Cleft Lip Repair Before & After Case 1
Anatomic repair of the muscles in the lip, and of key landmarks on the lip, restore balance and symmetry.
Cleft Lip Repair Before & After Case 2
The lip from either side of the cleft is repaired in the midline, with attempt made to reconstruct a more normal appearance of the lip.
At the first surgery, some repair is performed on the nose as well to lengthen the columella and improve the appearance and function of the nasal passage.
Cleft Lip Repair Before & After Case 3
The scar for this repair usually falls along the normal philtral column, making the scar less noticeable in conversation.
Slight asymmetries in the red part of the lip may be touched up as needed, including at the time of other procedures like the cleft palate or cleft rhinoplasty repair.
Cleft Lip Repair Before & After Case 4
Extreme care is taken to align the vermilion (or red) margin of the lip, as even a stepoff of 1mm is noticeable in conversation.
Cleft Lip Repair Before & After Case 5
Making the Cupid’s bow peaks of the lip even requires reorientation and repair of the orbicularis muscle in the lip.
Cleft Lip Repair Before & After Case 6
One way to reduce unwanted attention to a repaired cleft lip is a smooth and well-aligned white roll.
The “white roll” is the lighter highlight along the border from the skin (cutaneous part) of the lip down to the red part of the lip (i.e., vermilion).
I do think the Z-plasty just above the Cupid’s bow helps with the natural contour of the lip — a little more snug transversely, with a concavity above the white roll. Then a transition back outwards with a convexity at the white roll, continuing around the vermilion and into the mucosa on the inside of the lip.
Sometimes following up on patients undergoing a different technique, I do see some flattening of this natural S-shape when looking from the side. In part, I think it’s because the straight scar across it can lead to scar shortening (which is an inevitable and normal part of scar healing).
Cleft Lip Repair Before & After Case 7
She has an infectious smile and magnetic spirit that brightens our day every time she comes to visit.
Cleft Lip Repair Before & After Case 8
Her primary lip and nose repair were performed earlier, for most patients usually at 3-6 months of age.
The cleft palate is then repaired usually in a single stage at 9-12 months, as babbling begins and speech development starts taking off.
This timing tries to balance scarring (which can restrict growth of the palate and midface), with optimizing speech development.
Cleft Lip Repair Before & After Case 9
Repair of the orbicularis muscle of the lip guides the alveolus (or gum line) to realign and narrow the cleft, even in the absence of nasoalveolar molding (NAM).
Complete treatment of the muscle at the first operation is also key for preventing future problems.
Release of the muscle from the septum helps to reduce the deviation typically seen as patients get older, improving both breathing and appearance.
The lip scar and nasal symmetry will continue to improve over time, especially with optimal scar care and massage.
Thank you for trusting our team with the care of your loved ones!
Cleft Lip Repair Before & After Case 10
The orbicularis oris muscle normally completes a ring around the mouth, allowing one to eat without food spilling out, and drinking through and straw.
In bilateral clefts, there is no muscle in the central portion, so the muscle must be brought all the way across from the sides.
This restores function, and helps to bring the premaxilla back in line with the lateral maxillary arches.
Elongation of the columella was also performed in the initial operation to reduce the flat and wide nasal appearance usually seen with bilateral cleft patients.
Cleft Lip Repair Before & After Case 11
This lovely girl is seen at 6 months old after her bilateral cleft lip repair.
The first year for our families with cleft lip and palate are the busiest. This may involve NAM (nasoalveolar molding), cleft lip repair, and cleft palate repair.
The timing of these procedures take into account the normal milestones for growth and speech development, to give children the best chance to reach their potential. At the same time, we also aim to minimize the number of surgeries and exposures to anesthesia as we can.
Nothing makes us happier than seeing our patients thriving!
Cleft Lip Repair Before & After Case 12
This handsome patient was born with a complete bilateral cleft lip and palate.
He underwent repair of his lip at 3 months of age, and his palate repair at 9 months.
Repair of the orbicularis oris muscle early on helps to bring the central part of the palate and gums back in line with the rest of the gums over time.
He did also have some wider, thicker scars early on, and these improved gradually over time with massage and a steroid injection.
He is seen now, about to celebrate his 2 year birthday!
Cleft Lip Repair Before & After Case 13
This sweet girl is one month after her cleft lip repair.
Normally surgery is done between 3 and 6 months of age.
This is a good balance when weighing anesthesia safety, scarring, activity level, and time to heal before the palate surgery.
Afterwards, children may continue breastfeeding or bottlefeeding the same as before surgery.
Most of our cleft lip patients also go home the same day after their lip repair.
After cleft palate surgery, patients usually stay 1 or 2 nights until we are confident the child is feeding well.
She has done beautifully, with a scar that will soften and fade over time.
Cleft Lip Repair Before & After Case 14
One month after cleft lip repair, this girl is thriving.
Cleft lip repair is normally done between 3 and 6 months of age, though for the right patient, it is reasonable to discuss performing surgery at as early as 4 weeks of age.
Factors to consider include:
– prematurity, which increases the risk of apnea after surgery
– weight and feeding, to minimize risks of anesthesia and of postoperative problems
– width of the cleft, as additional nasoalveolar molding may be recommended before going ahead with surgery
Cleft lip surgery can safely be done as a same day surgery, though patients and families sometimes choose to be observed in the hospital overnight.
Cleft Lip Repair Before & After Case 15
A few things I think about during this repair:
Pic #2 – The white roll (at the border between the skin and dry mucosa) draws attention if there is a break in that light reflex, so creating continuity with good quality white roll is priority number 1 to reduce unwanted attention.
Pic #3 – The muscle fibers not only need to be repaired, they must be reoriented back to their original direction. This is similar to what we have learned from our cleft palate repairs, as the muscle action has a vector that should be returned to normal anatomic direction as possible. Judicious backcuts help to unfurl the muscle and bring the noncleft side down.
Pic #5 – The septal deviation is due to the muscle imbalance, with the noncleft side muscle pulling unopposed. The septum here is straightened without any resetting or unseating of the cartilage; rather, it was achieved by balancing the forces on the septum by releasing the muscle on that side.
Pic #5 – The release of that muscle can be achieved underneath and separately from the skin, so that the scar on the surface stays along the philtral column without adding scar at the base of the columella if one chooses.
Cleft Lip Repair Before & After Case 16
Most clefts are due to random chance in the first couple months after conception.
Normally there is nothing that the parents or families could have done any differently to prevent it. (Some things like smoking, alcohol, or other drugs, can slightly increase the odds.)
The premaxilla is the central part of the upper jaw. It extends from the forehead and nose, growing down from the frontonasal prominence.
From the sides, the lateral maxillary prominences come towards the middle to join with the frontonasal prominence.
When the lip doesn’t fuse on one side, a unilateral cleft lip is seen.
When both sides don’t fuse, a bilateral cleft lip occurs.
When the maxillary prominences don’t meet on the inside of the mouth, that is when a cleft palate occurs. (Specifically, of the secondary palate, the part posterior to the premaxilla.)
This sweet child is seen at 1 month after lip repair, eating well and thriving!
Cleft Lip Repair Before & After Case 17
Something to note is that the early redness and thickness of immature scars, will soften and fade significantly with time.
The biggest impacts on scarring are:
– Genetics. Thicker, darker scars tend to be seen more in Asian, Hispanic, and African-American patients.
– Technique. Ensuring the tension is on the muscle repair, and not on the skin, helps with the scar quality.
– Scar care. Massage, sun protection, hydration, taping, silicone sheets or gel. These all can help.
In the end, patience and time are a necessary piece of the puzzle.
Cleft Lip Repair Before & After Case 18
While some patients disappear for years at a time, follow-ups every 1-2 years are a good time for a few things:
– Evaluating for and reassuring about expected, common issues (like a small nasolabial fistula until bone grafting), versus treating early any abnormal delays with speech development or bone growth.
– Providing personal support and a sense of home and belonging for patients and families. We have a number of patients and families who we connect families with, and several other foundations and charities that combine to provide a strong network for our patients and families.
– Interacting with the team outside of surgeries to develop trust and comfort.
– Ensuring all the right specialists are being seen at the right time. This includes ENT’s, speech therapists, dentists and orthodontists, genetic counselors, psychiatrists and psychologists, and more.
We do operate a little differently than most team clinics. Rather than seeing every specialist on a certain day in one clinic, we see cleft and craniofacial patients every day, and then help coordinate with other specialists as needed.
There are pros and cons to this, but our families seem to appreciate fewer co-pays if not needed, fewer unproductive visits where the actual dental or other care can’t be provided, and shorter trips that are easier to schedule.
We also pride ourselves in taking care of patients of all ages. This has given us a longer perspective on treatment outcomes, more flexibility in timing surgeries for our teenagers and young adults, and accepting insurance payment for our older patients who may need treatment at adult hospitals.
Cleft Lip Repair Before & After Case 19
The skin markings are a hybrid of techniques based on Millard / Noordhoff / Chang Gung / Fisher principles.
Adequate muscle release and reorientation is crucial for that Goldilocks-level of lip rotation and balance.
Scarring can be thicker and darker — especially in our darker-skinned patients (e.g., Hispanic, Asian, African-American) — and a number of scar care techniques are used as needed.
Cleft Lip Repair Before & After Case 20
We love helping patients and families beginning with #prenatal visits after referral from our #maternalfetalmedicine doctors.
Repair for a cleft lip can be done as early as 4 weeks in otherwise healthy infants, and some recent studies suggest that feeding and weight gain may be improved in those first few months if repair is done sooner.
Safety is the number one priority, though, and any sort of cough, fever, or other medical problem, would be good reason to postpone that surgery.
At this age, children also are required to be monitored overnight, rather than be able to be done as a same day surgery at an older age.
Cleft Lip Repair Before & After Case 21
Some of the initial tightness of the on-table repair relaxes as the premaxilla falls back into place if needed, and as the absorbable sutures give way.
I have been happy with the results of
1) minimizing/eliminating incisions at the alar sill and base (especially for patients prone to thick and dark scars!), and also
2) recruiting the medial crurae in the initial cleft lip/nasal repair to help with columellar height and tip projection.
Cleft Lip Repair Before & After Case 22
Some centers have moved this up to 2-4 weeks, once the child is doing well and gaining weight. There may be some benefits to feeding and weight gain doing this on the earlier side.
On the other hand, some other surgeons are pushing the cleft lip repair back towards 9-12 months. This is to mitigate concerns about the effects of general anesthesia on the developing brain.
I get into these details with families in prenatal and initial visits, and work with them to decide on what’s best for them and their child.
For this patient, the lip was repaired at 3 months, and she is seen in her after photos in preparation for her cleft palate repair at 9 months.
Cleft Lip Repair Before & After Case 23
Some of our families decide to go home the same day as cleft lip repair, and others choose to stay a night for observation.
Either is safe and reasonable for almost all of our patients without other medical conditions / syndromes.
If your surgeon decides to perform an anterior palate repair at the same time, there is a higher rate of bleeding and pain, so that can make the initial recovery a little tougher. There are pros and cons either way that are worth discussing with your team when coming up with the right plan for your child and family.
Cleft Lip Repair Before & After Case 24
Cleft lip repair normally is offered at 3-6 months of age.
Palate repair then follows at 9-12 months of age as speech development speeds up. This can also be a good time to perform a tip rhinoplasty while under the same anesthetic, to bring the nasal tip closer together, and helping to round out the nostrils to have more height medially.
Ideally we then wait to perform a definitive rhinoplasty at full skeletal maturity and after any orthognathic surgery that may need to be done to align the upper and lower teeth.
Cleft Lip Repair Before & After Case 25
A lip adhesion (2-stage lip repair) may have been offered by some teams, but I’d prefer to do this in 1 stage to minimize the number of surgeries, anesthesia exposures, and hospital stays, if we can still provide a safe and quality outcome.
As the foundation comes together, the balance and bulk of the lip will continue to even out. Small touchups of the lip may be offered at the time of later scheduled surgeries, such as the palate repair, bone grafting at 7-9 years old, or cleft rhinoplasty at 16-18 years old.
Cleft Lip Repair Before & After Case 26
Annual visits in the 4-6 year range center around speech. Kids are now able to participate more with an evaluation. Parents often also have a few videos of their kids speaking at home to give some more context and information to go off of.
Rarely, patients have come as far as possible with speech therapy, but anatomically need a lengthening of the palate, or closure of the space in the back directly with a pharyngeal flap.
At this visit, we also start talking about teeth, orthodontics, and getting ready for bone grafting to fill the gap in bone. That grafted bone then gives a place in which the teeth around it can live happily and securely.
Also rarely, we also discuss a revision of a cleft lip or nose repair. Sometimes the septum of the nose is causing severe nasal obstruction. Sometimes patients had poor healing from their original surgery due to an infection or a fall.