The birth of a child is a joyous event full of new challenges and difficulties for the parents. For the parents of a child born with a facial deformity such as cleft lip and/or palate, the challenges may seem overwhelming.
To provide parents with hope and expert medical care, Plastic and Craniofacial Surgery for Infants and Children specializes in the treatment of children born with cleft lip, cleft palate and other facial abnormalities.
If you are the parent of a child with one of these challenging conditions, request a consultation online or call us at (469) 375-3838 to schedule a time to meet with our skilled team. You can also review our online resources about the following conditions:
- The Importance of Early Treatment
- Cleft Lip Repair
- Cleft Palate Repair
- Alveolar Bone Grafts
- Velopharyngeal Insufficiency
The Importance of Early Treatment
A child born with a cleft lip and/or palate can begin early treatment to enable the restoration of as normal an appearance as possible before the child begins peer interaction. The early treatment minimizes the social discomfort a child born with a facial deformity may feel as the child grows.
In addition to correction of lip, palate, nose and facial structures, the team will work to prevent hearing and speech difficulties that may accompany such anomalies. The specialized approach to correcting deformities of the lip and palate is unique in the care and attention given to enhancing a child’s quality of life as soon as possible.
While it is known how cleft lip and palate deformities occur before birth, it is not known why they occur. Yet, one in 500 births results in a deformity of the lip and/or palate. As the cause and possible preventative treatment for this facial deformity is sought, the team at Medical City Children’s Hospital of Dallas is ready to provide the best possible treatment for your child and to make possible the smile he or she was meant to have.
Children with a cleft palate are particularly prone to ear infections because the cleft can interfere with the function of the middle ear. To permit proper drainage and air circulation, the ear-nose-and-throat surgeon on the Cleft Palate Team may recommend that a small plastic ventilation tube be inserted in the eardrum. This relatively minor operation may be done at the same time of the cleft repair.
Cleft Lip Repair
To repair a cleft lip, the surgeon will make an incision on either side of the cleft from the mouth into the nostril. The goal in lip repair is to create a structure of normal appearance and function. This is accomplished by reconstructing the normal anatomical landmarks such as the philtral ridge, vermilion cutaneous border, nostril floor, and orbicularis muscle for lip function. The inclusion of muscle in the prolabium of the bilateral cleft lip is important to bring motion to a structure which otherwise would remain virtually without animation. The surgeon will then turn the dark pink outer portion of the cleft down and pull the muscle and the skin of the lip together to close the separation. Muscle function and the normal “cupid’s bow” shape of the mouth are restored. The nostril deformity often associated with cleft lip will also be improved at the time of lip repair.
Cleft Palate Repair
Repair of the palate is directed at producing normal speech, restoring Eustachian tube function, attaining closure of oronsasal fistulas, and minimizing alterations in maxillary growth. In some children, a cleft palate may involve only a tiny portion at the back of the roof of the mouth; for others, it can mean a complete separation that extends from front to back. Just as in cleft lip, cleft palate may appear on one or both sides of the upper mouth. The soft palate may be repaired at the time of lip repair if it is involved, also. This is usually done at 3 months. The hard palate is done when the baby is older and the teeth have erupted (avoiding growth disturbance to the teeth and maxilla), usually at the age of 18 months.
To repair a cleft palate, the surgeon will make an incision on both sides of the separation, moving tissue from each side of the cleft to the center or midline of the roof of the mouth. This rebuilds the palate, joining muscle together and providing enough length in the palate so the child can eat and learn to speak properly.
Alveolar Bone Grafts
Children with clefts including the alveolar dental arch will require bone grafting to maintain the dental arch and allow the ingrowth of teeth immediately adjacent to or within the cleft. The timing of this procedure varies but is at approximately age six to eight and is determined by dental x-rays which show the development of the permanent teeth. Cancellous bone from the iliac crest will be inserted into the alveolus once the dental team has aligned the arch or growth and lip closure have brought the alveolar ends into approximation. At this time, any residual oronasal fistulas can be closed as well.
Children generally spend one night in the hospital in order to insure they are taking fluids and ambulating with help. Complaints of hip discomfort and reluctance to walk are common. A soft, blenderized diet and restriction from strenuous activities is recommended for 10 days.
In a small percentage of cases, some children, in spite of cleft palate repair, will continue to exhibit hypernasal speech. This defect can be demonstrated by good physical examination, speech pathologist evaluation, cine-fluoroscopy and nasal endoscopy. The fogged mirror test, conducted with the patient’s nose alternately open and occluded, is one of the simplest methods used to document nasal air escape, which in turn demonstrates soft palate dysfunction. The condition known variously as velopharyngeal insufficiency (VPI) or velopharyngeal dysfunction (VPD) may be seen after cleft palate surgery or noted after adenoidal tissue undergoes involution as the child grows. In some patients who have undergone palatal repair, short sentences may sound relatively normal. Long, sustained speech, however, may deteriorate, resulting in increasing hypernasality as the palate tires. In those cases, consultation with the “Cleft Palate Team” will most likely result in a recommendation for some type of surgical intervention to help with the soft palate closure.
Surgical procedures for correction of velopharyngeal insufficiency include pharyngeal flaps, in which the posterior pharyngeal wall is elevated and sutured to the soft palate, thereby reducing the gap present from the short or poorly functioning soft palate. Other surgical approaches may be used which involve some alteration of the anatomy surrounding the soft palate and posterior pharyngeal wall (described as a “pharyngoplasty”). A variety of approaches have been described and the choice rests with the surgeon in consultation with the speech pathologist. In the past, injectable Teflon into the posterior pharyngeal wall has been described, but is not currently of significant use.
The age and timing of this surgery varies and has been reported in very young children before school age and late in teen years. Early diagnosis with good speech therapy to produce maximal function of the soft palate, however, is important as a prelude to surgical intervention. Once the speech pathologist can no longer produce correction in speech patterns and sounds, consideration for surgical repair should be made. This again is the advantage of a coordinated approach to children with clefting deformities by the coordinated and active “Cleft Palate Team.”