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Description - Video - After Surgery Within the first 2-3 months after birth, surgery is performed to close the cleft lip. While surgery to repair a cleft lip can be performed soon after birth, the oft preferred age is at approximately 10 weeks of age, following the "rule of 10s" coined by surgeons Wilhelmmesen and Musgrave in 1969 (the child is at least 10 weeks of age; weighs at least 10 pounds, and has at least 10 g haemoglobin). If the cleft is bilateral and extensive, two surgeries may be required to close the cleft, one side first, and the second side a few weeks later. Often an incomplete cleft lip requires the same surgery as complete cleft. This is done for two reasons. Firstly the group of muscles required to purse the lips run through the upper lip. In order to restore the complete group a full incision must be made. Secondly, to create a less obvious scar the surgeon tries to line up the scar with the natural lines in the upper lip (such as the edges of the philtrum) and tuck away stitches as far up the nose as possible. Incomplete cleft gives the surgeon more tissue to work with, creating a more supple and natural-looking upper lip. D. Ralph Millard pioneered the technique of rotation-advancement procedure for cleft lip repair, performing the first procedure at a Mobile Army Surgical Hospital unit in Korea.[5] This technique is the standard used to repair unilateral cleft lip all over the world. Often a cleft palate is temporarily closed using a palatal obturator. The obturator is a prosthetic device made to fit the roof of the mouth covering the gap. Furthermore a tympanostomy tube is often inserted into the eardrum to aerate the middle ear. This is often beneficial for the hearing ability of the child. Cleft palate can also be corrected by surgery, usually performed between 9 and 18 months. Approximately 20-25% only require one palatal surgery to achieve a competent velopharyngeal valve capable of producing normal, non-hypernasal speech. However, combinations of surgical methods and repeated surgeries are often necessary as the child grows. One of the new innovations of cleft lip and cleft palate repair is the Latham appliance. The Latham is surgically inserted by use of pins during the child's 4th or 5th month. After it is in place, the doctor, or parents, turn a screw daily to bring the cleft together to assist with future lip and/or palate repair. If the cleft extends into the maxillary alveolar ridge, the gap is usually corrected by filling the gap with bone tissue. The bone tissue can be acquired from the patients own chin, rib or hip. Speech problems are usually treated by a speech-language pathologist. In some cases pharyngeal flap surgery is performed to regulate the airflow during speech and reduce nasal sounds. Most children with a form of clefting are monitored by a cleft palate or craniofacial team through young adulthood. Care can be lifelong. Note that treatment procedures can vary between craniofacial teams. For example, some teams wait on jaw correction until the child is aged 10 to 12 (argument: growth is less influential as deciduous teeth are replaced by permanent teeth, thus saving the child from repeated corrective surgeries), while other teams correct the jaw earlier (argument: less speech therapy is needed than at a later age when speech therapy becomes harder). Within teams treatment can differ from each individual case depending on the type and severity of the cleft. The goal after surgery is to protect the new repair and stitches. For this reason there will be some changes in the child's feeding, positioning, and activity for a short time. Remember, these are only temporary! Infants will not be able to suck on a nipple/bottle or pacifier for 10 days after surgery. A syringe with a short piece of soft rubber tubing will be used for feeding. Older children may drink from a cup. It is helpful if the child has practiced drinking from the syringe before surgery. As soon as the infant awakes from anesthesia and acts hungry they may be offered a feeding of clear liquid ( Pedialyte , sugar water, apple juice). When this is tolerated they may resume their regular formula. Infants who have already begun cereal or baby foods may be offered diluted feedings with the syringe. Older children will be on a blenderized diet that pours easily from a cup. There may be some discomfort as the child swallows so they may not drink much the first evening. This is why IV fluids are continued until their drinking improves. Pain medicine will also be given to relieve distress. A child who has had a cleft lip repair should be positioned on their side or back to keep them from rubbing their face in the bed. A child with only a cleft palate repair may sleep on their stomach. It is important to keep the stitches clean and without crusting. Parents are shown how to clean the suture line and apply ointment while in the hospital. This will continue until the stitches are removed about a week later. It is important to keep the child from hurting the incision or putting hands or toys in their mouth. For this reason they will wear arm restraints ( NoNo's) which keep them from bending their elbows. These are also used for 10 days after surgery. Children usually spend one night in the hospital and are discharged when they begin to drink an adequate amount of fluids. Parents are encouraged to stay with their child and participate in their care. Chair beds are available in the rooms for overnight sleeping.
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