SURGICAL TREATMENT OF CLEFTS

It is evident that a child born with a cleft of the lip, of the palate or of both will require a number of surgical procedures for his/her rehabilitation. Each one of these procedures must be performed at a certain age, observing a predetermined sequence. The timing and sequence of operations may vary from team to team. Here we present our personal preference.

In cases of unilateral or bilateral complete cleft of the lip the first surgical procedure to be carried out is called a lip adhesion, which is generally carried out at the age of three months and consists in simple approximation of the lip segments without attempt to achieve the final aesthetic result. The goal of this procedure is the relaxation of tissues in order for the definitive repair of cleft to be carried out with the maximum possible accuracy.

The repair of the unilateral (single) cleft of the lip is carried out at the age of three months if the cleft is incomplete or at the age of six months if the cleft is complete and a preliminary lip adhesion has been carried out. During this procedure two "flaps" are formed one of which is rotated and the other is advanced in the space created by the rotation of the other flap. The scars from such a repair follow the natural direction of the philtrum of the lip and in most cases become almost invisible with time. 

In the bilateral (double) cleft the problem is significantly more complex. The principles of repair are the same as in the unilateral (single) cleft, however two or three procedures may become necessary, depending on the cleft. During the first procedure (or the second one if a lip adhesion has been done previously) the lip is repaired while in the second one revision of any existing imperfections and additional lengthening of the columella (the part of the nose between the nostrils) which is almost always short might become necessary. 

Repair of the cleft of the palate is generally carried out at the age between eight and twelve months and consists in the repair of the soft palate ( i.e. of the portion of the palate that moves, which contains the muscles of the palate) and of the hard palate up to the area of the alveolus (the tooth bearing area of the upper jaw). The closure of the area of the alveolus is carried out later. 

The technique used in the repair of the palate is important for the development of the upper jaw. A poorly carried out repair may result in significant disturbances of development of the upper jaw. In cases where the cleft involves the alveolus (the tooth bearing area of the upper jaw) a bone graft becomes necessary in order for the orthodontic rehabilitation to be completed. The bone used to fill the area of the cleft is generally taken from the iliac crest (the hip bone). This procedure is generally carried out in the age of nine to eleven years depending on the state of the child's dentition and may be combined with correction of the deviation of the nasal septum and with revision of other imperfections which might still be present. In cases of bilateral clefts bone grafting of the cleft may be done in two stages in order not to endanger the middle part of the upper jaw (which is called premaxilla). 

The duration of hospital stay for each procedure has been greatly reduced and in most cases will not exceed one or at most two days. If one adds the total numbers of days required for the surgical rehabilitation of the child, one will realize that the total hospital stay will not exceed one week.