Surgery for Cleft Lip and Palate
Cleft lip and cleft palate are birth defects that affect the appearance and function of the lips and mouth, and they are more common than you might guess. Each year more than 7,000 babies are born in the United States with one of these conditions.
Yale Medicine offers a comprehensive, team-based approach to treating babies born with cleft palate, says Derek Steinbacher, DMD, MD, FACS, director of the Craniofacial Program for Yale Medicine. “We fix clefts in infancy for social, aesthetic and functional reasons. The goal is to help the baby eat, drink, nurse—and basically, to grow and thrive.”
What is cleft lip? What is cleft palate?
A cleft lip looks like a narrow opening or gap in the skin of the upper lip, and may include the base of the nose, the bones of the upper jaw and the upper gums.
A cleft palate is a split in the roof of the mouth: the hard palate in the front portion, the soft palate in the back, or both.
If a cleft is left untreated, a child may have difficulty eating and speaking. The conditions can also affect the development of other facial features, including the nose, jaw and teeth. Also, children with cleft palate are more prone to fluid buildup in the middle ear. This can cause more ear infections and even lead to hearing loss.
What causes cleft lip and cleft palate?
Cleft lip and cleft palate occur when the tissues that make up the lips and the roof of the mouth do not join properly during fetal development. This can happen to any child, but the problem is more common in children of Asian, Latino or Native American descent. Scientists aren't completely sure why, but believe that genetic and environmental factors are involved.
In some situations, cleft lip and cleft palate may be part of another medical condition, such as Pierre Robin Malformation Sequence (a combination of birth defects including small lower jaw and breathing problems); Amniotic Banding (a group of defects believed to be caused by entrapment of fetal parts in the uterus); and Hemifacial Microsomia/Goldenhar Syndrome (when the lower half of one side of the face is underdeveloped and does not grow normally).
Another potential cause may be the medications a mother takes while pregnant. Some anti-seizure or anticonvulsant medications, acne medications containing isotretinoin, or methotrexate (a drug commonly used for treating cancer, arthritis and psoriasis) have been linked to cleft lip and/or cleft palate birth defects.
In the vast majority of cases, however, the cause of a child's cleft is unknown and unpreventable.
How are cleft lip and cleft palate diagnosed?
Prenatal ultrasound can sometimes identify a cleft in an unborn child. After the child's birth, the malformation is usually visible. A physical examination of the mouth, nose and palate can confirm the presence of cleft lip or cleft palate.
What surgical treatments are used to help babies and children with cleft lip and cleft palate?
"We do a series of procedures for cleft lip and palate," says Dr. Steinbacher. These range from soft tissue and lip repair in infants to rhinoplasty and jaw surgery in older patients. Here is the typical timeline for corrective surgeries in a child born with a cleft lip and/or cleft palate:
- The first surgery performed, typically in infants between three and six months of age, is to close the lip. Dr. Steinbacher says, “The lips are important for feeding and social interaction, so we try to operate on them as early as possible."
- The second surgery usually takes place when the child is about a year old. This procedure creates a functional palate, reducing the chances of fluid buildup in the middle ear, and aiding in the proper development of teeth and facial bones.The timing is critical, notes Dr. Steinbacher. "We wait to do this surgery until much of the growth of the upper jaw has taken place, so as not to interfere with development, but before the onset of speech."
- For some children, a third surgery may be done to repair the cleft in the gum line when the child is between 7 and 9 years old.
Each surgery typically requires a one- or two-day hospital stay. Additional procedures relating to the palate, gum tissue and jaws may be required later in childhood and into the teenage years, depending on the severity of a particular child's condition.
“For example, if the upper jaw does not grow normally, and is too far back, we may do procedures in the mid-to-late teenage years to move it forward and down, to improve the airway, breathing, occlusal function and appearance,” explains Dr. Steinbacher.
Plastic surgery such as rhinoplasty or to repair scars from the initial surgeries may done in the teen years, when facial development is complete, to improve the appearance of the lip and nose.
The goals of these surgeries aren't simply to close the gaps created by the cleft, notes Dr. Steinbacher, but to optimize facial function and make the child's lips, nose and face look as normal as possible.
What is recovery from cleft lip or cleft palate surgery like?
After surgery, babies stay overnight in the hospital, where they're monitored to make sure they're breathing and feeding well. A specially designed bottle that optimizes milk flow may be used for feeding for several weeks, because some babies aren't able to perform suction feeding.
About a week after surgery, the sutures in the lip area are removed. The stitches used for the palate dissolve on their own.
During the years after surgery and throughout childhood, the child's speech and dental functions will be monitored by specialists to ensure that they're developing and on track.
Ideally, the child's face will develop with little or no visible evidence that he or she was born with a cleft lip and/or palate, notes Dr. Steinbacher.
What makes Yale Medicine’s approach to cleft lip and palate surgery unique?
There are many potential implications for a child born with a cleft lip or cleft palate and it's important that all are addressed early on and through the child's growing years. A wide variety of oral health and medical problems can be associated with these conditions and each requires the attention of a specialist.
“One of our greatest strengths at Yale Medicine is that we offer a 'whole team' approach to make sure patients are getting the most comprehensive care possible,” says Dr. Steinbacher. “From surgeons to psychologists, radiologists, orthodontists, pediatric dentists, pulmonologists, speech therapists and so on, we have specialists that work together to provide truly multidimensional care.”