American Society of Plastic Surgeons
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Pediatric plastic surgery: A focus on cleft lip and palate repair

a focus on cleft lip and palate repair

Many tend to think of facelifts, breast augmentations and other elective cosmetic procedures when thinking of plastic surgery. While this area of plastic surgery may be more well-known and sought after, there are other areas within the field that serve the unique purpose of restoration and repair.

One such subset of procedures that is often overlooked yet so important is that of pediatric plastic surgery, in particular cleft lip and cleft palate repair.

A cleft is an opening or split in the upper lip and/or the roof of the mouth that occurs during fetal development when these parts of the lip and/or mouth fail to grow together normally. This can cause difficulty with swallowing, eating and speaking, along with affecting the child's appearance.

Cleft lip and palate issues are among the most common birth defects. The American Cleft Palate Craniofacial Association (ACPA) advises that about one in every 1,600 babies is born with a cleft lip and cleft palate, about one in every 2,800 babies is born with a cleft lip and without a cleft palate and about one in every 1,700 babies is born with a cleft palate and without a cleft lip in the United States per year.

What is cleft lip and palate repair and what does it entail? How can this type of procedure benefit patients in both the short term and long term? In order to gather more insight on this topic and the area of pediatric cleft lip and palate repair in general, we spoke with ASPS Member Surgeons Christopher Derderian, MD, and Patrick Gerety, MD.

The difference between a cleft lip and a cleft palate

While both procedures are often grouped together in discussion, it's important to note that cleft lip and cleft palate are different.

"The terminology related to cleft lip and cleft palate is a little confusing," said Dr. Derderian. "You can have a cleft lip without cleft palate, and you can have a cleft palate without cleft lip – termed isolated cleft lip and isolated cleft palate, respectively. You can also have both a cleft lip and cleft palate together – termed cleft lip and palate."

Patients that are most often seen for cleft lip or palate repair, are primarily younger.

"When the palate is involved, the palate repair is performed between 9 to 12 months of age with the goals of closing the hard palate – which is the roof of the mouth – and repairing the muscle of the soft palate that are important for speech," said Dr. Derderian. "Speech development is monitored closely during childhood and speech therapy is often needed to achieve normal speech. In about 25 percent of children with cleft palate, a second surgery to help improve speech is needed between ages of 5 and 10 years old."

Babies with a cleft palate may have their case sent to a plastic surgeon before they're even born – though surgery typically will not happen until they are at least a few months old.

"Most of my patients with cleft palates are referred either before they're born from their obstetrician, or they are referred just after they're born from the newborn nursery or from the neonatal intensive care unit," said Dr. Gerety. "Because ultrasounds during pregnancy are so good, most patients with cleft lip are caught with them and parents can have prenatal testing as well as a consultation with my cleft lip and palate team and me."

While it's most common to see patients who are infants and toddlers, there are some older children who come in for these procedures too.

"Some of my patients have been adopted from other countries like China where they didn't have access to surgery," said Dr. Gerety. "In those instances, I try to treat them as quickly as possible so that their palate is healed and they're language development with a new language is as fast as possible. Other patients may come for second opinions or move into our community, and I see them in our multidisciplinary cleft team."

An overview of cleft lip and palate repair

While cleft palate and cleft lip repair often involve a variety of techniques to achieve the desired results, the procedures can be generally described as a method of effectively closing the split of the palate from the gumline to the uvula.

"It involves taking apart the layers of the palate," said Dr. Gerety. "The repair closes off the nasal cavities from the mouth and reorients the soft palate muscles to help it function normally and produce normal speech."

When there is a cleft in the lip and/or palate, it can not only affect someone's appearance but also their speech.

"Both the cleft lip and palate have a dramatic impact on a person," said Dr. Gerety. "In the media, on social media and in our own minds, with a focus on appearance and beauty, we would all assume that having a cleft lip that is unrepaired or having a cleft lip that is poorly repaired or poorly scarred versus having a beautiful cleft lip repair would have the greatest impact on a person. But the reality for people is that a cleft palate and the quality of a cleft palate repair probably have a greater impact on a patient even though the palate is essentially invisible."

When performing a cleft lip and/or cleft palate repair, the goal is to create an end result with normal closure and no future issues plaguing the patient.

"The main concerns when performing cleft palate repair are careful tissue handling so that the repair heals with any issues and a focus on lengthening the soft palate and reorienting the soft palate so that it produces normal closure and good speech," said Dr. Gerety.

What parents need to know about cleft lip and palate repair

For patients or the parents of patients who need cleft lip and/or cleft palate repair, there are certain steps that you can take to find the right surgeon and set yourself up for a successful procedure. Here is what our experts would advise.

Find a properly accredited team of surgeons

When considering the right surgeon or team of surgeons to perform cleft lip or palate repair, credentials are key. Always take a close look at accreditations and certifications to ensure that you truly have the best of the best performing this procedure.

"The cleft teams are vetted by the ACPA and a list of teams is available on its website to help parents find the team that is most convenient for their location," said Dr. Derderian. "The goal of cleft team care is to consolidate care plans with input from all of the providers and specialists that patients with a cleft diagnosis commonly need help from. Those specialists include plastic surgeons, dentists, orthodontists, ENTs, oral surgeons, speech therapists, psychologists, geneticists and social workers."

Take a closer look at before and after photos

Whether you are considering a surgical team for a child or are seeking out cleft lip or palate repair on your own, always look through before and after images from your potential surgeons. This will not only show their expertise in this area but will also give you an idea of the results that can be expected post-procedure.

"The best advice that I can give someone with a cleft diagnosis contemplating surgery to improve the appearance of their lip and/or their nose is to go to someone who is experienced in these procedures and that the surgeon has many before and after images that show consistently good results," said Dr. Derderian.

Ask for a prenatal consultation

Now, many parents can see potential cleft lip and palate issues before a baby's birth thanks to advancements in ultrasound technologies, so it's important to plan ahead and opt for a prenatal consultation to prepare for repair.

"As all of us do when we want information quickly, they turn to the web for information about the diagnosis and they're often traumatized by some of the images they come across," said Dr. Derderian. "For this reason, I highly recommend that parents get a prenatal consultation with an experienced provider who is part of a multidisciplinary cleft team as soon as possible after they find out their child's diagnosis. This is helpful to provide some understanding of what the diagnosis and treatment entails. Perhaps more importantly, is that parents are able to see before and after photos that can help diffuse some of the anxiety that they are feeling about their child's appearance and how it may impact their child's wellbeing."

Make sure that you feel supported throughout the process

In addition to finding the right team of accredited surgeons to perform cleft lip or palate repair, it's important to make sure that you feel like you are properly supported. This process should involve a comprehensive, multifaceted process of preparation and recovery.

"On my team, we emphasize multidisciplinary care where families are supported by feeding specialists, speech therapists, pediatric ear, nose and throat surgeons and a plastic surgeon," said Dr. Gerety. "We've created an argument that supports patient and parent-centered care, allowing their preferences to be heard."

Don't be afraid to seek out additional support

The process of having a child undergo cleft lip or palate surgery can be stressful and exhausting for parents and caregivers. With the boom in social media and access to online information, don't be afraid to seek out additional support from communities with individuals who have gone through or are going through the same experience.

"I think that community groups on Facebook can be really powerful in terms of helping parents understand from other parents the path that they will be on and caring for their child and getting direct endorsements for high quality surgical and medical care for their babies," said Dr. Gerety.

Getting your child the care they deserve

As a parent of a child with cleft lip or cleft palate, determining what to do next to support them can be a stressful and harrowing process. Opting for cleft lip and/or cleft palate repair is an important step in setting them up for future success, allowing your child to obtain a better ability to speak and eat alongside a more balanced appearance.

When pursuing this type of plastic surgery procedure, it's important to find the right team of surgeons for the job, stay informed throughout the process and set up the right community of support in order to achieve the most successful results.

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.


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