Cleft lip and palate repair surgery

Cleft palate and lip repair surgeries are performed to repair/restore a cleft lip, a birth defect of the upper lip, and cleft palate, a birth defect of the roof of the mouth.

A cleft is a facial birth defect that results in a split or gap in either the palate or the upper lip (sometimes the opening extends up to the bottom of the nose) or both. The condition occurs during fetal development if the structures that form the palate and lip of the child fail to join properly. The correct source of the condition remains unknown yet; however, it is sometimes associated with drinking alcohol, smoking, lack of folic acid during pregnancy and genetic issues inherited from the parent. A cleft lip and palate can create various problems in the early months of the child’s life, such as difficulty feeding, ear infections, glue in the ear (the accumulation of fluids inside the ears), and nasal sounding voice or unclear speech. There is a major risk of tooth decay in such children. The surgery to repair the cleft lip is usually performed in children aged between 3 and 6 months, whereas the surgery to repair the cleft palate is performed in children aged between 6 and 12 months. During the procedure, the surgeon repairs the cleft, rearranges the muscles in the area, and closes the cleft with stitches.

The surgery is recommended in children with cleft lip and palate. The condition is characterised by the following symptoms:

• A split or gap/opening in one or both sides of the upper lip
• A gap that extends from the upper lip to the bottom of nose
• Abnormal space in the back of the mouth
• A split that extends from the back of the mouth to the front portion
• Difficulty in talking and eating

The surgeon may postpone the procedure if your child suffers from any life-threatening conditions such as a lung disease or heart disorders that need to be operated on priority.

Prior to the procedure, the surgeon will conduct a preoperative assessment in which several diagnostic tests will be conducted, including physical examination and blood tests. The surgeon will discuss with you the details related to the pre-surgical procedures, instructions for the day of the surgery, use of anaesthesia and postoperative care. Additionally, he/she will ask you:

• To share a complete medical history of the child.
• To share a list of all the medications, including herbs, vitamins and over-the-counter drugs, being taken by your child.

Additionally, the surgeon will provide the following instructions to prepare your child for the surgery:

• If your child is being administered any blood-thinning medications, discontinue the use of the medications about 10 days before the scheduled day of the surgery. Such medicines include aspirin, warfarin, ibuprofen, and so on. The surgeon will give you a list of medicines that your child must take on the day of the surgery.
• If your child is taking formula milk, the surgeon will allow you to feed him/her until six hours before the surgery. If your child is breastfeeding, you will be allowed to feed him/her until four hours before the procedure.
• If the surgery is performed in children aged above 12 months, you will be advised to not feed the child any solid or non-clear liquids (milk, pulp juice or formula) after midnight before the day of surgery.
• Clear liquids (e.g., water, white grape or apple juice) can be fed to the child (of any age) up to two hours before the procedure.
• You should bring loose, comfortable clothes for the child to wear at the hospital.

After arriving at the hospital on the surgery day, the surgeon will review the child’s medical history and check his/her vital signs (blood oxygen level, blood pressure and body temperature). Subsequently, you will be given a consent form for signature, thus establishing your approval for the surgery. Some children get very upset and scared before the surgery. For such children, surgeons will first give a flavoured sedative to help him/her relax. The sedative takes about 10-15 minutes to work. You will be allowed to stay with the child during this period. 

Once your child becomes drowsy, he or she will be transferred to the operating room. You will be asked to stay in the waiting room. In the operating room, the surgeon will administer anaesthesia (sleep medicine) to your child through a gas mask. After the child is asleep, the surgeon will introduce an intravenous (IV) line in his/her arm or leg for administering medicine to keep the child asleep throughout the procedure. The vital signs of the child will be continuously monitored during the procedure.

In a cleft lip surgery, the surgeon introduces cuts on one side of the split/gap in the lip to produce flaps of skins and other tissues. These flaps are pulled towards the other side of the cleft and sewn together to close the abnormal opening. The surgery is finished in about one to two hours. In a cleft palate repair surgery, the surgeon creates cuts on both the sides of the split for making specialised flaps to reposition the tissues and muscles of the roof of the mouth, including the muscles involved in speech. The flaps are then sewn together, thus allowing the child to feed properly. The surgery takes about two hours to complete. The stitches used in the surgery could be removable or absorbable. The external scars arising from the surgery are usually placed alongside the natural outlines of the upper lip. The scars disappear over time, and the operated region will continue to grow and function normally with time.

The child will need to stay at the hospital for around five to seven days after the surgery. You can expect the following events at the hospital:

• The child will be moved to the recovery room wherein his/her vital signs will be monitored until their condition is stable.
• The child will have an IV line inserted in his/her arm or leg for medication.
• The child will be fitted with arm restraints with pads to prevent bending at the elbow. The restraints should be in place for about two weeks until the proper healing of wound.
• If the stitches used in the surgery are absorbable, then they will melt away over the next two weeks. If the stitches are not absorbable, they will need to be removed during the first follow-up appointment.
• The child will be moved to the hospital ward after they regain consciousness.
• The hospital staff will provide you with specific instructions to clean the incisions for feeding the child and important tips to take care of him/her.
• The child will be given pain-relief medications every four to six hours during the stay at the hospital.

The surgeon will place the following restrictions to take care of the child after the surgery:

• A liquid diet is advised until your child’s surgical wound heals. Young infants should be fed only formula or breastmilk. The child needs to be held in an upright position for feeding. The surgeon will recommend specialised nipples and bottles to feed your child.
• For older infants who consume foods other than formula or breastmilk, the food should be softened and fed with a spoon. Avoid the use of straws, forks and other utensils that can damage the operated area.
• While holding the child, it is recommended to avoid resting the child’s face on your shoulder since the operated area can bump into the shoulder, resulting in a tear or other damages.
• Make sure to clean the operated area after every feed. The surgeon will prescribe a special liquid to clean the area and an ointment to apply on the operated site after cleaning.
• Avoid letting the child indulge in activities such as jumping and running unless the surgeon gives permission for it.
• Hand restraints should be removed every few hours during the day to allow your child to bend and move their elbow.

The child may require about four weeks for a complete recovery after the surgery. The surgery will improve the ability of your child to speak, eat and breathe, thereby improving the overall quality of life. The child may need to undergo additional procedures (rhinoplasty, bone graft, etc.) to improve the appearance and function of the operated site.

When to see the doctor?

Contact the surgeon at the earliest if you observe any of the following symptoms in your child:

• Persistent pain or discomfort
• Fever with body temperature over 38.5^°C
• Unrestricted flow of blood from the nose or mouth
• Absence of wet diapers for eight or more hours
• Difficulty drinking or eating

The potential risks and complications associated with this surgery are as follows:

• Improper attachment of the joined portion between the mouth and the nose
• Incorrect development of bones around the operated area
• Breathing issues
• Infection
• Reaction to anaesthesia
• Uncontrolled blood flow
• Need for additional surgeries

The surgeon will provide you with a schedule for follow-appointments before your child is discharged from the hospital. You may need to take the child to a speech therapist after surgery to eliminate all speech-related issues, if any. The therapy may last for about two months. Additionally, your child may need to be taken to a dentist for the correction of teeth, if needed. The surgeon may recommend a hearing test for your child as hearing problems are common in children with cleft lip and/or palate.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.