July is Cleft and Craniofacial Awareness Month, a time to raise awareness about craniofacial anomalies. Each year in the U.S., thousands of babies are born with a cleft, occurring when tissue in the baby’s upper lip (cleft lip) and/or roof of the mouth (cleft palate) does not completely or properly form together during pregnancy. Cleft lip and cleft palate are among the most common congenital defects. Other common craniofacial birth defects include craniosynostosis (premature closure of an infant’s skull), hemifacial microsomia (underdeveloped tissues on one side of the face), microtia (missing or underdeveloped ear) and anophthalmia/microphthalmia (missing or abnormally small eye).
Children with craniofacial deformities often have eating issues, hearing loss, speech problems, dental problems and emotional or social problems. The unique needs of patients with cleft and craniofacial conditions make multidisciplinary care essential. Early intervention by a plastic surgeon experienced in treating children is an integral component of the care plan that not only provides cosmetic repair to create a more normal appearance but also gives the child the ability to function and grow correctly.
South Florida-based Pediatrix® Plastic and Reconstructive Surgical Specialists is a leader in the field of this highly specialized branch of plastic surgery. The group has cared for children with craniofacial conditions for more than 20 years and completed thousands of complex facial reconstruction procedures. We sat down with Eric Stelnicki, M.D., practice medical director, to learn more about cleft lip and cleft palate and how the team is advancing care with the use of innovative procedures.
What is a cleft lip and cleft palate?
Between four and seven weeks of pregnancy, tissues from both sides of the head connect at the center of the face to form the lips and mouth. When the tissues don't join completely, a cleft lip occurs, leaving a gap between the two sides of the upper lip. The cleft ranges in size from a small notch to a large opening that extends to the nose. This separation can include the gums or the palate (roof of the mouth).
Between six and nine weeks of pregnancy, the palate forms. A cleft palate is an opening in the roof of the mouth that forms in utero. It can consist of the hard palate (the bony front portion of the roof of the mouth) or the soft palate (the soft back portion of the roof of the mouth).
Cleft lip and cleft palate can appear on one or both sides of the mouth. Because the lip and the palate develop separately, it's possible to have a cleft lip without a cleft palate, cleft palate without a cleft lip or both a cleft lip and cleft palate (the most common condition).
What causes a cleft lip and cleft palate?
There is no definitive cause of cleft lip or cleft palate, nor is it preventable. It is generally thought to be caused by genetic (inherited) factors. A newborn has a greater chance of developing the condition if a sibling, parent or relative has a cleft.
Environmental factors can also increase the risk of a birth defect. These include taking certain medications during pregnancy; vitamin deficiency (folic acid); obesity; smoking and/or substance abuse during pregnancy; and fetal exposure to viruses or chemicals.
Cleft lip and palate repair
A cleft lip repair may require more than one surgery. The first surgery is typically performed between the ages of 3 and 6 months. This closes the baby’s lips and realigns the muscle of the upper lip to provide normal lip function and facilitate suckling. A primary nasal repair is often performed at the time of lip repair. If needed, the second surgery is performed around 6 months of age.
“Cleft lip repair is a very complicated repair that involves repairing not only the lip but many times also repairing the nose and the gums,” said Dr. Stelnicki. “The plastic surgeon has to understand the three-dimensional relationship between the lips, the nose and the gums to properly restore the lip.”
A cleft palate is typically repaired between the ages of 10 and 12 months. The goal is to close the opening between the nose and the mouth, create a functioning palate and reduce the risk of fluid development in the middle ears.
Nearly half of children with a cleft palate need additional surgeries to help improve their speech, which is usually performed around age 5. If a child’s cleft involves the gum line, they may also require a bone graft between the ages of 6 and 10. This fills in the upper gum line to support permanent teeth and even out the upper jaw. Additional surgeries may be needed to enhance the appearance of the lip and nose; close gaps between the mouth and nose; help with breathing; and stabilize and straighten the jaw.
“Unique to our palate repair method is that we don’t just close the skin and the muscle, we close the hole in the bone of the palate,” said Dr. Stelnicki. “We do this using stem cell-like proteins that convince the body to make its own bone. This yields better outcomes in terms of less infections, less holes in the palate after surgery and less problems with growth, therefore decreasing the amount of surgeries our patients have and improving how their jaw bones grow over time.”
Unique pre- and post-surgery techniques
Prior to surgery, the team utilizes nasoalveolar molding to aid in reducing the size of the cleft deformity, which improves surgical outcomes. “Bringing the palate and the gum together and reshaping the nose pre-surgery decreases the overall number of surgeries that the child may have by at least three operations over the course of their life,” said Dr. Stelnicki.
Cutting-edge Virtual Surgical Planning (VSP) Orthognathics technology is used to plan surgery in a computerized, digital atmosphere based on the patient's cat scans and models of their teeth. This allows the patient and their orthodontist to see exactly what the surgical team plans to do prior to surgery. “More than that, it allows us to design custom plates and screws and precisely where we’re going to cut the bone,” said Dr. Stelnicki. “So, what we get on the computer can be replicated exactly in the patient down to the millimeter, allowing us to produce highly accurate outcomes. The patient gets what they expect, and we don’t typically have to wire them together so they can eat after surgery.”
Post-surgery techniques include Botox use to decrease facial scarring and minimally invasive touch-up work using stem cell technology with fat grafting. “We use this as a way of restoring volume and contour in the lips and nose without having to do major surgery involving cartilage and bone in a lot of our patients,” said Dr. Stelnicki. “It’s even used to help with speech in cleft palate patients.”