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Cleft Palate

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Cleft Palate Surgery in Dallas

A cleft palate is a birth defect in which the tissues of the roof of the mouth do not join properly. The opening may be in the soft palate, which is the tissue toward the back of the mouth, and/or in the hard palate, which is the bony front area of the mouth. In many cases, a child born with a cleft palate also has a cleft lip, which is a split or opening in the upper lip. Children born with clefts are at risk for ear infections, dental problems, and speech- and feeding-related disorders.

A cleft palate is a congenital condition that may be hereditary. Other cases of cleft palate may be caused by using alcohol or tobacco, or by taking certain medications, during pregnancy. A cleft palate can cause feeding and speech problems, and surgery is necessary to correct it.

Cleft palate surgery is usually performed between the ages of 9 and 12 months, after the palate has grown but before speech has begun. The child is put under general anesthesia, and the surgeon makes incisions on both sides of the cleft, creating flaps of tissue. The flaps are then stitched closed with absorbable stitches.

After cleft palate correction surgery, children go on to live relatively normal lives. Speech therapy may be required for children with residual muscle problems. Additional surgery is sometimes required to improve speech intelligibility or to repair a fistula, or hole in the palate.

Additional Resources

• MedlinePlus
• National Institutes of Health
• Centers for Disease Control and Prevention
• Eunice Kennedy Shriver National Institute of Child Health and Human Development
• S. Department of Health & Human Services
• S. National Library of Medicine
• WebMD

Cleft Palate Surgery Specialist in Dallas, TX

A cleft palate is a birth defect. This defect can occur with or without a cleft lip. When a cleft lip and cleft palate occur simultaneously, the term used when referring to this combination defect is orofacial clefts. This defect can cause changes to the upper lip, roof of the mouth (palate) and nose. In addition, the child’s teeth may require treatment at some point later in life. Dr. Huay-Zong Law is a board-certified, compassionate, highly experienced plastic surgeon who treats individuals with orofacial clefts at Law Plastic Surgery, in Dallas.

What Are the Benefits of Cleft Palate Surgery in Dallas?

The benefits patients receive through the series of surgical correction procedures that Dr. Huay-Zong Law performs to address a cleft palate, cleft lip and nasal irregularities, are both cosmetic and functional.

These benefits include:

• Improved facial features.
• The ability to drink from a bottle or nurse more effectively.
• Improves the child’s ability to breathe
• Helps with the child’s language development and his or her ability to articulate words properly.

Dr. Law is a Dallas plastic surgeon with experience correcting orofacial clefts. His experience performing these procedures allows him to maximize the benefits his patients receive while minimizing the potential for complications.

The Time Frame of Cleft Palate Correction with Dr. Huay-Zong Law in Dallas

Typically, a plastic surgeon corrects a cleft lip within the first 12 months and a cleft palate within the first 18 months of life. Since most children will need to undergo a series of surgical procedures to correct facial irregularities and gain normal function, the timing of surgical intervention is crucial.

The series of surgical procedures to address orofacial clefts must be performed at a specific point in the child’s life. This requires that the surgeon be familiar with the ideal timeframe for performing each of a patient’s corrective surgeries. Furthermore, during the creation of the custom-designed treatment plan, the plastic surgeon must always take the unique growth patterns of each patient into consideration. For these reasons, choosing an experienced plastic surgeon to perform orofacial cleft correction surgeries is vital.

What is a Cleft Palate?

A cleft palate refers to a defect in which the tissue that makes up the palate does not unite properly. Some babies have a palate that is only partially open, whereas others have an opening in the front and back of the palate.

What is a Cleft Lip?

During pregnancy, each side of the embryo’s head has special cells and body tissues. As these tissues grow, they move toward one another. When development is normal, these tissues meet in the center joining together to create the facial features, including the mouth and the lips. However, when this fusion does not occur, an opening remains. This opening can be large, continuing through the lip and into the nose, or just be a small slit. A cleft lip can affect the middle, one side, or both sides of the lip. A cleft palate and a cleft lip frequently occur together.

The Negative Aspects and Prevalence of Orofacial Clefts in the US

Although orofacial clefts in and of themselves are not fatal, these defects can make it difficult for an infant to suckle, cause chronic ear infections, disrupt the child’s ability to grasp speech, as well as cause hearing difficulties. It is also common for a child with orofacial clefts to have misaligned teeth and irregularly shaped nostrils.

The prevalence of Orofacial Cleft deformities in the United States:

• Approximately one in every 1,700 babies is born with only a cleft palate.
• About one in every 1,600 babies is born with a cleft lip and palate.
• Approximately one in every 2,800 babies is born with just a cleft lip.

What Causes Orofacial Clefts to Develop?

Orofacial clefts develop at some point between the fourth and seventh week of pregnancy. Depending on the severity of the orofacial clefts, a patient may need cleft palate surgery (palatoplasty), cleft lip surgery (cheiloplasty) and nasal reshaping surgery (cleft rhinoplasty).

Studies Search for the Reasons Behind the Development of Orofacial Clefts

At the Centers for Birth Defects Research and Prevention (CBDRP), researchers work with other facilities to determine why birth defects occur and whether there are preventable risks associated with a particular birth defect. One such study is The National Birth Defect Prevention Study (NBDPS).

The NBDPS is the largest birth defect study ever performed in the United States. Study participants include babies born within a specific 14-year period (i.e., 1997 to 2011). One of this study’s most notable findings is the potential link between a pregnant woman’s exposure to polycyclic aromatic hydrocarbons in the workplace and the embryo’s development of orofacial clefts.

The newest study, the Birth Defects Study to Evaluate Pregnancy ExposureS (BD-STEPS), aims to understand the risks and causes of a variety of birth defects, including orofacial clefts. Study participants include infants born in 2014. The researchers are also using data collected during previous studies.

Recent Studies Discover Some Potential Causes of Orofacial Clefts

Recent studies have discovered some of the factors that can increase the likelihood an embryo will develop a cleft lip, cleft palate or both:

Polycyclic aromatic hydrocarbons exposure and the development of orofacial clefts — The connection between polycyclic aromatic hydrocarbons (PAHs) and oral clefts is one of the most notable findings of The National Birth Defect Prevention Study. A pregnant woman who is working in a place where PAHs are present is more likely to have a baby with a cleft lip. This cleft lip may be present as a single birth defect or in conjunction with a cleft palate. The higher the level of polycyclic aromatic hydrocarbons, the more likely it is that the embryo will develop a cleft lip, with or without the palate defect. This is the first study showing a link between PAHs and orofacial clefts, therefore, additional research to understand this connection would be beneficial.

Prepregnancy Diabetes — A woman who has diabetes before she becomes pregnant has a higher risk of her baby developing a cleft lip, with or without a cleft palate.

Medications used for the treatment of epilepsy — During the first trimester, women who take certain types of epilepsy medications (e.g., valproic acid and topiramate) have an increased risk of their baby being born with orofacial clefts.

Smoking — Women who smoke during their pregnancy increase the risk of their baby being born with a cleft lip, cleft palate, or both.

Studies into the reasons orofacial clefts occur and what women can do to prevent the development of these defects continue.

The Goals of Cleft Palate Repair in Dallas

For the most part, cleft lip repair is a cosmetic procedure, whereas cleft palate repair focuses on correcting the structure of the mouth. By correcting the mouth structure, the likelihood of chronic ear infections and delays in the child’s speech development decrease.

Managing and Treating Orofacial Clefts in Dallas

Treatment plans vary based on the type and severity of the cleft. Other factors include the age that the child is when treatment begins and whether the child has any other birth defects requiring treatment.

Once the child is fully grown, he or she may have nasal reshaping surgery. During this surgery, Dr. Huay-Zong Law addresses nasal irregularities, such as asymmetrical nostrils.

Cleft Palate Surgery in Dallas

Choosing the right time to perform a child’s palatoplasty is vital because it must coincide with the infant’s growth cycle. Performing a palatoplasty too soon negatively affects the ability of the child’s maxilla (i.e., upper jawbone) and face to grow properly. Nonetheless, performing the surgery too late can result in delayed speech development.

The surgical technique Dr. Law uses depends on the severity and specific characteristics of a patient’s cleft.

A general overview of surgical techniques frequently used for cleft palate repair in Dallas:

The Von Langenbeck Technique

This technique emphasizes the significance of separating the nasal and oral cavities. For this reason, nearly every cleft palate repair that plastic surgeons perform today incorporates principles of the initial Von Langenbeck Technique.

The procedure:

1. This technique corrects the palate defect with bipedicle mucoperiosteal flaps. Using specifically placed incisions, Dr. Huay-Zong Law creates these flaps and then uses them to correct the hard and soft palates.
2. After lifting the bipedicle mucoperiosteal flaps, Dr. Law closes the palatal cleft by advancing these flaps medially.

One disadvantage of this technique is that it cannot increase palate length, which makes it a poor choice for closing primary and secondary clefts.

The advantages of the Von Langenbeck Technique include its simplicity and the need for less dissection.

A Double Reverse Z-Plasty

This z-incision technique helps minimize scarring and is a good option for narrow clefts or when a submucous cleft is present.

The procedure:

1. Dr. Huay-Zong Law creates the initial z-shaped incision diagonally on the side of the oral mucosa.
2. He creates the second z-shaped incision, which mirrors the first, on the nasal mucosa side.
3. Dr. Law dissects the oral mucosa, setting it free from the underlying muscle.
4. On the left side, the patient has muscle within the oral mucosa flap.
5. On the right side, Dr. Huay-Zong Law keeps the muscle with the underlying nasal mucosa.
6. He moves the two muscle-bearing flaps posteriorly (towards the back) and places the thinner, non-muscular flaps anteriorly (towards the front).

Using this technique, Dr. Law lengthens the soft palate and rotates the muscular sling posteriorly.

One of the potential problems associated with this technique is the possibility of fistula formation at the juncture where the soft and hard palates meet.

Two-Flap Technique

This technique is the most popular option when repairing a complete cleft.

The procedure:

1. Dr. Huay-Zong Law creates incisions along the margins of the cleft.
2. He dissects the levator veli palatini muscles to free them from the bony palate.
3. Potential modifications include stripping the levator veli palatini muscle away from the hamulus, or just narrowing the hamulus.
4. Dr. Law frees the nasal mucosa from the nasal surface of the bony palate.
5. He closes the oral and nasal layers anteriorly.
6. Dr. Huay-Zong Law closes the nasal, oral and muscular layers posteriorly.

Three-Flap/V-Y Technique

The Three Flap/V-Y Technique is typically used to repair clefts affecting the secondary palate or incomplete clefts.

The procedure:

1. Dr. Law creates incisions along the free margins of the cleft. These incisions extend anteriorly from the top of the cleft to the area where the patient’s canine teeth will erupt.
2. Dissection continues posteriorly, moving along the oral side of the alveolar ridge to the section of gingival tissue behind the last molar.
3. Dr. Law elevates the mucoperiosteal flaps from the oral and nasal surfaces of the hard palate.
4. He lengthens the pedicle by freeing the greater palatine vessels from the foramen. Even if these vessels sustain an injury or become detached, the blood flow from the posterior nasal septal arteries and the lesser palatine are usually adequate.
5. To gain additional length, Dr. Huay-Zong Law can open the bony foramen that surrounds the vessels posteriorly.
6. Dr. Law lifts the tensor veli palatini muscle off the hamulus, which allows the midline closure to relax.
7. He frees the nasal mucosa from the hard palate and closes either side. When necessary, Dr. Huay-Zong Law uses vomer flaps to close the openings.
8. Dr. Law closes the oral mucosa and the muscle using a second single layer of sutures. This layer usually runs horizontally.
9. Anteriorly, Dr. Law attaches the third flap (i.e., the mucosa overlying the patient’s primary palate) to the oral mucoperiosteal flaps.
10. Posteriorly, he closes the oral mucosa, nasal mucosa and levator muscles using three layers of sutures.

Theoretically, the advantage of this technique is the ability of the surgeon to push back the flaps, adding length to the patient’s palate.

Schweckendiek Technique

Dr. Law uses this technique when a child’s cleft palate needs to be completed in stages.

When using the Schweckendiek Technique, Dr. Huay-Zong Law repairs the soft palate first. The soft palate repair typically takes place when the child is three or four months of age.

Then, once the child is about 18 months old, he closes the hard palate. During the interim, the child receives an obturator. This obturator is a prosthetic device that closes any openings so that the child can speak and swallow.

Schweckendiek Technique’s initial soft palate repair procedure:

1. Dr. Law creates incisions along the margins of the cleft.
2. The levator muscle is incorrectly attached, so he dissects the muscle to free it and then reorients it.
3. Dr. Huay-Zong Law uses a three-layer closure. He closes the nasal mucosa, the levator muscles and then the oral mucosa.
4. Dr. Law closes the hard palate fistula resulting from this surgery during another procedure.

Schweckendiek Technique’s Second Stage Hard Palate Repair (At 18 Months)

Plastic surgeons have numerous methods that they can use to close the hard palate. One such closure technique is the Schweckendiek Technique using the vomer flap.

The procedure:

1. Dr. Huay-Zong Law elevates the vomer bone’s mucoperiosteum in an inferior-to-superior direction.
2. He rotates the flap laterally and then attaches it to a palatal mucoperiosteal flap. With only a slight elevation of the palatal mucoperiosteal, this procedure provides the patient with a watertight closure.
3. Typically, when closing the mucoperiosteal flaps on the hard palate’s nasal and oral surfaces, Dr. Law uses two layers of sutures.
4. When a patient has a bilateral or a wide cleft, the vomer flap is the recommended closure technique. However, one disadvantage of the vomer flap is the need to close two suture lines on the patient’s nasal surface.
5. If Dr. Huay-Zong Law uses the vomer flap in conjunction with the oral mucoperiosteal flaps, he attaches the flaps to those elevated from the nasal surface of the patient’s cleft.

The advantage of this technique is the ability to achieve closure while the patient is young, which causes minimal disturbance of his or her facial growth. Nonetheless, there are disadvantages, which include the need for multiple surgical procedures, difficulty managing speech disorders and frequent dental prosthesis changes, which can be somewhat costly.

Submucous Clefts (Soft Palate Clefts)

The characteristics associated with a submucous cleft are palatal muscle separation, a divided uvula and an indentation in the posterior surface of the bony palate.

Three factors contribute to the submucous cleft, these factors include:

1. The membraneous part of the soft palate is missing.
2. A short palate.
3. An expansive nasopharynx (i.e., the upper portion of the throat).

The anterior displacement of the muscles determines the degree of velopharyngeal insufficiency that exists. Velopharyngeal insufficiency refers to the inability of the soft palate to close tightly enough against the back of the throat. This lack of full closure allows air to enter the nasal passages, causing hypernasal speech, which makes it difficult for the child to speak clearly.

A patient requires surgery if his or her diagnosis falls within one of the two categories of conditions listed below:

1. An obvious soft palate cleft with velopharyngeal insufficiency.
2. An overt defect that goes undetected at birth, but is recognized once the child presents with hypernasal speech.

Pharyngoplasty to close a submucous cleft palate:

Dr. Law can address a submucous cleft using a pharyngeal flap technique (aka pharyngoplasty).

A pharyngeal flap is a superiorly based pedicle flap consisting of mucosa and some of the underlying constrictor muscle. The pharyngeal flap works well when the main issue affecting velar closure is movement of the lateral wall (i.e., a sagittal closure pattern). A cleft palate and sagittal closure pattern frequently occur simultaneously.

Pharyngoplasty procedure:

1. Dr. Huay-Zong Law positions two flaps on either side of the patient’s pharynx.
2. To reduce the size of the velar opening, he rotates the two flaps superiorly.
3. If a coronal or circular closure pattern exits, a pharyngoplasty is the preferred technique because it will not affect the posterior movement of the patient’s palate.

Alveolar Bone Grafting in Dallas for Repairing Clefts Involving the Anterior Maxilla

When a cleft affects the front of the upper jaw, Dr. Law uses alveolar bone grafting to close any openings between the nasal passageway and the oral cavity. Closing these openings helps prevent segments in the upper jaw from collapsing. In addition, alveolar bone grafting encourages tooth eruption.

Whether the patient’s palate repair is scheduled for before the child reaches 24 months or at some point thereafter, he or she needs to be fitted with an obturator within the first four weeks of life.

The grafting material can be harvested from the patient’s ribs, hips, outer table of the skull or extremities.

Although there are risks associated with collecting material from various sites, the benefits of alveolar grafting outweigh any potential risks.

A palate repair procedure in Dallas using alveolar bone to correct a maxillary defect:

1. Dr. Huay-Zong Law raises the mucosal pedicles on each side of the defect.
2. He places the harvested alveolar bone into the area requiring reinforcement.
3. Dr. Law closes the mucosal flaps.
4. He may also correct the alar base depression.

Recovering After Orofacial Cleft Surgery in Dallas: What the Caregiver Needs to Know

During surgery, the patient receives general anesthesia. Following the use of anesthesia, some children develop a stuffy nose. Therefore, he or she may breathe through the mouth for about a week.

Caregivers should expect some drainage from the mouth and the nose. This drainage usually subsides within seven days of surgery.

Heading Home After Cleft Repair Surgery in Dallas

Following surgery, children must avoid jumping and running. These restrictions remain in effect until Dr. Huay-Zong Law releases the patient to resume normal activity.

Arm Cuffs/Splints

To ensure a smaller child does not rub or scratch the surgical area, Dr. Law may provide the patient with cuffs/splints. These must be worn consistently until he informs the parent/guardian that the child can stop wearing them.

Daily Cuff/Splint Removal

Remove one of the cuffs/splints two or three times a day, alternating sides. Following removal, examine the child’s arms to ensure that the cuffs/splints are not too tight. Any signs of redness or sores indicate that they are being placed too tightly.

Help the child move his or her arm and hand around. This movement is crucial for proper development of the upper extremities, therefore, please be sure to make temporary cuff/splint removal a priority. Releasing the child’s hand at any point during this exercise is not recommended because chances are he or she will reach for the face.

Caring for the Incisions Following Cleft Palate Repair in Dallas

After feeding is complete, the caregiver needs to clean the child’s incisions. Dr. Law may provide a special liquid to use for cleaning. If he does not, warm water and baby soap is fine.

Cleaning around the incisions:

1. Before cleaning the wound, the caregiver must wash his or her hands.
2. Do not use a rag/washcloth to clean around the child’s incisions; instead use a cotton swab dipped in the soapy water or cleaning liquid provided by Dr. Huay-Zong Law.
3. Start cleaning the incisions at the end closest to the child’s nose.
4. Avoid rubbing directly on the wound; instead, use small circles and begin cleaning at a location away from the actual incision.
5. Once clean and air-dried, use a clean cotton swab to gently apply antibiotic ointment to the incision.

Protecting the Incisions Following Orofacial Clefts Surgery

Dr. Law needs to remove some stitches, whereas others break apart and dissipate on their own. Parents/Guardians must never attempt to remove their child’s stitches as this could lead to unwanted results.

Parents/Guardians:

• Should only use the feeding techniques and products recommended or provided by Dr. Law and his medical staff.
• Must refrain from giving the child a pacifier.
• Need to keep hard toys away from the baby while his or her incisions heal.
• Must place the child in his or her infant seat during sleep.
• Avoid holding the child with his or her face toward their shoulder. This position can easily cause a bump to the nose, which can harm the incision.
• Choose clothes for the child that do not require being pulled over the head or touching the face.
• When feeding formula or breast milk, parents need to hold their infant upright.
• Older children need to use a cup or the side of a spoon when drinking (avoid drinking from cans and bottles or using straws).
• Children who are already eating foods must remain seated as they eat. In addition, children will need their food to be puréed or softened following cleft palate repair surgery. This makes it easy for them to swallow. Foods can be prepared using a food processor or a blender.
• Children who use utensils must only use spoons. They should not use forks, chopsticks or any other utensil that could cause harm to their incisions.

When to Call Law Plastic Surgery

There are instances when parents/guardians need to seek medical treatment following surgery. For a non-emergency issue, parents/guardians should call Law Plastic Surgery at (972) 331-1900.

Non-Emergency issues include:

• Drainage from the incision.
• Slight bleeding from the mouth, incision or the nose.
• Incision redness.
• Stitches that have come apart.
• Part of the incision appears to be opening.

Parents/Guardians need to call 911 or go to the emergency room if their child:

• Is bleeding heavily.
• Has a fever of at or above 101° F (38.3° C).
• Is unable to drink fluids.
• Has a fever of any degree that remains for two days.
• Is having trouble breathing.

Outcome

Most of the children with orofacial clefts who undergo treatment lead a healthy life. Nonetheless, due to the differences they notice between themselves and other children, self-esteem issues can arise. For this reason, Dr. Law recommends that parents/guardians seek treatment for their children as early as possible.

Good Food Options Following Cleft Palate Repair in Dallas

Food must be cooked until soft and puréed.

Good options include:

• Mashed potatoes or mashed tofu (must be thin and smooth).
• Pudding.
• Yogurt (no solid fruit or purée before eating).
• Gelatin.
• Cooked meat, blended with water, broth or milk.
• Cream soups (no solid pieces of food or purée before eating).
• Cottage cheese (small curd, puréed).
• Cooked cereals (e.g., farina, oatmeal) that are thinner than usual and puréed.
• Milk or formula (infants).

Foods to avoid after cleft palate surgery in Dallas include:

• Candy (e.g., hard candy, jellybeans, suckers and gum).
• Nuts, seeds, granola and chocolate chips.
• Peanut butter (neither creamy nor chunky).
• Chunks of meat (e.g., beef, chicken, fish, sausage), hard-boiled eggs, lettuce, solid pieces of fruits or vegetables, fried vegetables and fresh fruit.
• Dry cereal, bagels, toast, pastries, pretzels, popcorn, cookies, potato chips and crackers.
• Any other food that is crunchy.

How Much Does the Initial Cleft Palate Correction Surgery in Dallas Cost?

The cost of orofacial cleft repair varies from one patient to the next. Therefore, to find out the cost of this surgery, please schedule an initial consultation with Dr. Law.

If you are in the Dallas area and your child has a cleft palate, cleft lip, or both, contact Law Plastic Surgery today at (972) 331-1900 to schedule an appointment with Dr. Huay-Zong Law. Dr. Law is a board-certified plastic surgeon who is dedicated to providing each of his patients with the highest quality of care and natural-looking results. Dr. Law’s Dallas office is located at 7777 Forest Lane, C-528.

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