Cleft Lip and Palate
A cleft is a congenital split or gap in the bone and/or soft tissue of the face. It results from a failure of fusion during embryogenesis. The most common location of a facial cleft is in the upper lip and palate (roof of mouth).
In addition to the obvious aesthetic concerns, many important functional implications need to be considered. Difficulty feeding (whether breast or bottle) is usually the first challenge parents must face. As the child ages, problems with speech development and hearing ability may also be affected.
The best care to a child with a cleft lip and/or palate is therefore delivered by a multidisciplinary team. In addition to the craniofacial surgeon, other important team members include the otolaryngologist, orthodontist, dentist, speech pathologist, nutritionist, nurses, and social worker.
Epidemiology of Cleft Lip and Palate
Cleft lip and palate affects 1 in 1,000 Caucasians. The incidence changes with ethnicity, as Asians are affected 1 in 500 while African-Americans are affected 1 in 2,000. Genetics influence the likelihood of having a child with a cleft lip/palate.
For unaffected parents who already have one child with a cleft lip and palate, the probability of having a second affected child is 2.7% if the first child’s cleft is unilateral (one-sided) and 5.4% if the first child’s cleft is bilateral (both sides). For unaffected parents with two children with cleft lip and palate, the risk for a subsequent pregnancy to result in an affected child is 10% In the case of parent with a cleft lip and palate who already has one affected child, the risk for future offspring is 14%.
Types of Cleft Lip and Palate
Terminology in cleft lip and palate is important. Clefts may be unilateral (one-sided) or bilateral (both sides). The cleft starts at the bottom part of the upper lip in the pink vermilion and progresses superiorly towards the nose. Clefts that involve only the lip are termed “incomplete” (Fig.1) while those that involve the lip and nose are labeled “complete.” (Fig.2)
Clefts of the palate involve the gums and roof of the mouth. Just as in the case of a cleft lip, cleft palates may be unilateral or bilateral and may be incomplete (Fig.3) or complete (Fig.4).
Treatment of Cleft Lip and Palate
Advances in prenatal ultrasound and diagnosis have allowed the treatment of a child with a cleft lip and palate to begin before they are even born. Prenatal counseling and parent education are extremely important and usually performed by specialized pediatric nurses, speech pathologists, and nutritionists.
While breast feeding in most affected children is not possible due to their inability to create proper suction, adequate nutrition can, and should, be provided using a variety of specialized bottles and techniques. The initial stressful period for the parents is ameliorated once they are educated and able to properly care for their child.
Timing of surgical correction largely depends on the typical treatment plan of your craniofacial team. Presurgical orthodontics may be used in some cases to reduce the width of the cleft and elongate parts of the nose that are collapsed. Surgical repair of the cleft lip typically occurs around 3 months of age. This involves lenghtening the lip and repairing all three layers (mucosa, muscle, skin) in their proper anatomic position. The depressed and flared nostril on the cleft side is also elevated and shaped during this initial surgery.
Repair of a cleft palate is typically performed around 12 months of age, as this coincides with the normal development of speech production. The palate functions to separate the oral and nasal cavities. This prevents not only the regurgitation of liquids during drinking, but also stops the leakage of air through the nose with certain sounds during normal pronunciation. Therefore, the main goals of the cleft palate surgery are to create a water-tight separation between the mouth and nose, and to repair the levator veli palatini muscles, which are responsible for elevating the soft palate and sealing off the back of the mouth from the back of the nose.
The palate also helps the eustachian tubes drain fluid from the middle ears. When this function is impaired, ear infections can occur and hearing may be affected. Therefore, each child with a cleft lip and palate should be evaluated by the Craniofacial team’s otolaryngologist to determine if ear ventilation tubes are needed at the time of palate repair.
Once the lip and palate are repaired, our goal is let each child grow and develop normally. Children subjected to frequent visits to the doctor can become emotionaly traumatized and averse to any future treatment.
It is important to monitor the development of speech production and proper pronunciation. This is done mainly by a speech pathologist, many times at school or home. In some children who develop hypernasal speech (leakage of air through the nose), a video endoscopy to identify the cause is usually performed. Depending on the reason for incomplete closure of the soft palate (also known as velopharyngeal incompetence or VPI), there are surgical and non-surgical options to treat this.
Proper growth and development of the teeth and upper jaw is also very important. Around age 6 to 8, just before the eruption of their permanent teeth, some children need a small operation which involves taking some bone from the hip and grafting it to the gums. The goal of this is to provide adequate structural support for the erupting teeth.
The final phase of treatment happens once the child has stopped growing and reached “skeletal maturity.” At this point (age 17-19), any additional work that needs to be done on the nose (to help breathing and appearance) or upper jaw (to help with their bite and appearance) is performed by the craniofacial surgeon. The team orthodontist is extremely important during this period, as the final alignment of the teeth is established.
Let’s Get Started
Do you want to learn more about New York Cleft Lip and Palate treatment options? Contact one of our doctors online to meet with them at the New York Group for Plastic Surgery. You can also give us a call at 800-433-7410 to reach our New York City office or 914-366-6139 to reach our Tarrytown office. Call 845-294-2018 to reach our Goshen office in Orange County, New York.
Be sure to review our gallery of before-and-after photos to see some of our actual patients.
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