Cleft lip and palate
Cleft lip
Reconstruction of the lip and muscle function
What is it?
Paediatric plastic surgery, particularly cleft lip and palate surgery, is one of Mr João Nunes da Costa’s areas of special interest.
Cleft lip is a congenital condition that may also include a cleft palate, forming a cleft lip, alveolus and palate. In most cases it is not associated with other conditions, although some syndromes may include cleft lip as one of their features. The cleft may affect one side (unilateral) or both sides (bilateral), and may be complete, involving the whole lip and the base of the nostril, or incomplete.
Because it can interfere with feeding and have functional and psychosocial effects, repair is usually performed at around 3 months of age. Premature babies may need to wait a few more weeks. At this stage, the lip structures are large enough for effective repair and the anaesthetic risk is lower than during the neonatal period. Current techniques aim to reconstruct the anatomical subunits of the lip, with particular attention to symmetry and orbicularis oris muscle function.
The gum and alveolar ridge may also be affected, with a bony gap between the teeth. At around 9–11 years of age, this can be treated by transferring bone from another part of the body, usually the iliac bone of the hip, to support dental development. Dental and orthodontic follow-up is essential.
The lip difference is often associated with nasal deformity. An initial nasal procedure may be performed during lip repair, but formal rhinoplasty is often required in late adolescence or early adulthood. When maxillary hypoplasia or dental malocclusion is present, orthognathic surgery may need to be performed before rhinoplasty.
Procedures that may be combined
Cleft palate
Reconstruction of the palate and speech function
What is it?
Cleft palate is a defect in the “roof of the mouth” that allows communication between the nasal cavity and the inside of the mouth, and may cause important problems for the child, including:
- Feeding difficulties, including food passing through the nose and difficulty sucking from a bottle.
- Important changes in the physical ability to produce speech, including difficulty producing certain sounds, a nasal voice and air escaping through the nose during speech, with effects on communication and relationships with others.
Cleft palate is a congenital condition that may also include a cleft lip. In most cases it is not associated with other conditions, although some syndromes may include it as one of their features. The cleft may extend from the lip to the palate, involve most of the palate, or affect only the posterior region, including the soft palate and the uvula.
Even smaller clefts may cause similar speech problems because the muscles that produce the sound variations required for speech are located in the posterior part of the palate, near the throat.
Repair therefore involves both closing the communication between the mouth and nasal cavity and reorienting the muscles responsible for speech. Surgery is ideally performed between 9 and 12 months of age, before the baby begins to speak, when the anaesthetic risk is lower and the structures are large enough to be mobilised effectively and safely.
Treatment does not end with surgery. Long-term follow-up and speech and language therapy are needed to optimise the results. Videofluoroscopy may be indicated from 3–4 years of age to identify palatal function problems that may require surgical revision, such as velopharyngeal insufficiency.
Cleft nose rhinoplasty
Correction of cleft-related nasal deformity
What is it?
Cleft lip often results in nasal deformities that can be improved with rhinoplasty. Common features include a wide nasal base, a drooping nasal tip, lateral deviation, inadequate support of the nostril on the cleft side, and fragile or poorly positioned cartilages.
Open rhinoplasty involves a small scar on the columella, the skin between the nostrils. In complex cleft-related cases, this approach provides better visualisation and control of the structures than a closed approach.
When orthognathic surgery is indicated to correct maxillary hypoplasia or dental malocclusion, it should be performed before rhinoplasty because it changes the shape and position of the nose.
Frequently asked questions
Answers to common questions from parents, caregivers and patients about cleft lip, cleft palate and cleft nose rhinoplasty.
What is a cleft lip?
It is a congenital condition in which the structures of the upper lip have not joined completely. It may occur on its own or together with a cleft palate.
Can a cleft lip affect one or both sides?
Yes. It may be unilateral, affecting one side, or bilateral, affecting both sides. It may also be complete, involving the whole lip and the base of the nostril, or incomplete.
When is cleft lip repair usually performed?
Repair is usually performed at around 3 months of age. Premature babies may need to wait a few more weeks, depending on their clinical assessment.
What is the aim of cleft lip repair?
The aim is to reconstruct the anatomical subunits of the lip, restore tissue continuity and improve symmetry and orbicularis oris muscle function.
Can cleft lip affect the gum and teeth?
Yes. There may be a cleft in the alveolar ridge, with missing bone between the teeth. This may require a bone graft at around 9–11 years of age, together with dental and orthodontic follow-up.
Can the nose also be affected by cleft lip?
Yes. A cleft-related nasal deformity may be present. An initial nasal procedure may be performed during lip repair, followed by formal rhinoplasty later in life.
What is usually involved in cleft lip surgery and the hospital stay?
Repair is performed under general anaesthesia. In many centres, surgery takes about 1–2 hours and the hospital stay is approximately 1–2 days, although the plan varies with the extent of the cleft and the child’s health. A lip scar remains, but it usually becomes less noticeable with time.
What is a cleft palate and how can it affect feeding?
It is an opening in the roof of the mouth that allows communication between the mouth and nasal cavity. It can make sucking difficult and allow milk or food to pass through the nose.
How can cleft palate affect speech?
It can make certain sounds difficult to produce, cause a nasal voice and allow air to escape through the nose during speech. These changes are related to the function of the muscles in the posterior part of the palate.
Are all cleft palates the same size?
No. A cleft may extend from the lip to the palate, involve most of the palate, or affect only the posterior region, including the soft palate and uvula. Even a small cleft can impair the muscle function needed for speech.
When is cleft palate repair ideally performed and what is its aim?
It is ideally performed between 9 and 12 months of age, before speech begins. The operation aims to close the communication between the mouth and nose and reorient the palatal muscles responsible for speech.
Does cleft palate treatment end with surgery?
No. Long-term follow-up, including speech and language therapy, is required. Videofluoroscopy may be indicated from 3–4 years of age when there are signs of velopharyngeal insufficiency or a possible need for surgical revision.
Why should hearing be monitored in children with cleft palate?
These children are more likely to develop otitis media with effusion, often called glue ear, which can reduce hearing and affect speech development. Regular hearing assessments are important, with treatments such as ventilation tubes or hearing aids used when required.
What can be expected from cleft palate surgery and the early recovery?
The operation is performed under general anaesthesia, often takes about 2 hours and may require a hospital stay of 1–3 days. Pain, swelling and temporary feeding difficulty can occur initially. A soft diet and protection of the repair from hard foods, dummies, fingers or objects may be advised. Possible risks include bleeding, infection, temporary breathing difficulty caused by swelling, and partial reopening or a small fistula that may sometimes require further surgery.
What nasal differences may persist after cleft lip?
These may include a wide nasal base, a drooping tip, lateral deviation, inadequate support of the nostril on the cleft side, and fragile or poorly positioned cartilages.
When may formal cleft nose rhinoplasty be considered?
Formal rhinoplasty is often considered in late adolescence or early adulthood, after the main phases of growth and dentofacial treatment have been completed.
Why may an open rhinoplasty be used and where is the scar?
An open approach provides better visualisation and control of complex cleft-related nasal structures. It involves a small scar on the columella, between the nostrils.
Why should orthognathic surgery, when required, be performed before rhinoplasty?
Orthognathic surgery corrects maxillary and dental occlusion problems and changes the shape and position of the nose. Performing it first allows rhinoplasty to be planned on the corrected facial framework.
Can more than one lip or nose operation be needed during growth?
Yes. Secondary procedures may be considered for persistent asymmetry, muscle differences, scarring, nasal deformity or functional problems. The decision and timing should be individualised, while avoiding unnecessary revisions that increase scarring and the burden of treatment.
What are the risks and usual course after cleft nose rhinoplasty?
Swelling, bruising and temporary nasal blockage are common, and the contour may continue to refine for several months. Possible risks include bleeding, infection, breathing difficulty, altered sensation or smell, unfavourable scarring, septal perforation and the need for revision surgery. In a previously operated cleft nose, recovery and risks should be discussed individually with the surgeon.
This information is general and does not replace an individual medical assessment.
