Chapter 11: Repairs for Cleft Lip with Cleft Palate and Cleft Palate Alone

These are the more complicated group of clefts. The aims of treatment are to achieve normal jaw growth, facial form, appearance, speech and hearing. In the first few weeks after birth the bones of the face and skull are still quite soft and, therefore, easily shaped. Your orthodontist will be able to treat the jaw and gum at this stage and an obturator plate (frequently called a sucking or feeding appliance) may be used.

If your baby has a bilateral cleft lip and palate, a small preliminary operation is sometimes performed at about 6 weeks of age on the lip or nose tip before the main repair a few weeks later, to enable a better end result to be achieved.

The cleft palate is repaired at about 6-9 months of age. The operation is done as soon as it is safe because speech development starts very early and so your baby needs the palate intact to use as soon as possible. The palate is usually repaired in one operation, though small defects are sometimes left to allow for growth. Sometimes a very extensive isolated cleft palate needs two operations about three months apart to achieve a sound repair. This operation has two aims: to close the cleft palate, and to create a long movable soft palate that permits the closure of the back of the throat, thus allowing normal speech to develop (see Section 16 on speech).

The surgery itself involves the creation of flaps on either side of the cleft. These flaps will be brought across with the palate muscles to cover the cleft. They are held together by stitches or sutures (see figure 11.1).

11.1 Cleft palate repair

The areas from which the flaps are taken will heal by themselves, but they will be quite tender for a few days and this may make initial attempts at feeding difficult. The operation will take up to two hours, and your child will then spend some time in the recovery ward before going back to the main ward.

The sutures used for the palate repair do not need to be removed as they are self-dissolving. After the operation your child will be fed a liquid or very soft diet for ten to fourteen days. He or she can be fed by spoon (but be careful not to put the spoon into the mouth where it may damage the repair site) or your child can drink from a cup or a feeding cup with a small spout. Your child will remain in hospital for about four to seven days or until the palate is so well healed nothing can go wrong after the child goes home. If your child is taught to drink from a cup before this surgery, then the immediate post-operative period will run more smoothly.

Your child must not be allowed to put hard objects, including a toothbrush, into the mouth for two or three weeks. Therefore, in hospital, restraints will be used on your child's arms, as after the cleft lip surgery. During this two to three weeks the child's pureed diet may include custards, milk, strained baby foods, pureed meat or vegetables, soups and so on. After three weeks a normal diet can be resumed and gentle teeth cleaning commenced.

In the condition known as submucous cleft palate, the soft palate looks intact when one looks into the mouth, but the muscles of the palate are not correctly aligned so that the soft palate cannot move normally. As a result, speech is affected. This condition may not be diagnosed until the child is learning to speak.

A submucous cleft palate requires an operation to repair the muscles so that they work normally. The operation is similar to that needed for the more obvious open cleft.

Finally, there are instances when, despite intensive speech therapy, a somewhat 'nasal' quality to speech persists. This may be because the repaired soft palate is not long enough to seal off the mouth from the nose, and thus, air escapes through the nose (see Section 16 speech). This can be remedied by further surgery (pharyngeal flap surgery).

Further Information

To obtain further information on "Cleft Lip and Palate: A Parent's Guide", please contact Belinda Liston:

Belina Liston
Cleft Palate Clinic Coordinator
The Cleft Palate Clinic
The Children's Hospital at Westmead
Locked Bag 4001
WESTMEAD NSW 2145
AUSTRALIA
T: + 61 2 9845 2079
F: + 61 2 9845 2078
E: BelindaS4@chw.edu.au