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A cleft lip procedure usually takes about anywhere from 45 minutes to two hours, depending on the severity of the cleft and the experience or speed of the surgeon. A cleft palate, if it’s a simple primary cleft palate can usually be done within about an hour. Most patients do undergo revisions for velopharyngeal insufficiency or other types of problems or fistulas afterwards. And the timing and duration of those really depends on the severity of the problem. There no significant risk to doing these procedures as long as they’re done at the right time for the child, with a pediatric anesthesiologist who knows how to treat these patients well. Following surgery for cleft lip and palate, there’s a very, very low risk that you would have any infection. The face overall is very well vascularized and it is very uncommon to have infections.
The recovery time after a surgery for cleft lip and palate is rapid in some patients. The cleft lip where you can have them, actually I’m sucking on a straw usually within that first week pretty easily. When it’s a combination procedure, the cleft is deeper in, we have to leave little tubes in the nose. It makes it a little bit more difficult for the child. A cleft palate, the problem becomes the pain. They’re in a lot of pain that first couple of days, especially if they’re older patients, they notice it a little bit more. Still you can assume that within the first couple of weeks, patients are recovering well and are starting to eat fine again.
In general for Cleft Lips, you go see a doctor as needed after surgery. Typically, after the surgery is done and you’re out of the initial healing period, the physician or the group will follow-up with you over time just to make sure you have no other issues with speech or phonation. The cleft palate, similarly, once you’re out of the initial healing period, and if you’re swallowing and speaking fine, the only followup you typically have is just for the hearing, just in case you’re having middle ear ventilation issues.
In certain cases where cleft palates are repaired, but patients are still having issues, there are appliances that can be used. This will be formed either by an oral surgeon or again the group of speech and swallow specialists. The oral appliances can be used to close off a fistula by putting it in the mouth or to push the palate slightly posterior. There’s a large, a number of things that it can be used for.
Overall medical insurance, from my knowledge, all insurances do cover repairs of cleft lip and palate. And they do also cover the sequelae of cleft lip and palate, meaning all the problems that happen in the future from them. The one thing that it might not cover is small little cosmetic changes that need to be made for the lip which really varies from situation to situation.
So cleft lip and palate fall into a category of openings in the midline of the face. Most people would consider them the same if they don’t know about them, but they’re very different. They do happen together, however, they occur in different parts of the face and cause different problems for the baby. Babies who are born with a cleft lip, we used to call them hare lip because it looked like a rabbit, but that’s fallen out of favor. We call it now just cleft lip. What they look like is they have an opening on one side or on both sides of the lip where you can see through to the teeth or straight through all the way to the back of the nose. Cleft palate is different. Cleft palate actually occurs inside the mouth where you see the teeth over here. There’s a failure of the shelves inside the mouth themselves to join and they can end up with an opening. And the opening is between the nose and the mouth itself. Cleft lips and cleft palates cause different problems altogether. But they’re all in the same kind of vicinity of problems around the mouth. A cleft lip, if not treated early on in life, and typically we treat it in the first couple months of life, can lead to severe issues with swallowing. Patients cannot suck very well when they don’t have a closed lip. They have to use something called an Haberman (or Haberman) nipple which is a type of pacifier cover that you would put on or just the regular nipple cover that you would put on a bottle that helps them feed better. Ultimately, they do need closure of that lip. its performed with a simple cleft lip surgery. In this country, there’s a slightly lower incidence of clip lift of cleft lips than in other countries. Typically we would see maximum, might say one in a thousand, over here is the highest I’ve seen in any paper. But it’s generally lower than that and that’s with cleft lip and palate. The cleft palate occurs a little more frequently. A cleft palate is a failure of closure of the palatal shelves inside the mouth. And again, this can lead to feeding problems. However it is treated a little bit later than the cleft lip is cleft lips. You treat pretty much in the first two months of life. The cleft palate, sometimes you need to wait to about 10 months of age or a little bit longer until they have enough tissue within their mouth to fix it with a surgery.
So cleft lips and palates are both a failure of closure of the shelves that occurred during fetal growth. The type of failure of closure can be one side, it can be both sides, it can be halfway through, all the way through, and it can also just be areas that are thin, so they’re completely incomplete, meaning you could have skin closed, but the muscle doesn’t close. So there are varying forms of cleft lip and cleft palate, and they are all treated differently and they all cause different problems.
So diagnostically you can see in utero or when the baby is still inside the womb, if there is a cleft lip or palate in a large percentage of patients. You can check for genetic disorders that are involved within that as well. If the baby is born with a cleft lip or palate, you do need to do other testing. Mainly the first test that people would do is to go and look at the heart in different ways to make sure that there are no anomalies with the heart. There are different types of syndromes such as Velo-Cardio-facial syndrome, or other ones. I can name probably 20 that you do need to check for to make sure that there are no other anomalies with the patient.
There’s no direct causation or correlation of a patient with a cleft palate having a cleft lip. However, you’ll see that most patients with the cleft lip can have a cleft palate. However, they can be completely exclusive of each other.
Overall, the causes of cleft palate and cleft lip are unknown with the exception of having increased incidences with fetal alcohol syndrome, premature birth, and certain syndromes such as van der Woude Syndrome. So there are certain syndromes that do have a higher incidence of cleft lip and palate. And then we do see that in certain populations there is a higher amount. Part of that is due to the genetics of the population, and part of that is due to the diet and nutrition in that area.
So cleft lip is seen immediately on birth. You’ll see that the patient’s lip is open, it’s very easy to see. And the thing that you tried to do immediately is help them feed as soon as possible. Patients, these little babies, can’t go very long without nutrition, so you get them the right type of nipple and then as soon as you can, you get them to surgery once they’re old enough to undergo the surgery. The youngest is probably about four weeks. Most patients around six weeks will undergo that surgery and that’s a very simple surgery to do for people who do it. But you do need a specialist. If they can’t get feeding that way, they have to get a nasogastric tube or orogastric tube, which is a tube that goes down into the throat to feed them. The cleft palate overall is not always seen immediately in other countries. But in our country we do check all the time to make sure the patient doesn’t have a cleft palate. And you see that simply by opening the mouth and looking for a gap. In those situations we plan for surgery a little bit further down the line to close it. And that’s a cleft palate surgery. Overall, if you look at the issues patients have until the lip is closed, the patient’s gonna have trouble swallowing and sucking. If the patient has a cleft palate, they will have a 100% incidence of having hearing issues or ear problems from otitis media or poor fluid drainage out of the nose. That’s a 100% chance. Every single one of them will, even if they get repair over time, they do have a very, very, very high chance of needing lifelong either procedures or maintenance of the middle ear to make sure that it ventilates well. So you can assume that if you have a child with a cleft palate, they will have some sort of hearing issues throughout their life. Otherwise, the differences that you see are the issues with patients with cleft palate are velopharyngeal insufficiency. And this can result in difference in resonance, meaning the patient sounds different as they speak, and this can cause other friends and family to make fun of them as they grow up, which is very traumatizing for them, and difficulty swallowing. So when they swallow, a lot of the fluid will come out through their nose, especially if it doesn’t close properly.
Overall, if a patient has their cleft lip treated early in childhood, they will not suffer any severe significant consequences throughout life. They tend to do very, very well. Patients with cleft palate, however, do have issues for quite some time. A lot of that, again, was with speech resonance. A lot of it was with hearing. these patients can have learning disabilities and they can also develop issues, interaction issues with other children growing up. So there are a lot of psychosocial issues involved with cleft palate, even though it is such a mild issue.
So overall in dealing with cleft lips and palates, you are dealing with a specialist in that area. The specialist can be either an ear, nose and throat doctor or a specialist from plastic surgery. So plastic surgeons and ear, nose, and throat doctors are both trained, uh, in it throughout their training in general. But you want to go to the plastic surgeon or the ear, nose, and throat doctor who performs the procedure the most in the United States. These are specialists who either traveled to other countries and do it often or they have established practices here. My advice is to find a plastic surgeon or the ear, nose and throat doctor who is part of a group that takes care of these patients. You do not just need a doctor to take care of you and help with the surgery. You also need the speech pathologist, someone to help with swallowing issues, there are a whole host of other issues that you need to deal with, aside from the fact that a lot of these patients, when treated later in life, will have some psychiatric issues to deal with as well. So it is best to pursue a group rather than a single doctor because you do want continued care. If you can get that in the area that you live in, it’s much better because these patients do need some care throughout their lives, most of them throughout the beginning of childhood, and then as they get older, it just becomes simply monitoring the hearing and the drainage in the ear.
There are certain areas in the world that have a higher preponderance or incidence of cleft lip and palate. Part of that is genetic and we have found genetic predisposition in patients with such things as van der Woude syndrome or other syndromes, that you would see more likely in Honduras or areas like that. In general, in the US we have one of the lower incidences. Um, there’s different incidence also between men and women. We see a difference in different populations regardless of nutrition. So we do know that there is a genetic predisposition for people to get cleft lips and palates, but we haven’t really nailed down exactly what it is since it has so many different causes. Cleft lip and cleft palate can actually be diagnosed before the baby is born. So you can see in an ultrasound and you can plan properly for that baby, what the next step is.
Patients with cleft palate typically do require surgery. The only exceptions to this are patients who have the most insignificant type of clefts like a bifid uvula. That’s when the little dangling piece in the back of your throat doesn’t completely come together. That doesn’t need to be operated on, however, patients who do have other clefts do need to have them treated, uh, for proper swallowing function, vocal function, and improvement of overall hearing.
Patients with cleft palates, uh, other than the most minimal type of cleft, which is a Bifid Uvula or a dangling a UV light in the back of the throat do need to have the cleft repaired. If not, they will have lifelong problems with swallowing and speech resonance. They do need to have the hearing monitored over time because if they do not get the proper clearance of the middle ear throughout, especially the beginning of their lives, they could develop learning disabilities from difficulty hearing. This is the case, not just with cleft palates, but with any kid or any child growing up with any kind of hearing issue.
Cleft lip surgeries are usually done once and the problem’s solved. If they do need any kind of repair, it’s typically performed for either a fistula meaning a connection somewhere inside the nose or in the future for cosmetic purposes to get the lip a little bit lower from notching that happens from some of the surgeries. Cleft palate, you hope you never have to do it again. But again, just depending on the anatomy of the patient, sometimes one more surgery is needed, sometimes five more are needed. It really, really depends on the anatomy of the patient.
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