Cleft Lip And Palate Reconstruction Houston
What is Cleft lip?
What is bilateral cleft lip and palate?
What is a cleft palate?
What causes cleft lip and palate?
WHAT IS CLEFT LIP?
Cleft lip, also known as hair lip, is a congenital condition wherein there exists a cleft
between the medial and lateral lip segments. This clefting causes characteristic
distortion of the lip. It also causes characteristic distortions of the nose, and often of the
upper jaw as well. Cleft lip can be associated with cleft palate, though this is not always
the case. Dr. Boutros has performed many cleft palate reconstruction surgeries with
WHAT IS BILATERAL CLEFT LIP AND PALATE?
Bilateral cleft lip exists when there is a cleft on both sides of the premaxilla. In these
cases, there is often severe facial disfigurement with the premaxilla well outside the oral
cavity. In these cases, nasal alveolar molding (NAM see below) is critical to reestablish
a more normal anatomic alignment and therefore, allow a more accurate cleft lip and
cleft nose repair.
WHAT IS A CLEFT PALATE?
A cleft palate is a condition that may or may not occur with cleft lip. With a cleft
palate, there is a loss of separation of the oral and nasal cavities. The oral and nasal
cavity is usually separated by two distinct mechanisms. One is the immobile hard
palate; this is the bony portion of the palate that does not move. The other portion is the
soft palate; this is the portion of the palate that intermittently divides the nose and the
mouth. For example, with speech, the soft palate closes on the back of the pharynx,
thereby allowing air to exit only the mouth. This also separates the nasal and oral
cavities when swallowing. With a cleft palate, varying degrees of regurgitation of air
and food into the nose may occur. This can have significant speech and feeding
sequelae. The cleft palate repair is typically performed at approximately 11 months of
age in order to allow for normal speech development.
WHAT CAUSES CLEFT LIP AND CLEFT PALATE?
The cause of cleft lip is largely unknown. Cleft lip is, on a rare occasion, part of an
underlying genetic condition. However, in most cases, the cause of cleft lip is not
identified. Cleft palate, especially when in isolation without a cleft lip, is more often,
though not always, associated with an underlying condition such as Pierre Robin.
WHAT ARE THE RISKS FOR CLEFT LIP IN SUBSEQUENT
The risk for cleft lip in subsequent children is approximately 9%. This risk is additive if
the parent also had a cleft lip. Furthermore, if two children have a cleft lip, the risk is
also higher in subsequent children.
WHAT ARE THE CONSIDERATIONS FOR PATIENTS WITH
CLEFT LIP? - (NAM)
The first consideration in cleft lip is preoperative adjustment. This is performed via the
technique known as nasal alveolar molding or NAM. With a cleft lip, especially those
cases that have a concomitant cleft palate, there can be rather dramatic malalignments
of the lip, nose, and bone of the upper jaw. Nasal alveolar molding (NAM) serves three
goals. These are: to realign the cleft segments of the upper jaw, to bring the edges of the
cleft lip in closer proximity to allow for more accurate cleft repair with minimal
scarring, and most importantly, begin correction of the nasal deformity in order to allow
a more normal appearing nose. Nasal alveolar molding (NAM) is a long and
complicated process. The process begins with formation of maxillary impressions.
Using dental impression material, a mold of the upper jaw is created. Using this mold,
an acrylic plate is constructed. This plate fits into the baby’s mouth much as an
obturator would. This plate is adjusted on a weekly basis in order to guide the growing
bone into more anatomic alignment. As the jaw is drawn into better alignment, the lip
tissues follow and the lip alignment is significantly improved. Once the jaw alignment
is begun, correction of the nose is allowed to proceed. With nasal correction, a separate
stent is placed from the molding plate extending to the nostril. This extension is also
modified on a weekly basis, elevating the nasal tip. This stretches the lining of the nose,
allowing for a more accurate and aesthetic nasal repair at the time of the cleft lip
surgery. An added advantage of the nasal alveolar process is the plate itself serves as an
obturator. This obturator can greatly assist with the baby’s feeding. It allows for
development of normal swallowing mechanisms and often improves weight gain in the
early neonatal period. Nasal alveolar molding (NAM) is begun shortly after birth,
usually within one to two weeks. The earlier the intervention is begun, the more
complete and more rapid it can proceed. It is important to note that the exact duration of
nasal alveolar molding is different for every child. Patients with more severe deformity
will require longer molding periods than patients with less severe deformity. This is
especially true in patients with bilateral cleft lip and palate, where nasal alveolar
molding has its greatest advantage. With bilateral nasal alveolar molding, the near
absent columella can be lengthened to almost normal lengths. This allows primary nasal
repairs that were unthinkable just a few years ago.
FEEDING YOUR CHILD WITH CLEFT LIP/PALATE
If your child has been born with a cleft of the palate with, or without cleft lip it is
unlikely that you will be able to directly breast feed, or use a standard bottle alone. The
reason your baby will not be able to use a regular bottle is because of the opening in, or
cleft of the palate. This prevents your baby from making adequate suction to pull the
milk from the bottle. Without good suction your baby will likely be tired before she/he
takes in enough milk/formula at each feeding. Most, but not all babies with cleft lip
only, can nurse, or use standard bottles. Some babies with cleft lip only do better
nursing or with the wide neck bottles because the breast or wide nipple helps to fill the
cleft and improve suction. There are some bottles that are available to you to make
feeding a wonderful experience for your baby and you. You can use them with pumped
breast milk or formula. Babies with clefts can, and should gain weight as babies without
clefts do. Babies with clefts should advance their diet for cereal and solids as babies
without clefts do. On average a feeding should not take longer than 30 minutes.
Houston Plastic and Craniofacial Surgery
Dr Sean Boutros
6400 Fannin, Suite 2290
Houston, TX 77030
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