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Cleft Palate Cleft Lip

cleft lip-palate

The condition known as cleft lip and palate deformity is seen on average in 1/1000 births and occurs between 8-12 years of age during the development of the baby in the womb. It is an anomaly that occurs due to developmental disorders that can be seen in weeks.

The biggest problem seen in the early period (first months after birth) in babies born with this anomaly is the slow development of these children due to feeding difficulties and frequent upper and lower respiratory tract infections. This quite common anomaly can be completely corrected with a good and orderly multidisciplinary team approach, and children born with this anomaly lead a completely normal life.

Reason

The causes of cleft lip and palate have been examined in detail and it has been seen that both genetic and environmental factors play a role in its formation. Genetic factors play a role in 5-10% of all clefts. If there is an anomaly of the cleft lip and palate in the family, the risk of having it in the baby increases. If there is no such story in the family, it may occur with cleft mutant genes and chromosomal deletions, or with syndromal anomalies such as trisomy D and trisomy E, and isolated genetic anomaly. Environmental factors play a more active role in cleft formation and a specific cause cannot be found more than once. Experimentally, high doses of cortisone can cause cleft lip and palate in offspring of pregnant animals. A rubella infection that the mother will pass in the first trimester of pregnancy causes clefts. Smoking and some vitamin deficiencies have also been shown to have an effect on cleft formation. In addition, in cases where the socioeconomic level is low, the risk of cleft lip and palate is higher.

The following point should be carefully underlined that; In the formation of cleft lip and palate, the parents, especially the mother, do not have a random crime in many cases. Parents often blame each other and themselves for giving birth to such a child after birth, but such an approach is not real and has no positive effect on the treatment of the child.

epidemiology

Cleft lip and palate roughly:

  • Pure cleft lip: 25%
  • Pure cleft palate: 25%
  • Cleft lip and palate together: 50% is seen.

While cleft lip and palate is seen in approximately 1/1000 births, isolated cleft palate is seen at a rate of 1/2500 and cleft lip and palate is seen twice in boys, while isolated cleft palate is seen twice in girls. The reason for this is that the fusion of the mesodermal protrusions in the mouth in the embryonal period is 1 week later in female babies, and if these mesodermal protrusions do not merge, cleft palate occurs.

Anatomy of cleft lip, palate anomaly:

  • Cleft lip anomaly occurs in the upper lip.
  • Unilateral incomplete cleft lip
  • Unilateral complete cleft lip
  • Bilateral incomplete cleft lip
  • One-sided complete unilateral incomplete cleft lip
  • Bilateral complete cleft lip
  • Midline cleft lip (rare)

Cleft palate:

  • clefts of the soft palate
  • Cleft hard palate
  • Submucous clefts
  • It occurs as a bifid uvula. (small tongue splitting into two)
  • These are the classification of cleft lip and palate that should be known by families in general, and Plastic Surgeons use a more anatomical classification.

Cleft Lip Treatment

Surgical repair of the cleft lip aims to normalize the anatomy of the facial borders. Since the lip is both a cosmetic and a functional organ, the result should constitute both cosmetics and function. Since nasal deformity will always be seen in cleft lip cases, the aim is to create the lip mucosa and skin symmetrically together with the working lip muscles, and to create the Cupid arc in an aesthetic way with phytrum columns and vermillion tubercle in this middle. Symmetry of the nostrils, an adequate nasal lining and columella length, as well as a symmetric and sufficient projection of the nasal tip and symmetrical nostrils are the goals in nasal treatment.

Age of Operation

Rather than saying the age of the operation, it would be more truthful to say that it is actually time to start treatment. Treatment of babies with cleft lip and palate begins the first 48 hours after birth. While some surgeons perform cleft lip operation in the first week after birth, some surgeons consider this operation in the 2nd-6th week after birth, taking into account the development of the child. they do it in the middle of the month. Some surgeons, on the other hand, prepare the baby’s anatomical structures for the actual operation (lip adhesion) by performing a discontinuous lip operation before the actual lip operation. These systems generally do not differ much from each other. The Plastic Surgeon prefers whatever teaching he received during his training. Families need not be alarmed at this bet. On the other hand, regardless of the level of deformity, the baby should be evaluated by an orthodontist immediately after birth and a systematic development of anatomical structures should be ensured with various intraoral or extraoral devices according to the type of deformity. In the Far East, where this deformity is common, preoperative orthodontic treatment is very well applied, but unfortunately in our country it is applied, but it is definitely provided in centers. In addition, immediately after birth, these babies should be examined by a pediatrician and it should be investigated whether there is an additional anomaly. In this middle, parents should also be provided with a psychological support (especially if they have not been diagnosed with cleft palate and lip before birth). Since the sucking function is not sufficient in these babies, the mother is told about the feeding status of the baby (on the lap and with a spoon or a special bottle, and by using an intraoral obturator in babies with cleft palate).

It is a slightly more difficult method to perform the surgery within the first week. Because in this period, the baby is not stable now and carries risks from anesthesia. In addition, since the lip structures have not reached sufficient size, it is very difficult to perform an operation on them. Babies with cleft lip are mostly operated in 2-3 months after birth. It is valuable that the baby’s weight increases and develops before the operation. It is best not to do surgery in babies who are not well developed until the problem is resolved. It is necessary to show that the blood values ​​such as hemoglobin, hematocrit and bleeding coagulation time are at normal levels by preoperative analysis of the baby. Since these events are operated under general anesthesia, it is a rule that the baby should be properly prepared before the operation.

Cleft Lip Post-Operative Care

Patients are usually kept in the hospital on the day and night of the surgery and are sent to their homes the next morning. Feeding of babies is in sitting position with a spoon, starting from the day of surgery. Contamination of the incision borders with nasal discharge and food should be prevented. For this purpose, the incision is dressed with antibiotic ointments every day. Keeping the wound lines dry is valuable. 5-7 days after surgery. All sutures are removed on days.

Cleft Palate Treatment

The anomaly present in the cleft palate varies from complete clefts where the oral and nasal cavities are fully opened to each other, clefts only in the dental arch, and clefts only in the soft palate or small tongue. One condition of cleft palate is submucous clefts. These slits are clefts that can only be diagnosed by plastic surgeons and are a mucosal curtain in the middle of the nasal and oral cavities. However, since the muscles under this mucous membrane are different from each other, the baby’s rhinolalia aperta or cleft palate speech comes out of the nose and there is a “hm hm” speech. Although there is no visible cleft in these babies, the repair of the submucous cleft is necessary for the baby to speak properly in the future.

Goals in the treatment of cleft palate:

  • Creation of an airtight velopharyngeal valve
  • Hearing protection
  • Preservation of midface growth
  • Creating a functional and aesthetically sufficient upper dental arch
  • It is to ensure a smooth conversation in the future.

Age of Operation

In babies with only a cleft palate, treatment begins with orthodontic treatments in the first 48 hours after birth. Various intraoral appliances reduce the cleft and facilitate further surgery. As in lip surgery, the age of operation in palate surgery is different in various teachings. While one cluster says 6 months is appropriate as the treatment age, another cluster finds the middle of 12-18 months appropriate. These are purely academic arguments, as their various studies have shown, and each group argues that their own surgery is more appropriate. If the operation is done properly, it is actually not very valuable. However, the majority of plastic surgeons claim that it is necessary to wait at least 9 months for surgery.

Cleft Palate Postoperative Care

Postoperative care in babies with cleft palate is more valuable and difficult than cleft lip. From the early postoperative period, there may be bleeding in the form of leaking from the mouth, and this bleeding should be followed up adequately as it may cause asphyxia (suffocation). Likewise, a swollen tongue can run back and cause suffocation. In the early period and at least for the first 48-72 hours, the baby’s food should not be particulate and should receive clear nutrients. Although the care is difficult at the beginning, the incisions in the mouth quickly heal within 3-4 days.

Cleft lip and palate surgeries are operations performed by plastic surgeons. Although the expectations of the family in cleft lip and palate surgeries are to provide a completely flawless and scar-free face, a normal nose and a child without cleft lip and palate, the results obtained are often far from perfect. It is inevitable that scars will remain in the cleft area, especially after lip surgeries.

Patients definitely have nasal deformities, and these deformities need aesthetic nose surgery after the development is completed (17-18 years). The closure of the palate may not be complete and patients may experience speech defects, symptoms such as snoring and patients may have to use a palate prosthesis. The likelihood of such complications increases as many patients are not fortunate enough to obtain orthodontic treatment soon after birth. However, families should know that these children are completely normal (except for their deformities) and not unusual children.

Alternative Treatment

There is no alternative to cleft lip and palate surgery. These surgeries allow the child to improve functionally and aesthetically. The surgeries should be performed at the ages recommended by your doctor. Delaying or getting it done early can cause various functional and aesthetic problems. Even if you do not have an operation, in finite cases called bifid uvula and the cleft is only in the small language, no functional and aesthetic defect is observed. In such a deformity, the decision can be left to the family and the general health status of the patient is checked.
 

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