Cleft Lip Repair, Primary Unilateral Before & After Photos

This boy is seen at 4 weeks after repair of his unilateral cleft lip.

Anatomic repair of the muscles in the lip, and of key landmarks on the lip, restore balance and symmetry.

Our cleft cuties always bring a smile to our faces!

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!

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.

An “incomplete” cleft lip, meaning there is still a skin bridge, still requires full separation and dissection of the lip to fully repair the anatomy and minimize long-term asymmetries.

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.

This boy is seen after repair of his unilateral cleft lip.

Extreme care is taken to align the vermilion (or red) margin of the lip, as even a stepoff of 1mm is noticeable in conversation.

This child is seen after repair of his unilateral cleft lip.

Making the Cupid’s bow peaks of the lip even requires reorientation and repair of the orbicularis muscle in the lip.

This sweet girl is seen soon after her palate repair at 9 months of age.

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.

This boy is seen after repair of his unilateral cleft lip.

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.

This handsome boy is seen after initial repair of his unilateral cleft lip.

The scar is more likely to be thicker and/or darker early on for patients of certain ethnicities (African-American, Hispanic, Asian), but does soften and fade with time and scar care.

The first year often includes:
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– Prenatal visits for when the cleft is seen on ultrasound, to talk about expectations and timing. Most children have otherwise very normal childhoods and lives! Almost all clefts we see are random, and not caused by anything that the mother or father did during pregnancy.
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– Day 1 working with our speech therapist @monicakemp and the team at the hospital where you deliver, to immediately get on track with feeding and weight gain.
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– Cleft lip repair between 3 and 6 months.
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– Cleft palate repair between 9 and 12 months. That seems to be the best balance between waiting for the child to grow as much as possible, and before speech begins taking off.

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.

This delightful girl is seen after repair of her unilteral cleft lip.

She has an infectious smile and magnetic spirit that brightens our day every time she comes to visit.

Such a sweet visit with this cleft cutie.

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.

Even wider clefts are able to be repaired in a single stage with our technique.

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.

Of everything we do, our cleft lip and palate patients are the core of the practice and are our greatest joys.

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.

1 month follow-up for this cutie after his cleft lip repair.

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.

While I prefer to repair a cleft lip and palate after NAM (nasoalveolar molding) that brings the two sides closer together, a single-stage repair is still possible with adequate release of the muscle, and release and reconstruction of the nasal sidewall.

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.