Cleft Lip and Cleft Palate Procedures

Nasoalveolar molding (NAM) is a pre-surgical, custom-made orthopedic appliance that brings together the two sides of a cleft lip or palate and narrows a wide cleft. It also forms and shapes the nose and facial structures to provide a more symmetrical appearance. Pedro Santiago, DMD, a Duke craniofacial orthodontist, helped develop the NAM technique in the 1990s. His expertise with the NAM device ensures your child experiences the best possible aesthetic and functional cleft surgical results.

Cleft lip surgery is usually performed between the ages of 3 to 6 months to repair the anatomic structures of the lip, such as the Cupid’s bow; red and white lip elements; and the muscle underneath the skin. 

The surgery usually takes 3 to 6 hours to perform (depending on whether the cleft is unilateral or bilateral) under a general anaesthetic.

The repair of the lip is important because it creates a dramatic change in appearance. Although revision surgeries may be done, our goal is to achieve a lifelong result during the first attempt. 

Most techniques rely on the geometric rearrangement of the lip and nose structures to normalize shape and contour. When performed with precision, these techniques can provide excellent results.

Your child may go home the next day when they are drinking and feeling comfortable. We train the parents on feeding, cleaning the incision, and how to treat the scar. 

Babies can resume normal activities after day 3 to 4, and suture removal is performed at one week with a brief mask anaesthetic.

Gingivoperiosteoplasty (GPP) is a specialized technique that may be performed during cleft lip surgery. It closes the cleft in the gum line and may help prevent the need for bone grafting at a later age. Success is dependent on the gum segments being closely aligned.

The palate is the roof of the mouth and the floor of the nose, and separates the nasal and oral cavities, creating a valve at the back of the throat. 

Many techniques can close the cleft and bring the muscles of the palate together. 

Cleft palate surgery is performed around one year of age so that the structures can grow as much as possible, but the palate is closed before speech develops. 

Surgery is done under a general anaesthetic and takes 3 to 4 hours. 

Usually, the child stays in the hospital for 1 to 2 days and goes home when they are drinking well and comfortable. Normal activities can be resumed in 3 to 4 days. All sutures are dissolvable.

Alveolar bone graft surgery is usually performed before the canine tooth adjacent to the cleft site starts to erupt. This surgery is done under a general anaesthetic and involves taking a bone graft from the hip and placing it in the cleft site. At the same time, the fistula is closed. It takes 2 to 3 hours and involves a one- or two-night hospital stay. Your child will wear a splint or mouth guard on the teeth for several weeks after surgery to promote healing.

In some cases, after cleft palate surgery, the function of the palate isn’t adequate to seal off the area between the nose and the mouth when making certain sounds. This can result in hypernasal or “nasal-sounding” speech when not intended. When this is present, an assessment of palate function will involve a consultation with a cleft speech-language pathologist along with the plastic surgeon. Nasoendoscopy may be performed where a small camera is inserted in the nose to provide a view of how the palate is closing during sound production.

After surgery, your child will work with a speech therapist on strategies and therapy goals to unlearn poor habits or learn how to use their “new” functioning structures. Having surgery alone does not “fix” this speech issue. It is performed with the expectation that it be done with speech therapy.

The nose is always affected in cases of unilateral or bilateral cleft lip. An initial correction may be performed during cleft lip surgery. A persistent deformity of the nose can affect breathing and social well-being. A formal septo-rhinoplasty to correct the nasal asymmetry and help with breathing can be done when growth is complete (your child reaches skeletal maturity).

Sometimes, the upper and lower jaws do not develop correctly when a cleft palate is present, and an underbite may occur. Strategic craniofacial orthodontic intervention may be able to correct this condition, however, if an imbalance remains, then jaw (orthognathic) surgery can be performed at skeletal maturity. While this is considered major surgery, our surgeons perform it safely and achieve excellent outcomes.