A cleft palate or cleft lip is an opening in the upper lip or the roof of the mouth that forms because facial tissues did not join completely during early fetal development. These conditions, collectively known as orofacial clefts, affect approximately 1 in every 700 live births worldwide. The repair process is a comprehensive, multi-stage journey that often begins shortly after birth and continues through adolescence. A multidisciplinary team manages this extensive timeline to restore function, normalize appearance, and support the child’s development.
Defining Cleft Conditions and Initial Management
A cleft lip (cheiloschisis) is an opening in the upper lip, ranging from a small notch to a gap extending into the nose. It can occur on one side (unilateral) or both sides (bilateral) when the tissues fail to fuse between the fourth and seventh weeks of pregnancy. A cleft palate (palatoschisis) is a split in the roof of the mouth, involving the hard palate (bony front) and/or the soft palate (muscular back portion). This forms between the sixth and ninth weeks of pregnancy. Patients may have a cleft lip alone, a cleft palate alone, or both conditions simultaneously, which is the most common presentation.
A cleft palate creates an open connection between the mouth and the nasal cavity, significantly impacting the infant’s ability to feed efficiently. Before the first surgery, the focus is ensuring the baby receives adequate nutrition and managing structural differences. Specialized feeding systems, such as elongated nipples or squeezable bottles, are employed to help the infant achieve proper suction and prevent liquid from entering the nasal cavity.
To prepare the mouth structure for surgery, some infants undergo Nasoalveolar Molding (NAM). This non-surgical technique uses a custom-fitted acrylic plate to gently guide the separated gum segments and nasal cartilage closer together. NAM is initiated within the first few weeks after birth and helps reduce the width of the cleft. Reducing the cleft width improves the surgical outcome and minimizes scarring. This stabilization ensures the infant is healthy and the tissues are in the best position before the initial repair.
The Primary Surgical Timeline (Lip and Palate Repair)
The initial surgical phase focuses on closing the openings in the lip and palate, generally performed separately during the first year and a half of life. The sequence prioritizes lip repair first, followed by palate repair a few months later. This timeline balances the need for early repair with ensuring the infant is medically stable and adequately developed for general anesthesia.
Cleft Lip Repair (Cheiloplasty)
Cleft lip repair, known as cheiloplasty, is commonly scheduled between 3 and 6 months of age. Surgical readiness is often determined by the “Rule of 10s,” which suggests the infant meet three safety criteria. The baby should be at least 10 weeks old, weigh at least 10 pounds (4.5 kg), and have a hemoglobin level of at least 10 g/dL. Following these benchmarks ensures the infant has sufficient physiological maturity to safely undergo the procedure.
The surgical goal is to close the gap and restore the normal appearance and symmetry of the upper lip and nose. The surgeon repositions the muscle, skin, and mucosal tissues to create a natural-looking Cupid’s bow and floor of the nose. For a bilateral cleft lip, the repair may be performed in two separate stages or a single, complex operation to achieve the best functional and aesthetic result.
Cleft Palate Repair (Palatoplasty)
Cleft palate repair, or palatoplasty, is typically performed later than lip repair, generally between 9 and 18 months of age. This timing is selected to close the opening before the child develops complex speech patterns. Clear speech depends on the soft palate’s function, which separates the oral and nasal cavities during talking and swallowing.
The objectives of this surgery are to close the opening between the nose and mouth and to reconstruct the muscles of the soft palate. Realigning these muscles establishes a functioning velopharyngeal valve. This valve is necessary for clear, non-nasal speech and prevents food and liquids from entering the nasal passage. An earlier repair, often closer to the 9- to 12-month mark, is preferred to support optimal speech development, though the exact timing is individualized.
Ongoing Care and Secondary Procedures
Surgical management of a cleft condition is a continuum of care extending beyond the first few years of life. Secondary procedures are often necessary to refine function and appearance. The long-term treatment plan requires regular monitoring by the cleft team throughout childhood and adolescence, addressing issues that become apparent as the child grows.
Velopharyngeal Insufficiency (VPI) is a common issue where the soft palate cannot adequately close off the nasal cavity during speech, resulting in an overly nasal voice quality. While speech therapy is the first line of treatment, persistent VPI may require secondary speech surgery, typically between ages 3 and 6 years. Common procedures, such as a pharyngeal flap or a sphincter pharyngoplasty, narrow the opening to the nasal passage to improve speech resonance.
When the cleft extends through the gum line (alveolus), an Alveolar Bone Graft (ABG) is necessary to close the defect in the upper jawbone. This surgery is timed between ages 7 and 10, just before the permanent canine tooth erupts into the cleft area. The procedure involves taking a small piece of bone from the patient’s hip or leg. This bone fills the gap in the gum ridge, providing structural support for the teeth and stabilizing the arch of the mouth.
As the patient enters late adolescence (typically ages 16 to 18), a final surgical stage addresses any remaining facial or jaw discrepancies. Cleft conditions can restrict the growth of the upper jaw (maxilla), potentially leading to an underbite. Corrective jaw surgery, known as orthognathic surgery, is performed once facial growth is complete to align the upper and lower jaws. Secondary rhinoplasty, a procedure to refine the nose’s shape and symmetry, is delayed until this time to ensure stability after all other facial growth and bony procedures are finished.