Surgery

Illustrated techniques for cleft lip repair date back as far as the 1500s. This means that for over 500 years surgeons have diligently worked to correct and restore that differences that are seen in children with a cleft. Duke’s Pediatric Plastic Surgeons bring the most up-to-date ideas and technology and combine them with time-proven techniques to deliver the very best possible results. As plastic surgeons, we use every means to control the healing process to our advantage. We have refined our techniques to camouflage the scar as artfully as possible. We can teach you, as parents, techniques in postoperative care that will help in this endeavor. However, complete elimination of scar is not yet a possibility in modern surgery due to factors in wound healing that are still beyond our control. The following sections explain the strategies of the surgeon, timing of surgery, and the expected result.

The Duke University Cleft Lip and Palate Team is led by two pediatric plastic surgeons -- surgeons with a commitment to the care of children; surgeons with a firm dedication to children with facial differences and their families. There is nothing more important to you than your child; and there is no surgical procedure that can create so profound a positive impact on the lifelong emotional well-being of an individual than the surgical correction of a cleft.

The Initial Consultation

The pediatric plastic surgeon is often asked to see a newborn with a cleft shortly after birth. In some cases, if an ultrasound exam is able to detect the abnormality, the plastic surgeon can even be consulted prior to birth. For parents in both instances, the early period is one of education. There is no need to panic; your surgeon and team will explain the situation. This is a time for learning. The amount of information will seem overwhelming. Don’t worry -- we’ll go over it as much as is needed. The pediatric plastic surgeon will conduct a detailed examination. If any other developmental abnormalities are present, they need to be identified. In addition to the surgeon, you will meet with several other members of the team initially. Do take the time to read what you can find in books and on the internet. Don’t be afraid to ask questions.

The Lip

A cleft lip has great visual impact, and consequently, it is natural for a parent to want it corrected as soon as possible. Surgery is done after enough time has passed to allow the baby to gain weight and grow somewhat stronger. During these early weeks before surgery the child can be evaluated for other deformities which occasionally accompany clefting. The parents also have a chance to bond with their baby without adding the burden of an operation to this precious period.

Unilateral cleft lip

Surgery on the cleft lip is usually performed around three months of age and takes approximately two to three hours. A general anesthetic is required. At this age, anesthesia is considered to be quite safe, and the child still has healing advantages with respect to formation of scar tissue. Most children stay in the hospital for one to three nights. The lip repair is performed to most closely resemble the unaffected side in unilateral cleft lip. In a bilateral cleft, a symmetric repair is performed to most closely approach the normal structure of the upper lip and nasal regions. Other than the external lip, two other areas are addressed at the time of the first surgery. First is the labial sulcus: place your tongue between your teeth and your upper lip. It can almost reach the base of your nose on the inside of the lip. It is important to recreate this "sulcus" for dental health and for appearance. The other important area that is addressed at the lip repair is the nasal abnormality. The correction of the nose is a specific area of interest to Duke’s surgeons. At the first surgery, our goal is to get the best early appearance without making it more difficult to correct minor irregularities later. Our expectations are very high, but we know that some children will require additional surgery for the nose as they get older. Some children will need nasal revision for the tip at the age of seven to nine. Some will not. Some will need revision for the tip, the septum, and the nasal bones after they finish growing (in their teens), and some will not. More on the nose below.

After cleft lip surgery, the incision must be kept clean. It is important for the parents to be involved in keeping the incision line as clean as possible. This can be done by gently rolling a Q-tip with diluted hydrogen peroxide over the incision line. Cleaning should be done four times per day and antibiotic ointment (like polysporin or bacitracin) is applied after each cleaning.

The stitches are removed about five days after surgery. Generally, we will schedule for this to be done with a bit of anesthesia so that the baby can be still and comfortable.

Repaired unlateral cleft lip

Bilateral cleft lip

Repaired bilateral cleft lip

The Nose

With a unilateral cleft, the nostril is splayed widely and slumps downward. It causes the tip to look angled or shifted to one side. We try to correct these features at the first surgery, but we are careful not to be so aggressive that growth will be disturbed or any future work will be made more difficult. It is safe to do limited work on the nasal tip and floor at the first surgery. However, because of possible effects on growth, the bony structure of the nose and the septum (the cartilage between the right and left side of the nose) cannot be adjusted until later in life, when the nose is fully grown. At that time, a complete rhinoplasty can be performed if needed for cosmetic or functional reasons (like nasal obstruction).

The Palate

The palate is important for the development of speech. Speech is specifically addressed later in The Duke Guide. In order to allow for speech development, a cleft palate is surgically closed before the baby begins to talk to allow those first words to be normally formed. Most cleft teams agree that the palate repair should be done early enough for speech development, but not so early that the surgery can affect growth of the facial bones. Like others, we find that the optimal age is between nine and 12 months. Several operative procedures are employed for closure of the hard and soft palate depending on the type and severity of the cleft. In general terms the tissue on either side of the cleft is mobilized and brought to the midline. The muscles that allow the soft palate to move displaced when a cleft is present. At surgery, these muscles are placed in their proper alignment.

Surgery for Speech Problems

In spite of an adequate closure of the soft and hard palate approximately 20 percent of patients develop speech abnormalities related to the ability of the palate to separate the nasal and oral airways. This is called velopharyngeal insufficiency (VPI). The detection of VPI is of prime importance and consideration by our Speech and Hearing specialists. Through various sophisticated tests and clinical observation they will make recommendations to the plastic surgeon as to whether or not speech is developing properly, if it can be treated with therapy only, or if an additional surgical procedure should be performed.

The Teeth

We have discussed the lip repair and the palate repair. Between the lip and the palate is the alveolar ridge (the gum line). When the cleft goes through the alveolar ridge, there is a bony gap. It can result in missing teeth and/or crooked teeth since the roots of the teeth need to be surrounded by good bone. The surgeon and orthodontist work together to ensure that when the permanent teeth erupt they will be well aligned and that each will have room in the alveolar ridge. The alveolar ridge cannot be closed at the time of the lip repair or the palate repair. Children whose cleft goes through the alveolar ridge will need surgery to fill the gap once their adult teeth start to erupt. The right time can be between five and 11 years, depending on the child.

Possible Surgical Itinerary

The chart below addresses the timing of the surgeries for a child with a cleft that involves the lip, alveolar ridge, and the palate (i.e., complete cleft lip and palate). Not all children will have all of the structures affected; therefore, they will not require all of the procedures below. The chart also includes timing of surgeries for speech and for the nose. These surgeries may not be necessary for all children.

• The Nature of Clefts
• Feeding