cleft lip and palate procedures

Cleft lip and cleft palate are birth abnormalities of the mouth and lip. These abnormalities affect about one in every 700 births and are more common among Asians and certain groups of American Indians than among Caucasians. They occur less frequently among African-Americans. Cleft lip and cleft palate occur early in pregnancy when the sides of the lip and the roof of the mouth do not fuse together as they should. A child can have cleft lip, cleft palate, or both. Cleft lip and cleft palate together are more common in boys. It is also important to know that most babies born with a cleft are otherwise healthy with no other birth abnormalities.

• cleft palate
  Cleft palate occurs when the roof of the mouth does not completely close, leaving an opening that can extend into the nasal cavity. The cleft may involve either side of the palate. It can extend from the front of the mouth (hard palate) to the throat (soft palate). Often the cleft will also include the lip. Cleft palate is not as noticeable as cleft lip because it is inside the mouth. It may be the only abnormality in the child, or it may be associated with cleft lip or other syndromes. In many cases, other family members have also had a cleft palate at birth.
  
  
• cleft lip
  Cleft lip is an abnormality in which the lip does not completely form during fetal development (early pregnancy). The degree of the cleft lip can vary greatly, from mild (notching of the lip) to severe (large opening from the lip up through the nose). As a parent, it may be stressful to adjust to the obvious abnormality of the face, as it can be very noticeable.
  
  There are different names given to the cleft lip according to its location and how much of the lip is involved. A cleft on one side of the lip that does not extend into the nose is called unilateral incomplete. A cleft on one side of the lip that extends into the nose is called unilateral complete. A cleft that involves both sides of the lip and extends into and involves the nose is called bilateral complete.

Cleft lip and cleft palate may occur together in an infant, or separately. The degree of the abnormality of both cleft lip and cleft palate can vary greatly. The most common early problem associated with these abnormalities is feeding your baby.

What causes cleft lip and cleft palate?

The exact cause of cleft lip and cleft palate is not completely understood. Cleft lip and/or cleft palate are caused by multiple genes inherited from both parents, as well as environmental factors that scientists do not yet fully understand. When a combination of genes and environmental factors cause a condition, the inheritance is called "multifactorial" (many factors contribute to the cause). Because genes are involved, the chance for a cleft lip and/or cleft palate to happen again in a family is increased, depending on how many people in the family have a cleft lip and/or cleft palate.

Treatment for these abnormalities includes surgery and a complete team approach to help with the multiple complications that can occur. Specific treatment will be determined by Dr. Goodman based on:

• your child's age, overall health, and medical history
• specific qualities of your child's abnormality
• your child's tolerance for specific medications, procedures, or therapies
• involvement of other body parts or systems
• your opinion or preference

For most infants with cleft lip alone, the abnormality can be repaired within the first several months of life (usually when the baby is 10 to 12 pounds). This will be decided by Dr. Goodman. The goal of this surgery is to fix the separation of the lip. Sometimes, a second operation is needed.

Cleft palate repairs are usually done between the ages of 9 to 18 months, but before the age of 2. This is a more complicated surgery and is done when the baby is bigger and better able to tolerate the surgery. The exact timing of the surgery will be decided by Dr. Goodman. The goal of this surgery is to fix the roof of the mouth so that your child can eat and learn to talk normally. Sometimes, a second operation is needed.

Surgery:
At your first visit with Dr. Goodman, he will discuss with you the details of the surgery, risks, complications, costs, recovery time, and outcome. At this time, Dr. Goodman will answer any questions you may have.

• Bone grafting:
  Bone grafting the dental ridge of the upper jaw is a procedure that may be performed on patients with cleft lips and palates. By taking small amounts of bone from elsewhere on the body, such as the hip, ribs, head, or leg, surgeons can reconstruct the area of the cleft near the teeth. The bone graft allows for the formation of a continuous upper gum, supporting the teeth, lip, and nose, and improving facial symmetry and stability. This procedure is often performed before the age of 10. Once the bone graft is in place, missing teeth can be replaced by moving adjacent teeth, using a dental bridge, or implanting dental metallic bone.

After the surgery for cleft lip:
Your child may be irritable following surgery. Dr. Goodman may prescribe medications to help with this. Your child may also have to wear padded restraints on his/her elbows to prevent him/her from rubbing at the stitches and surgery site.

• Stitches will either dissolve on their own or will be removed in approximately five to seven days. Specific instructions will be given to you regarding how to feed your child after the surgery. The scar will gradually fade, but it will never completely disappear.
• During the surgery, and for a short time after surgery, your child will have an intravenous catheter (IV) to provide fluids until he/she is able to drink by mouth. For a day or two, your child will feel mild pain, which can be relieved with a non-aspirin pain medication. A prescription medication may also be given for use at home.
• Your child's upper lip and nose will have stitches where the cleft lip was repaired. It is normal to have swelling, bruising, and blood around these stitches.

After the surgery for cleft palate:
This surgery is usually more involved and can cause more discomfort and pain for the child than cleft lip surgery. Dr. Goodman may order pain medicine to help with this. As a result of the pain and the location of the surgery, your child may not eat and drink as usual. An intravenous (IV) catheter will be used to help give your child fluids until he/she can drink adequately.

• Your child will have stitches on the palate where the cleft was repaired. The stitches will dissolve sometime between several days and a few weeks. They do not have to be taken out by the physician. In some cases, packing will be placed on the palate. Do not take the packing out unless you are told to do so by Dr. Goodman.
• There may be some bloody drainage coming from the nose and mouth that will lessen over the first day.
• There will be some swelling at the surgery site, which will diminish substantially in a week.
• For two to three days, your child will feel mild pain that can be relieved by a non-aspirin pain medication. A prescription medication may also be given for use at home.
• Many infants show signs of nasal congestion after surgery. These signs may include nasal snorting, mouth breathing, and decreased appetite. Dr. Goodman may prescribe medication to relieve the nasal congestion.
• Your child will be on antibiotics to prevent infection while in the hospital. Dr. Goodman may want you to continue this at home.
  Your child may be in the hospital for one to three days, depending on Dr. Goodman's recommendation.
• A small amount of water should be offered after every bottle or meal to cleanse the incision. You can continue to rinse this area gently with water several times a day, if necessary.

Diet after surgery:
You may be allowed breastfeeding, bottle-feedings, or cup feedings after surgery. Your child should be placed on a soft diet for seven to 10 days after surgery. For older infants and children, age-appropriate soft foods may include strained baby foods, popsicles, yogurt, mashed potatoes, and gelatin. Note: your child should not use a straw or pacifier, as both could damage the surgical repair.

Activity after surgery:
Your child can walk or play calmly after surgery. He/she should not run or engage in rough play (i.e., wrestling, climbing) or play with "mouth toys" for one to two weeks after surgery. Dr. Goodman will advise you when your child can safely return to regular play.

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