre-operative interventions such as cleft lip taping, orthodontic molding (called NasoAlveolar Molding – NAM), or staged surgery techniques may be recommended.
• Other cleft-related surgeries may be needed over time including ear tubes to treat fluid buildup, bone grafting to repair the gumline, and dental or jaw surgery to improve bite relationships

How Is   Cleft Lip And Cleft Palate  Repair  Done ?(Procedures)

Surgery to correct cleft lip and palate is based on your child’s particular situation. Following the initial cleft repair, your doctor may recommend follow-up surgeries to improve speech or improve the appearance of the lip and nose.

Surgeries typically are performed in this order:

• Cleft lip repair — within the first 3 to 6 months of age
• Cleft palate repair — by the age of 12 months, or earlier if possible
• Follow-up surgeries — between age 2 and late teen years

Cleft lip and palate surgery takes place in a hospital. Your child will receive a general anesthetic, so he or she won’t feel pain or be awake during surgery. Several different surgical techniques and procedures are used to repair cleft lip and palate, reconstruct the affected areas, and prevent or treat related complications.

In general, procedures may include:

• Cleft lip repair. To close the separation in the lip, the surgeon makes incisions on both sides of the cleft and creates flaps of tissue. The flaps are then stitched together, including the lip muscles. The repair should create a more normal lip appearance, structure and function. Initial nasal repair, if needed, is usually done at the same time.
• Cleft palate repair. Various procedures may be used to close the separation and rebuild the roof of the mouth (hard and soft palate), depending on your child’s situation. The surgeon makes incisions on both sides of the cleft and repositions the tissue and muscles. The repair is then stitched closed.
• Ear tube surgery. For children with cleft palate, ear tubes may be placed to reduce the risk of chronic ear fluid, which can lead to hearing loss. Ear tube surgery involves placing tiny bobbin-shaped tubes in the eardrum to create an opening to prevent fluid buildup.
• Surgery to reconstruct appearance. Additional surgeries may be needed to improve the appearance of the mouth, lip and nose.

Surgery can significantly improve your child’s appearance, quality of life, and ability to eat, breathe and talk. Possible risks of surgery include bleeding, infection, poor healing, widening or elevation of scars, and temporary or permanent damage to nerves, blood vessels or other structures.

Treatment for complications

Your doctor may recommend additional treatment for complications caused by cleft lip and cleft palate. Examples include:

• Feeding strategies, such as using a special bottle nipple or feeder
• Speech therapy to correct difficulty with speaking
• Orthodontic adjustments to the teeth and bite, such as having braces
• Monitoring by a pediatric dentist for tooth development and oral health from an early age
• Monitoring and treatment for ear infections, which may include ear tubes
• Hearing aids or other assistive devices for a child with hearing loss
• Therapy with a psychologist to help the child cope with the stress of repeated medical procedures or other concerns

Preparation & Recovery

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.

After surgery, bandages may be placed on incisions outside your child’s mouth. You will be given specific home care instructions that may include:

• How to care for the surgical site following surgery
• Medications to apply or take orally to decrease pain, aid healing and reduce the risk of infection
• Specific feeding instructions to help protect the surgical site during healing
• Feeding or activity restrictions necessary to promote normal healing
• Specific issues to monitor in the general health of your child
• When to follow-up with your plastic surgeon

Dietary restrictions are common after palate repair with liquid or puree diets recommended for several days. Some surgeons also recommend avoiding bottles, pacifiers, straws or other utensils as well for several days. Commonly, arm restraints are used after surgery to help prevent your child from touching or injuring the surgical site as it heals. Some surgeons allow these restraints to be removed temporarily, so long as your child is supervised and prevented from touching the surgical site or sucking their fingers.

Your child’s discomfort can be controlled with pain medication. Depending on the surgical technique used, sutures may need to be removed from the lip following surgery. Healing will continue for several weeks as swelling resolves. Lip scars will mature and fade over many months. After surgery, diligent sun protection is essential to prevent the formation of irregular scars.

Risks & Complication 

There are risks of problems after any operation. Cleft palate repair, or palatoplasty, is an effective and reliable operation in a large majority of children, but there are two main risks.

The first is the risk of fistula, or a hole in the repaired palate. This can be a problem as foods and drinks can escape through the hole and leak out through the nose. If the fistula is large enough, it can affect speech. Not all fistulas need to be repaired, but if there are any problems due to the hole, surgical repair is usually recommended.

The second is the risk of velopharyngeal dysfunction. This is a term to describe that the soft palate is not acting well as a valve to block air from traveling into the back of the nose and redirecting it into the mouth. As a result, there are problems with forming speech sounds. Depending on the severity of the velopharyngeal dysfunction, this can range from soft speech or speech with added noise from air leaking through the nose, all the way to speech that is impossible to understand, even by close family.

 If velopharyngeal dysfunction is suspected, then it is investigated using specialized tests, and surgery may be recommended.