Cleft Lip And Palate Surgery

Cleft lip and palate is one of the most common congenital facial deformity. It needs a multidisciplinary approach (Surgeon, Orthodontist, Prosthodontist, speech therapist, dietician, counselor and so on) to get the best results. At our centre we have the multispecialty setup and are ideally placed to provide a comprehensive and complete care for these complex problems. They also require a series of surgical procedures at predetermined times allowing the surgeon and his team to fully harness the benefits of growth to the benefit of the patient.

Our standard protocol for our cleft cases are:

1. Cleft lip closure (6 months to an year)
2. Cleft palate closure (at 1 year)
3. Alveolar bone grafting ( 9-11 years)
4. Orthodontic treatment
5. Orthognathic surgery if needed( at 18– 25 years of age)
6. Rhinoplasty if needed after completion of orthognathic surgery

We are currently the only centre in Madurai which has full time orthodontic and surgical specialists for world class, affordable and comprehensive management of cleft lip and palate under one roof.

This 12 year old girl came to us with an uncorrected partial cleft palate. Her main complaints were nasal regurgitation and poor speech. On clinical examination she had a partial cleft of her palate. Under general anesthesia, she had closure of his cleft palate done using Von Lagenback’s technique. Post-op she had no problems and no fistula and the wounds healed up well.

Cleft palate is usually closed at 1 year of age. Too early correction will lead to severe maxillary retrusion due to scarring, too late will lead to speech problems due to air escape via the nose during speech.

The aims of cleft palate surgery are:

1. Closure of the fistula to prevent food regurgitation
2. Correct speech problems and nasal twang ( that’s why closure is done before the child speaks)
3. The surgical procedure should be as atraumatic as possible so that maxillary growth is not affected. Poor traumatic surgery will lead to scarring that will prevent proper growth of the maxilla. This in turn leads to severe maxillary retrusion (Class III facies) during growth

There are three main techniques of cleft palate closure:

1. Von Lagenback technique ( most commonly used)
2. Furlow Z plasty
3. Veau– Wardill– Kilner technique

Every cleft surgeon should be familiar and well versed in all techniques as each technique has it own pluses and minuses. All techniques employ a layer by layer closure( nasal layer, muscle layer and mucosal layer), only the flap design is different. Meticulous attention to detail is vital for success in cleft lip and palate surgery.

Cleft lip and palate is an easily treatable procedure when done at the correct age with excellent results. We provide an comprehensive multidisciplinary treatment for the patient including cleft lip closure (6 months to an year), cleft palate closure (at 1 year), alveolar bone grafting (9-11 years), orthodontic treatment, orthognathic surgery ( at 18– 25 years of age), rhinoplasty if needed as well.

This 12 year old boy came to our centre with an uncorrected cleft palate. His main complaints were nasal regurgitation and poor speech. He has had cleft lip closure done elsewhere. He was admitted at our centre and had closure of his cleft palate done using Veau—Wardil Kilner technique. Post-op he had no problems and no evidence of a fistula. He is now currently undergoing orthodontic treatment in anticipation of alveolar bone grafting.

Cleft palate pre-op Immediate post op with cleft plate repair

This young girl came to us with a cleft of her alveolus. She had already undergone lip and palate closure at the correct time frames. However she still had nasal regurgitation and poor esthetics.

Under GA, buccal and palatal flaps were raised and the nasal floor was first reconstructed. The harvested iliac bone was then packed in the cavity and the palatal and buccal flaps were then advanced and closed in a water tight manner. Post-operatively there was a 100% “take” in the bone graft. The patient was mobilized within 24 hours and she had no complications post-op. She is now currently awaiting orthodontic treatment. Orthodontic treatment can be started after 3 months post bone grafting . Secondary alveolar bone grafting is quite a technically complex procedure but in the right hands produces excellent results.

One should understand that cleft palate and lip surgery closes only the soft tissues of the palate and lip; the bony alveolar region is not touched during these procedures. There is a 3-dimensional bony and soft tissue residual defect that needs to be addressed. If the bone grafting is done at the same time as palate closure (at 1 year of age) it is called primary alveolar bone grafting. Numerous studies have shown that this greatly damages/ retards the growth of the maxilla and will result in a severe dish face deformity (Class III malocclusion)

In 1972, Boyne and Sands published a landmark paper( J Oral Surg, 1972) which showed the best results are obtained at 9-11 years of age when maxillary growth is nearly complete and the canine is erupting. This is called secondary alveolar bone grafting and is the current gold standard worldwide. Primary bone grafting has now been abandoned in all major centers worldwide in favour of secondary alveolar bone grafting.

Secondary alveolar bone grafting helps in

1. closing the palatal fistula and makes the maxilla into one piece
2. allows eruption of canine into the arch correctly
3. provides support for the nasal ala—all without impeding maxillary growth

Iliac bone (Hip) is considered the gold standard and provides the best results as compared to rib, mandible etc. Scar in the hip is hidden in the “ bikini line”- complications are minimal and pt is mobilized within 24 hrs. Donating bone is similar to donating blood—the bone will grow back and there are minimal complications associated with the procedure.

A 17 year old cleft patient came to us with a complaint reduced maxillary growth. On clinical examination he had a skeletal Class III with reverse overjet. The cause for this problem was he was a cleft lip and palate child where the previous palate repair had caused maxillary growth restriction due to scanning.

He was started on pre-surgical orthodontics ( clips) using straight wire technique to level the arch and correct the dental compensation.

He was then taken up for surgery under general anesthesia– Le Fort I advancement osteotomy with iliac crest bone grafting. In this procedure the maxilla is cut at a Le Fort I level, mobilized and advanced to class I bite and plated. The gaps were then packed with bone harvested from the hip. Bone grafting is mandatory in cleft patients to prevent relapse due to scar contracture . In this case asymmetric advancement of the maxilla was done to correct the midline as well. He is now due for cleft rhinoplasty to correct his nose.

A joint orthodontic– orthognathic approach gives the best results in these complex facial deformity patients. Maxillary retrusion occurs in about 25% of all cleft palate repair patients due to the scar preventing maxillary growth.

This young man who came to us with a cleft lip and palate. He already had alveolar bone grafting, orthodontics & orthognathic surgery done with us in the past. Once his facial profile became good, he requested us to correct his nose. Cleft rhinoplasties are probably the most technically complex rhinoplasties to do. It was decided to do the rhinoplasty with rib graft. This harvested graft was then contoured and inset in the nose. Post-op he had no problems and the wounds healed up well. The collapsed nose was corrected and his air entry was also beter.

He was extremely happy with his result. The results as you can see are excellent considering his complex deformity.