Cleft lip and cleft palate are congenital birth defects. In other words, these problems occur during the developmental process in the mother’s womb. Normally, the mouth and nose of a baby develop between week 6 and week 12 of gestation (first trimester). This process involves downward growth of the nasal structures and medial (toward the middle) growth of the tissues that become the lips and mouth. In some babies, parts of the lips and roof of the mouth (palate) don’t grow together or fuse in the middle. Because the lips and the palate develop separately, it’s possible to have a cleft lip, or a cleft palate, or both.
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In most cases, we simply don’t know why lip and palate development go wrong. There are some environmental factors (nutrition or vitamin deficiency, exposure to toxins, etc.), but most studies support a strong role for genetic factors. Race or ethnicity and gender do play a small role, as clefts are most common in Southeast Asians and the indigenous peoples of Central and South America. Clefts are less common in whites (Caucasians) and least common in blacks (people of African descent). Boys are slightly more often affected than girls.
There are multiple medical problems associated with the cleft lip or palate, including poor feeding, delayed speech development, and possibly hearing issues. Medical professionals with special experience in the problems of cleft lip and palate have formed multidisciplinary teams all over the country and around the world to help parents plan for their child’s care and development from birth, or sometimes from even before birth if a cleft is diagnosed by fetal ultrasound. Members of a child’s cleft lip and palate treatment team usually include:
- an audiologist (who assesses hearing);
- a surgeon (such as a plastic surgeon, an oral/maxillofacial surgeon, or a craniofacial surgeon);
- a pediatric dentist or other dental specialist (e.g., a prosthodontist, who makes prosthetic devices for the mouth);
- an orthodontist (who straightens the teeth and aligns the jaws);
- a geneticist (who screens patients for craniofacial syndromes and helps parents and adult patients understand the chances of having more children with these conditions);
- a nurse (who helps with feeding problems and provides ongoing supervision of the child’s health);
- an otolaryngologist (an “ear nose and throat” surgeon, or “ENT”);
- a pediatrician (to monitor overall health and development);
- a psychologist, social worker, or other mental health specialist (to support the family and assess any adjustment problems);
- a speech-language pathologist (who assesses not only speech but also feeding and swallowing problems);
Treatment of clefts usually begins in the first few months of an infant’s life, depending on the overall health of the infant and the severity of the cleft. In cases where a cleft lip and a cleft palate are present, the cleft lip is repaired first, generally around 3 months of age. For cleft lip surgery, the surgeon will make an incision on each side of the cleft from the lip to the nostril. The intricate layers of the two sides of the lip are then sutured together, making sure that the muscle that helps the mouth move is repaired. All three layers of the delicate lip tissue are then repaired individually. Bilateral cleft lips require a different surgery which is more complex but based on the same principles.
In the medical field, general agreement exists that surgical correction of a cleft palate should be accomplished when patients are younger than one year old, before significant speech development occurs. The potential benefits of an intact palate as a child begins to speak are believed to outweigh the possible complications of early closure. Surgery for both cleft palate and a cleft lip requires general anesthesia because of the patient’s age and the need to closely monitor the breathing and other vital signs.
The goal of repair in patients with cleft palate is to separate the oral (mouth) and nasal (nose) cavities; this separation involves the formation of a valve that is both watertight and airtight. The valve is necessary for normal speech. The repair also helps with preserving facial growth and the development of proper dentition (teeth). Cleft palate surgery involves drawing tissue from either side of the mouth to rebuild the palate. It typically requires two or three nights in the hospital, with the first night often being spent in the intensive care unit (ICU).
The necessity for more operations often depends on the severity of the cleft, its shape, and the thickness of available tissue that can be used to create the palate. Some children with a cleft palate require more surgeries to help improve their speech. Additional surgeries may also improve the appearance of the lip and nose, close openings between the mouth and nose, help breathing, and stabilize and realign the jaw. Subsequent surgeries are usually scheduled at least 6 months apart to allow a child time to heal and to reduce the chances of serious scarring. Lastly, many patients with a cleft lip have an asymmetric tip of the nose. This is partially corrected in the first surgery, but a rhinoplasty (nose reshaping) can be performed after the child finishes growing (typically in the teenage years).
Please note that all patients are different and individual healing times and results may vary. The statements regarding procedures and recovery made here are general rules.
Dr. Evan Ransom is an Ivy League-educated and Ivy League trained Facial Plastic and Reconstructive Surgeon. He is a Double Board Certified Head and Neck Surgeon and Facial Plastic and Reconstructive Surgery and fellowship-trained in facial plastic, reconstructive, and laser surgery. His practice is in the San Francisco Bay Area, serving patients from San Francisco, Oakland, Marin County, Palo Alto, Silicon Valley, Walnut Creek, the East Bay, and all over Northern California.