Surgical Procedures
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 return for a follow-up appointment 7-10 days
after surgery for removal of sutures if needed. Additional appointments
will be made with the plastic 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 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 nasal speech despite closure of the palate. Z-plasty
may be done to extend 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 deflects
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 mild 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 boney ridge. This procedure
offers several advantages:
1. Provides bone support for the permanent teeth.
2. Provides stability of the boney segments of the upper jaw.
3. 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 boney
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 eye teeth erupt. Dental x-rays help in deciding when
to do the bone graft. Many children are around 7 or 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 may be 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.
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