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- What is Cleft Lip Repair (Cheiloplasty)?
- Effects of Cleft Lip Repair (Cheiloplasty)
- Candidates for Cleft Lip Repair (Cheiloplasty)
- Your Consultation
- The Cleft Lip Repair (Cheiloplasty) Procedure
What is Cleft Lip Repair (Cheiloplasty)?
A cleft lip and palate repair is a surgical procedure to repair birth defects of the upper lip and roof of the mouth. A cleft lip is an abnormal opening in the middle of the upper lip. A cleft palate is an opening in the roof of the mouth (palate).
Cleft lip repair is usually done within 6 to 12 weeks of age. Cleft palate repair is generally postponed until later to take advantage of the palatal changes that occur with normal growth. Most surgeons repair a cleft palate between 9 months to 1 year before the child develops faulty speech habits.
Effects of Cleft Lip Repair (Cheiloplasty)
Ideal surgical results for cleft lip include symmetrically shaped nostrils, and lips that appear as natural as possible and have a functional muscle. Many characteristics of the natural lip can be achieved; however, the outcome ultimately depends on a number of factors, including the skill of the surgeon, accurate presurgery markings, alignment of bones within the affected area, uncomplicated healing of the initial repair, and the effect of normal growth on the repaired lip. Additional surgical correction to reconstruct nasal symmetry is sometimes necessary.
Candidates for Cleft Lip Repair (Cheiloplasty)
- A patient who has had a single (unilateral) or double (bilateral) cleft lip.
- A patient with one or more family members who have had a cleft lip and also has asymmetry of the nose.
- A cleft patient whose nose is cosmetically unattractive or does not have a pleasing balance with other facial features.
- Overly prominent elements of the nose or underdeveloped parts of the nose
- A patient whose nose is crooked, too wide, long, excessively projecting, or flat.
- A cleft patient whose nasal septum (the cartilage separating the right and left internal nasal passages) is deviated and causes nasal airway obstruction. Correction of a deviated septum alone is called a septoplasty or submucous resection of the septum (SMR). A crooked nose may worsen this disorder and therefore, require correction at the same time. This surgery is called a rhinoseptoplasty. Turbinates are parts of the nose that help to add moisture and filter inspired air. These structures can be enlarged for many reasons and contribute to airway obstruction. When this occurs, the surgeon will recommend their removal as part of the nasal surgery. Other problems, such as narrowed passages and airway "collapse", may require placement of cartilage grafts for structural support. Occasionally, scar tissue within the nose from previous injury or surgery may block airflow and require correction.
At your initial consultation, your doctor will discuss the details of the procedure he or she will use, including where the surgery will be performed, the type of anesthesia to be used, possible risks and complications, recovery, costs, and the results you can expect. Your surgeon will also answer any questions you may have about feeding your baby both before and after the surgery.
The Cleft Lip Repair (Cheiloplasty) Procedure
While the patient is under general anesthesia, the anatomical landmarks and incisions are carefully demarcated with methylene blue ink. An endotracheal tube prevents aspiration of blood. The surgical field is injected with a local anesthestic to provide further numbing and blood vessel constriction (to limit bleeding). Myringotomy (incisions in one or both eardrums) is performed, and myringotomy tubes are inserted to permit fluid drainage.
There are several operative techniques for cleft lip reconstruction. The Millard rotation advancement (R-A) technique is the most widely accepted form of repair. This method involves rotation of the entire philtral dimple (groove in the upper lip) and Cupid's bow (double curve of the upper lip). The scar falls along the new philtral column (central section of the upper lip), and is adjusted as required since the procedure allows for flexibility.
The Millard procedure begins with an incision on the edge of the cleft side of the philtrum, and the cutting continues upward, medially, and to the side. A second incision extends to the buccal sulcus (top part of the upper jaw). The length of this incision depends on the size of the gap to be closed. In this second incision, the surgeon frees soft tissue, which allows him or her to completely lift the lip from the underlying bone. This dissection should be tested to ensure free advancement toward the middle (inadequate dissection is the root cause of poor results). Nasal deformity can be dealt with by a procedure known as the McComb nasal tip plasty, which elevates the depressed nasal dome and rim. Cartilage from the cleft side is freed from the opposite side, and is positioned and reshaped using nylon sutures.
Advantages of the Millard rotation advancement technique include:
- It is the most common procedure (i.e., surgeons more familiar with it).
- The technique is adaptable and flexible.
- It permits construction of a normal-looking Cupid's bow.
- A minimal amount of tissue is discarded.
- The suture line is camouflaged.
The disadvantage of the Millard rotation advancement technique is the possible development of a vermilion notch (shortening of the entire lip in the vertical direction), resulting from contracture of the vertical scar.
Cupid's bow is a critical part of the repair, making it very important to accurately determine the high point of Cupid's bow on the lateral lip.
For the first few days, the area may be swollen. Dressings should remain dry and intact. Pain or discomfort can be controlled by medication. Instructions on showering and dressings will be given to you by your physician. Follow up appointments will be scheduled and questions should be directed to the physician or staff.
Risks from any anesthesia are:
- Breathing problems
- Reactions to the medications
Risks from any surgery are:
Problems these surgeries may cause are:
- The bones in the middle of the face may not grow correctly.
- The connection between the mouth and nose may not be normal.
What is a cleft lip and cleft palate?
A cleft is an opening in the lip, the roof of the mouth or the soft tissue in the back of the mouth. A cleft lip may be accompanied by an opening in the bones of the upper jaw and/or the upper gum. A cleft palate occurs when the two sides of a palate do not join together, resulting in an opening in the roof of the mouth. A cleft lip and palate can occur on one side or both sides. A child can suffer from a cleft lip, a cleft palate or both.
What causes clefting?
The exact cause is unknown. Cleft lips and cleft palates are congenital defects that occur early in embryonic development. Scientists believe a combination of genetic and environmental factors, such as maternal illness, drugs or malnutrition, may lead to a cleft lip or cleft palate. If one child in a family is born with a cleft, the risk increases by 2 to 4 percent that future children in the family will suffer from the same defect.
Can clefting be prevented?
Scientists are researching methods to prevent cleft lips and cleft palates. One finding, according to research studies, is that mothers who take multivitamins containing folic acid before conception and during the first two months of pregnancy may reduce their risk of giving birth to a baby with a cleft.
Does a cleft lip or cleft palate cause problems for a child?
Ear disease and dental problems occur frequently, as do problems with proper speech development. Children who suffer from a cleft lip and/or cleft palate may have difficulty eating. To address these issues, a child and family may work with a team of specialists — a pediatrician, a plastic surgeon, dental specialists, an otolaryngologist (ear, nose and throat specialist), a speech-language pathologist and audiologist, a geneticist and a psychologist/social worker.
Can cleft lips and cleft palates be repaired?
Yes. Surgery provides excellent results. A pediatrician and a plastic surgeon work with a child's parents to choose the best timing for surgery. Most surgeons agree that a cleft lip should be repaired by the time a baby is 3 months old. To repair the partition of mouth and nose as early as possible, a cleft palate generally is repaired between the ages of 12 and 18 months. Any surgical procedure is dependent upon a child's general health and the nature of the cleft lip or cleft palate.
How frequently do cleft lips and cleft palates occur?
Cleft lip and cleft palate occur in approximately 1 per 500-700 births, the ratio varying considerably across geographic areas or ethnic groupings. (Source: World Health Organization International Collaborative Research on Craniofacial Anomalies).