Surgical Therapy Back

Undoubtedly, closure of the cleft lip is the first major procedure that tremendously changes children's future development and ability to thrive. Variations occur in timing of the first lip surgery; however, the most usual time occurs at approximately age 3 months. Pediatricians used to strictly follow a rule of "three 10s" as a necessary requirement for identifying the child's status as suitable for surgery (ie, 10 lb, 10 mg/L of hemoglobin, and age 10 wk). Although pediatricians are presently much more flexible, and some surgeons may well justify a neonatal lip closure, considering the rule of three 10s is still very useful.

Anatomical differences predispose children with cleft lip and palate and with isolated cleft palate to ear infections. Therefore, ventilation tubes are placed to ventilate the middle ear and prevent hearing loss secondary to otitis media with effusion. In multidisciplinary teams with significant participation of an otolaryngologist, the tubes are placed at the initial surgery and at the second surgery routinely. The hearing is tested after the first placement when ears are clear with tubes. If no cleft surgery is planned early, placing the tubes by age 6 months and monitoring hearing with repeated testing is recommended. Complications include eardrum perforation and otorrhea, particularly in patients with open secondary palates in which closure is planned for later.

For preventive reasons, ear tubes are usually placed when the child is still under general anesthesia for cleft repair.

The most common surgical procedures for a child with a cleft lip and palate anomaly are as follows:

  • Repair of the cleft lip
  • Repair of the cleft palate
  • Revision of the cleft lip
  • Closure and bone grafting of the alveolar cleft
  • Closure of palatal fistulae
  • Palatal lengthening
  • Pharyngeal flap
  • Pharyngoplasty
  • Columellar lengthening
  • Cleft lip rhinoplasty and septoplasty
  • Lip scar revision
  • LeFort I maxillary osteotomy

In addition, orthodontic treatment is very specialized and varies case by case. The 2 stages of orthodontic treatment of a child with cleft lip and palate are as follows:

  • Surgery-related orthodontics
  • Early management (since birth until the time of surgical closure of the palate)
  • Orthodontics related to alveolar bone graft
  • Permanent dentition management
  • Cleft-related orthodontics (not related to surgical treatments)
Unilateral cleft lip repair

Repair of the unilateral cleft lip (CL) is usually performed during the first year of life. Although some surgeons advocate immediate repair, most follow the “rules of 10”: hemoglobin more than 10 g, age older than 10 weeks, and weight more than 10 lb. Patients who satisfy the criteria can better tolerate general anesthesia, and surgeons can perform a more technically accurate surgical repair.

Presurgical orthodontics

Presurgical orthodontics facilitate repositioning of the palatal segments into normal alignment with the use of an appliance.[5] The simplest device is adhesive tape placed across the cheeks and prolabium of patients with bilateral clefts. Splints can also be used to maintain or adjust the alignment of the premaxilla while the patient awaits definitive cleft lip repair. These appliances have the potential to convert a wide complete cleft lip to an incomplete lip. In addition, preoperative realignment of the segments decreases tension on the wound and incidence of wound dehiscence.

Bilateral cleft lip repair
The bilateral cleft lip deformity is unique, because its management and postoperative results are affected by the status of the premaxillary segment and the degree of symmetry and completeness of the deformity. The goals of surgical correction of a bilateral cleft lip include correction of the cleft lip (CL) and nasal deformity in addition to establishment of a normal relationship between the premaxilla and the alveolar arches. Presurgical orthodontics are used to realign the maxillary arch and premaxilla and to minimize the tension placed on the lip closure.
Cleft palate repair

The goals of cleft palate (CP) repair include closure of the palatal defect and attainment of normal speech, hearing, dental occlusion, and facial and palatal growth. The timing of surgical correction remains controversial. Factors considered before repair must take into account the known and postulated affects on facial growth and speech development.

The trauma sustained during surgical intervention is thought to play a role in the underdevelopment of the midface. The persistence of a cleft deformity, per se, is not believed to affect normal craniofacial growth. Patients with cleft deformities that are left surgically uncorrected have been observed to have normal maxillary growth.

The development of speech is somewhat independent of craniofacial growth. That vocalization begins with birth is well known. In addition, an intact speech mechanism is required to ensure that the correct neural programming needed for integration of the musculature involved in speech occurs. This process is thought to transpire within the first year of life. Once established, compensatory speech patterns are difficult to change.

Common opinion maintains that although early palatal repair is associated with superior speech and hearing, it has negative effects on facial growth. Operative intervention at a younger age is also technically more challenging because of the small size of the structures and the limitations of the instruments.

Most centers perform palatal closure at age 12-18 months. Patients in this age group have larger anatomy, which facilitates surgical intervention. In addition, common belief asserts that normal speech development is not impeded at this age.

Surgical repair of the cleft palate falls into 2 categories. The first is a single- stage repair involving closure with mucoperiosteal flaps. The second involves a multistage approach in which the soft palate is closed initially, followed by a delayed closure of the hard palate.

In a 2008 retrospective study by Khosla et al concluded that the Furlow Z- plasty yielded excellent speech results for primary cleft palate repair with minimal and acceptable rates of fistula formation, velopharyngeal insufficiency, and the need for additional corrective surgery.

Distraction osteogenesis is a relatively recent technique used for maxillary advancement to correct skeletofacial deformities in older cleft patients. In 2008, Bevillaqua et al published results with this technique on 7 patients with significant anterior movements, which allowed excellent improvements in functional and facial aesthetic outcomes.

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