Cleft lip and cleft palate are among the commonest birth defects affecting children in Malaysia. The reported incidence of cleft lip and palate is about 1 in 700 live births. Cleft lip (separation of upper lip) and/or cleft palate (separation of roof of mouth), occurs due to failure of fusion of these structures during the early stages of fetal development. The spectrum of these oro-facial deformities may present as a mild form (small indentation on the lip) to an extensive deformity involving the lip and palate of either one or both sides of the face.

The management for cleft lip and cleft palate involves a multidisciplinary team approach, performed at specific age group to correct the structural and functional deformities of the oro-facial region to improve facial aesthetic, speech, dental occlusion and child’s self-esteem. This multidisciplinary team consists of plastic surgeon, pedodontist, orthodontist, ENT surgeon, speech therapist, psychologist and nurse. The team can work together to define a course of treatment at specific age, including surgical repair of the cleft, speech rehabilitation and dental restoration. The timing of management depends on the individual circumstances of the cleft child.

The schedule for management of cleft patients can be summarized as:

• Birth to 1 month: plastic surgeon & orthodontist – counselling & presurgical orthopaedic
• 3 to 6 months: plastic surgeon – cleft lip surgery
• 6 to 9 months: plastic surgeon – cleft palate surgery
• From 1 year onwards: speech therapist & ENT surgeon – speech assessment and education
• From 3 years onwards: pedodontist/ dentist – counselling and dental health care
• From 7 years onwards: plastic surgeon – correction of any residual or scar deformities
• 9 to 11 years: plastic surgeon – alveolar bone grafting
• From 11 years onwards: orthodontist – orthodontic management
• 18 to 21 years: plastic surgeon – orthognathic surgery

Surgical reconstruction of a cleft of any kind is a highly individualized procedure intended not only to close the defect, but also to ensure that the affected child will be able to function and grow normally.

The timing for cleft lip and cleft palate surgery depend on several factors:

• Age of the child – at least 10 weeks of age
• Weight – at least 10 pounds
• Hemoglobin level – at least 10 gm/dl
• Other associated congenital deformities or health status of the child.

The timing for cleft lip surgery or cheiloplasty is usually about 3 – 6 months of age for a healthy cleft child.

This surgery consists of:

• Closure of the cleft resulting in a scar located in the normal structures of the upper lip
• Formation of a cupid’s bow (the curve at the center of the upper lip)
• Considerations for adequate distance between the upper lip and nose.

In cases where the cleft lip/ palate also affect the shape of the nose, additional procedures may be recommended to:

• Achieve symmetry between the nostrils
• Create adequate length of the columella (the tissue that separates the nostrils)
• Increase the angle of the nasal tip, to avoid a flattened nasal tip or one that pulls downward.

The surgery for cleft palate (palatoplasty) is usually carried out when the child is about 6 – 9 months of age. The purpose of cleft palate surgery is not only repairing the cleft palate but also to preserve the speech function and allow normal oro-facial growth in later life.

PRE-OPERATIVE EVALUATIONS

Communication is vital in order to achieve the desirable goals. During the initial consultation, parents will have the opportunity to discuss with the plastic surgeon about the treatment plan. The plastic surgeon will work closely with the parents to reach an agreement about the expectations from the surgical procedures involved and their long term benefits for their cleft children.  Every patient is different, therefore a specific treatment regimen is planned to suit an individual’s need. The preoperative evaluation includes:

• Discussion about the treatment plan and schedule
• Available surgical options for cleft patients
• The child’s medical conditions, drug allergies and previous medical or surgical treatment
• Discussion on anaesthesia and its risks
• Discussion on the likely outcomes of the treatment and any risks or potential complications
• Physical examination
• Photography for preoperative and postoperative evaluation

PREPARATION FOR SURGERY

• Prior to scheduled surgery, parents will be given specialized feeding bottles to help them to feed the child and keep up the child’s body weight
• Pacifier or teats will be discouraged
• Preoperative medical evaluation and blood investigations will be done a day before the surgery
• Special instructions will be given on the day before and after surgery

RISKS AND SAFETY

The decision to have cleft surgery is extremely personal. Patients have to consider if the benefits will achieve their goals and if the risks and potential complications are acceptable. Therefore, it is important for parents to understand that every surgical procedure has its own complications and down time. However, if a cleft child is assessed properly before the surgery and postoperative care is given adequately, these risks can be eliminated or reduced.

Some of the common risks of cleft surgery:

• Infection
• Bleeding
• Poor wound healing
• Irregular healing of scars including contracture (puckering or pulling together of tissues)
• Residual irregularities and asymmetries
• Skin discoloration
• Skin contour irregularities
• Skin sensitivity
• Swelling due to blood clot or fluid accumulation
• Injury to deeper structures such as nerves, blood vessels or muscles
• Anaesthesia risks
• Possibility of revision or staged surgery.

POST-OPERATIVE EXPECTATIONS

After the surgery, dressings or bandages may be placed on incisions outside the child’s mouth. Special instruction will be given to parents on wound care, medications to apply or to take orally to aid healing and reduce the risk of infection, appropriate feeding method, specific concerns to look for in the general health of the child, and when to follow-up with the plastic surgeon. Occasionally, the child’s arm will be restrained during the recovery period to prevent from injuring the operated sites as it heals. Sutures over the upper lip will be removed about 5-7 days after the surgery, whereas the sutures in the palate need not be removed as they will resolve with time. If the child’s nose is repaired during the cleft lip surgery, parents are advised to wear the nostril retainer for the child for 1-2 months to maintain the shape of the nostrils. As the swelling resolved, the healing will continue for several weeks. Regular application of sun block and scar gel to the operated sites (upper lip) can prevent formation of irregular scars.

The outcome of the child’s initial cleft lip and/or cleft palate surgery will make a vast difference in the child’s quality of life, ability to breathe, eat and speak. However, secondary procedures may be needed for functional reasons or to refine appearance. Even though the scars of a cleft lip surgery are generally located within the normal contours of the face, they will always be visible.

POST-OPERATIVE CARE

• Regular application of prescribed ointment and cleaning the surgical wound as instructed
• Avoid excessive sun exposure during the healing phase
• Regular use of sun screen on the scar area
• Application of topical scar gel and massage around the scar area will improve the appearance and texture of the scar.

– COPYRIGHT OF DR LEOW AIK MING