Craniofacial Team of Texas Cleft Lip and Palate Surgery team are members of the American Cleft Palate-Craniofacial Association (ACPA) (see disclaimer), an international, non-profit medical society of health care professionals who treat and/or perform research on birth defects of the head and face. Our team provides an extremely important role in the management of children and adults with cleft lip and cleft palate, and craniofacial anomalies by performing cleft lip and palate surgery.
Cheiloplasty – Cleft Lip Repair Surgery
Timing of primary cleft lip repair surgery (cheiloplasty) generally occurs around 3 months of age. The timing and treatment are determined by a number of factors, including safety of undergoing general anesthesia, preoperative nasoalveolar molding (NAM), and sufficient development of the lip and surrounding facial structures to perform an accurate repair.
Prior to Cleft Lip Repair Surgery
Soon after birth, your child will be seen by members of the nursing team, the plastic surgeon, the craniofacial pediatrician, and the team orthodontist. The nursing team will help with feeding, general cleft care teaching, and will answer other questions about the care of your child. The team orthodontist will assess your child for the need for nasoalveolar molding, or NAM. NAM is an orthodontic procedure which will begin in the weeks after birth and continue up until the cleft lip repair. A mold will be taken of your child’s mouth to create an appliance consisting of a nasal stent and a palatal plate (retainer). The purpose of NAM is to provide for nasal symmetry by aligning the cleft segments of the palate, as well as shaping the nose. With wide clefts, NAM can be very useful in bringing the widened tissues and alveolus (front of the palate) closer together to improve the final surgical result. NAM may also lengthen the columella (area of the nose between the nostrils), which can be very important, especially in bilateral clefts. If your child is treated with NAM, they will be seen regularly by the orthodontics team for adjustments. By the time of the surgical repair, NAM will have lifted and narrowed the nose, shortened the gap in the gums, and brought the lips closer together. If your child has a cleft palate, you will also be referred to an otolaryngologist to determine whether or not your child may need tympanostomies (ear tubes). The cleft team will always be available to answer any questions you may have during this process.
Cleft Lip Repair Surgery
In the days before surgery, your child will have a final checkup to make sure surgery at this time is safe. Preoperative consent forms will also be reviewed and signed, and you will be given the opportunity to ask any questions you may have regarding your child’s procedure. You will get very specific instructions from the hospital/surgery center staff regarding where to go and when, as well as when your child needs to stop eating prior to surgery.
On the day of surgery, you will meet with your child’s physician to review the surgery. Any last minute questions or concerns can be addressed at this time. You will also meet with the pediatric anesthesiologist who will be providing your child’s anesthesia. Our pediatric anesthesiologists, who have extensive experience in cleft care, will review your child’s medical history with you and discuss the general anesthesia they will administer during your child’s surgery. You will be asked to sign the anesthesia consent prior to your child being sedated for surgery.
Surgery generally takes between 3-4 hours. The nurses, staff, and child life specialists work to make this as pleasant and comfortable an experience as possible for your child before and after surgery.
The goal of surgery is to undo the abnormal relationships between the tissues involved in the cleft, and to put them into a near-normal configuration, mirroring the normal side in a unilateral or one-sided cleft. This involves the mucosa (mouth and nasal lining), muscles, and skin. After the patient is asleep, the surgeon makes careful measurements of both the normal and cleft sides, and marks the incisions. Local anesthetic is then injected to make the tissues numb and help prevent bleeding; an effect that lasts for several hours after surgery is complete. The mucosa, muscles, and skin are then carefully freed from their abnormal cleft orientation, and sutured to the noncleft side. Often, the normal lip on the cleft side is significantly shorter than on the normal side. This is corrected using rotation-advancement flaps, making back-cuts in the columella (bottom of the nose) or across the philtrum and rotating the skin from across the cleft to provide length. At the end of surgery, nasal stents (plastic tubes) are placed into the nose and sutured into place. This helps produce a more normal nostril shape. Nasoalveolar molding may be used after surgery to maintain this shape. Bilateral (both-sided) clefts are treated in a similar fashion, except both sides are addressed. It should be noted that, especially in bilateral clefts, the repair may seem quite pinched and narrow in the weeks after surgery. This is normal, and the tissues will relax over time.
After Cleft Lip Repair Surgery
Immediately following surgery, your child will be taken to the recovery room where vital signs will be monitored and until he/she is alert. The length of time in recovery will vary, as some children take longer than others to wake up after anesthesia. Your child will then be taken to a room and admitted to the hospital for observation. Arm restraints are placed (no-nos) to prevent your child from touching the repaired lip. Patients will be able and are encouraged to drink soon after surgery. They are provided with pain medicine, and fluids through an IV until they are drinking enough. The staff will help you with feeding, care of the lip, and pain control while you are in the hospital. Patients generally stay in the hospital for one night, but some stay a bit longer if they are not yet drinking enough. Even after discharge from the hospital, there is always someone from the team available to answer any questions.
Some surgeons use disolvable sutures on the lip, with skin glue on the surface. Others use sutures that need to be removed. For these children, the incisions are cleaned and dressed with antibiotic ointment at home twice a day. Their sutures are then removed under anesthesia 5-7 days after surgery.
Palatoplasty – Cleft Palate Repair Surgery
Timing of cleft palate repair surgery (palatoplasty), is generally performed between 9 to 12 months of age. Children with cleft palates are able to feed and gain weight, even without repair. The most frequent issues that result from a cleft palate relate to speech, hearing, and facial growth. The main goal of palatoplasty is to restore the ability to produce normal speech. Normal speech requires the nasal airway to close off from the oral airway during certain speech sounds, including vowel sounds and consonant sounds such as “p”, “b”, “g”, “t”, and “d”. Several structures, including the soft palate (velum), lateral pharyngeal walls (walls on sides of throat), and posterior pharyngeal wall (wall at back of throat), must come together to allow for this velopharyngeal closure. When the velopharyngeal sphincter (soft palate muscle) closes improperly during speech, air escapes through the nose instead of the mouth. This is known as velopharyngeal insufficiency, or VPI. Children with cleft palates may have gaps in the hard and/or soft palates, which allow air to escape through the nose during speech. In addition, the muscles of the soft palate are oriented so that they are unable to move the soft palate sufficiently. Early surgery on the palate may affect the growth of the maxilla, or upper jaw. For this reason, we wait until the time of the usual production of speech before performing palatoplasty. The larger size of the tissues at this time also ensures a more accurate repair.
Prior to Cleft Palate Repair Surgery
Soon after birth, your child will be seen by members of the nursing team, the plastic surgeon, the craniofacial pediatrician, and the team orthodontist. The nursing team will help with feeding, general cleft care teaching, and will answer other questions about the care of your child. The muscles affected in a cleft palate also help with decompression of the eustachian tubes, the reason your ears pop when you yawn. Cleft palates may be associated with fluid buildup and recurrent ear infections, which may lead to hearing loss if not treated. Your child will therefore be referred to an otolaryngologist to determine whether or not there is a need for tympanostomies (ear tubes). The cleft team will always be available to answer any questions you may have during this process. If your child has a cleft lip, this will be repaired generally at between 3-4 months of age. Closer to the time of surgery, we will help transition your child from feeding with a bottle to feeding with a sippy cup. This is to prevent anything from entering the mouth after surgery, which may damage the repair.
Cleft Palate Repair Surgery
In the days before surgery, your child will have a final checkup to make sure surgery at this time is safe. Preoperative consent forms will also be reviewed and signed, and you will be given the opportunity to ask any questions you may have regarding your child’s procedure. You will get very specific instructions from the hospital/surgery center staff regarding where to go and when, as well as when your child needs to stop eating prior to surgery.
On the day of surgery, you will meet with your child’s physician to review the surgery. Any last minute questions or concerns can be addressed at this time. You will also meet with the pediatric anesthesiologist who will be providing your child’s anesthesia. Our pediatric anesthesiologists, who have extensive experience in cleft care, will review your child’s medical history with you and discuss the general anesthesia they will administer during your child’s surgery. You will be asked to sign the anesthesia consent, prior to your child being sedated for surgery.
Surgery generally takes between 3-4 hours. The nurses, staff and child life specialists work to make as pleasant and comfortable an experience as possible for your child before and after surgery.
The goals of surgery are to repair the palate, including the nasal and oral lining (mucosa), and to put the soft palate muscles into the correct orientation to allow for normal speech. Once your child is asleep, the mouth is kept open with a special retractor. The palate is injected with local anesthetic, which numbs the area and helps prevent bleeding. The tissues of the hard and soft palate are incised and mobilized, and the muscles are carefully dissected from their abnormal attachments and oriented normally. All of the layers are then sutured together using disolvable sutures.
Often, the palate is sufficiently short that there may be a risk of VPI or speech difficulties, even after repair. For these patients, we perform a Furlow lengthening palatoplasty at the time of the primary palatoplasty. The Furlow technique involves performing “double opposing z-plasties”, in which triangular flaps of tissue are transposed in order to lengthen the palate.
At the end of the procedure, prior to waking up from the anesthetic, a tongue stitch is placed. This is a suture placed in the tongue, and taped to the child’s cheek. The tongue may swell after palatoplasty. Very rarely, this may lead to problems with breathing. The tongue stitch helps pull the tongue away from the airway if this happens. The tongue stitch is removed at the bedside the morning after surgery.
After Cleft Palate Repair Surgery
Immediately following cleft lip and palate surgery, your child will be taken to the recovery room where vital signs will be monitored and he/she is alert. The length of time in recovery will vary, as some children take longer than others to wake up after anesthesia. Your child will then be taken to a room and admitted to the hospital for observation. Arm restraints are placed (no-nos) to prevent your child from touching the repaired palate. Patients will be able and are encouraged to drink soon after surgery. They are provided with pain medicine and fluids through an IV until they are drinking enough. The staff will help you with feeding and pain control while you are in the hospital. Patients generally stay in the hospital for one night, but some stay a bit longer if they are not yet drinking enough. Even after discharge from the hospital, there is always someone from the team available to answer any questions.
If you would like more information about cleft lip and cleft palate surgery, please contact the Craniofacial Team of Texas by calling 512-377-1142 or toll free 877-612-7069 to schedule an appointment or complete an online appointment request.
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