16 Clefts of the lip and palate

Introduction Table 16.1 Management of cleft deformities

Clefts of the lip and palate are one of the most common
Embryology
congenital facial malformations described in humans. Classification of cleft deformity
They remain, however, poorly understood and present a Structural abnormalities of cleft deformity
significant challenge for reconstruction. Patient management
Early records of successful repairs of clefts of the lip Surgical treatment
exist in Eastern texts and the earliest recorded case of Surgical procedures
Philosophy
a successful repair of a cleft lip appears to be around
AD 390 in China. Over the centuries, many techniques have
been reported to disguise the visible deformities of cleft
lip or the occlusion with cleft lip and palate, as well as
surgical techniques for their repair.
Surgeons dealing with clefts of the lip and palate today
must recognise that although significant advances have
been made in surgical and anaesthetic technology, the tech-
niques of repair are far from perfect and remain an area
of immense controversy and intense debate.
An understanding of the management of cleft
deformities requires a knowledge of the embryology
of the face and the classification of cleft deformity. The
structural abnormalities that comprise the cleft deformity
dictate the patient management and, in particular, the
surgical procedures employed. These will be discussed in
turn (Table 16.1).
Fig. 16.1 Development of the face at 5 weeks.

Fusion of the maxillary processes with the frontonasal

Embryology process results in the formation of the premaxilla, which
The embryological development of the face is a complex bears the incisor teeth. Facial features become recognis-
process but occurs very early in fetal life. The face de- able by the fifth to sixth week of intrauterine life. Fusion
velops from a central or frontonasal process, which grows of the maxillary palatine processes with each other and
forwards and over the developing brain. Two maxillary the premaxilla (between the lateral incisor and canine
processes advance anteriorly between the optic vesicles teeth) commences at around the eighth week of intra-
and the primitive stomodeum and two mandibular pro- uterine life at the area defined by the incisive foramen and
cesses advance beneath the stomodeum. The distal end of progresses posteriorly to the uvula by the twelfth week.
the frontonasal process is defined into medial and lateral It was initially believed that facial clefts occurred as a
131
nasal processes by the olfactory placodes (Fig. 16.1). result of failure of fusion of the ectodermal processes
 described above. However, patterns of presentation of deformity can range from this to a complete cleft of the
clefts of the lip and palate have resulted in increasing lip, alveolus, primary palate and secondary palate.
support for theories suggesting that clefts of this region Clefts of the palate alone may similarly manifest a
are likely to be due to a failure of migration of the wide range of severity. There may be no surface or visible
ectomesenchymal cells responsible for the formation of evidence of clefting, but abnormalities of soft palatal
the deeper tissues, such as the muscles and nerves, function only displayed by features suggestive of velo-
resulting in inadequate tissue support between the two pharyngeal incompetence. This occult submucous cleft
epithelial layers and consequent breakdown. may occur in an otherwise intact palate with minimal
The presentation of clefts of the secondary palate is surface evidence of an underlying abnormality of muscle
consistent with failure of fusion of the margins of the anatomy. The clinical features of submucous cleft
palatal processes. deformity are listed in Table 16.3.
Clefting may arise as part of a syndrome. Non- Although clefts of the lip and primary palate
syndromic clefting arises as a result of a genetic link associated with clefts of the soft palate and/or the
combined with environmental insults in utero, although posterior hard palate with an intervening bridge of intact
the mechanisms remain unclear. hard palate are rare, they have been described. Similarly,
clefts of the palate alone involving the bony palate may
be unilateral with partial or complete attachment of the
vomer to one side.
Classification of the cleft
deformity
The deformity in clefts of the lip and palate can range Structural abnormalities of
widely in severity and extent, rendering attempts to
classify them into a limited set of patterns somewhat
cleft deformity
impractical. The various terms used to describe palatal To fully understand the rationale for treatment of clefts of
clefts are defined in Table 16.2. the lip and palate, it is essential to comprehend the com-
Clefts of the lip may be barely noticeable, with plex nature of the underlying functional and structural
minimal surface abnormalities or asymmetry of vertical abnormalities associated with this deformity. The
height indicating an underlying abnormality of muscle components of the anatomical deformity are listed in
anatomy, a 'forme fruste' or microform cleft lip. The Table 16.4 and these will be discussed in turn.

Table 16.2 Terms used to describe palatal clefts Table 16.3 Clinical features of submucous cleft
deformity
Primary palate Palate anterior to the incisive
foramen Bifid uvula
Secondary palate Palate derived from the palatal Notching of the posterior edge of the hard palate
shelves of the embryo. Midline translucency of the soft palate
(posterior to the incisive Absence of musculus uvulae
foramen)
Complete cleft palate Cleft extending to the incisive
foramen Table 16.4 Anatomical components of a cleft
Incomplete cleft palate Cleft not extending to the deformity
incisive foramen
Submucous cleft Cleft of the muscle layer only in Lip
the soft palate (usually with Nose
notch on the posterior Alveolus
border of the hard palate) Primary palate
Unilateral palatal cleft Vomer attached to one of the Secondary palate
palatal shelves Maxilla
Bilateral palatal cleft Vomer totally separated from Mandible
132 the palatal shelves Other
The lip floor. The alveolar arch component on the cleft side
(referred to as the lesser segment) tends to be rotated
There is soft tissue discontinuity of the lip involving the
mesiopalatally and the primary palatal component on the
vermilion and skin. Disruption of the orbicularis oris
non-cleft side (referred to as the greater segment) is
with abnormal attachments of the muscle to the skin, the
rotated outwards by the action of the abnormally attached
lateral crus of the alar cartilage and the underlying bone
facial muscles. The combination of these deformities can
occurs. Some authorities have proposed that the extent of
result in a virtual appearance of a significant tissue deficit
muscular abnormality is far more extensive on the affected
at the site of the cleft. The septal cartilage is also deviated
side and includes the muscles of facial expression and
as the premaxilla is rotated out.
nasal sphincters, thus requiring a meticulous restoration
of functional muscular anatomy.
The secondary palate
The nose The secondary palate extends posteriorly from the
incisive foramen to the uvula and is composed of the
The deformity of the nose is minimal or absent in clefts
bony hard palate and the soft palate. Unilateral clefts of
of the lip that are incomplete with a largely intact
the bony hard palate result in the separation of the palatal
anatomy of the orbicularis oris. 'Forme fruste' nasal
shelf on the affected side from the contralateral palatal
deformities may occur occasionally with otherwise intact
shelf at the midline. The affected shelf is often smaller in
lips, suggesting that components of the nasal deformity
length and width and may also be retrodisplaced. The
are related to abnormal insertions of the disrupted fibres
transverse deficiency (in width) can be exaggerated by
of the facial muscles.
the cranial tilt of the shelf. The attachment of the vomer
There is nasal deformity in more complete clefts of
to the contralateral shelf may be variable in extent. The
the lip. The alar cartilage is caudally displaced and the
posterior palatal arch width is greater than normal
medial crura and alar domes are separated. This results in
because of lateral displacement of the maxillary
apparent shortening of the columella on the cleft side and
tuberosities.
deviation of the nasal tip towards the cleft side. The body
The soft palatal component of a cleft palate results in
of the cartilage may be elongated and rotated. The caudal
a midline deficiency that can be overt (e.g. in a complete
edge of the septal cartilage may be dislocated. The nasal
cleft) or submucous, with continuity of the lining but a
floor may be stretched and lower in incomplete clefts and
deficiency of the muscles in the midline. The muscles of
absent in complete clefts. In addition, the nasal lining
the soft palate are attached abnormally to the posterior
may be webbed with a band of skin across the upper
edge of the hard palate and the edges of the cleft. The
lateral wall.
anteroposterior length of the soft palate is reduced.

The alveolus
The maxilla
The premaxillary portion of the alveolus carries the
The maxilla on the affected side is deficient in vertical
incisor teeth and forms the primary palate, which is the
and anteroposterior dimensions.
part of the palate anterior to the incisive foramen. The
gap in the alveolus usually occurs between the lateral
incisor and canine teeth and extends obliquely towards The mandible
the incisive foramen. The extent of alveolar clefting may
The dimensions of the mandible may be smaller in
range from barely visible notching of the gingiva to a
patients with clefts of the palate, especially as part of the
complete cleft, but the visible manifestations may not
Pierre Robin sequence and the potential for growth might
correlate directly with the extent of underlying bony
be compounded by the existing maxillary deformity.
disruption.

The primary palate Other anomalies

Clefts of the primary palate extend posteriorly to the The abnormal anatomy of the muscles of the soft palate,
133
incisive foramen, resulting in a deficiency of the nasal especially the tensor veli palatini, is believed to be
 responsible for interference with aeration of the middle Airways
ear due to failure of adequate eustachian tube opening
Newborn babies are obligate nasal breathers and any
during swallowing, yawning and other pharyngeal
evidence of airway obstruction should be assessed
movements.
immediately by careful suction of secretions occluding
the oropharynx, and by measures to prevent the tongue
from blocking the airway.
Patient management The Pierre Robin sequence is associated with
The management of clefts of the lip and palate is micrognathia (a small mandible with obvious lack of
multidisciplinary and requires the involvement of several chin prominence), relative macroglossia (a tongue that
specialities, which constitute a cleft team. In most cen- appears disproportionately large) with a tendency to
tres, the minimum complement of a cleft team involved develop glossoptosis (falling backward of the tongue into
in the primary management would consist of a surgeon, the oropharynx) resulting in intermittent airway obstruc-
orthodontist, speech and language therapist, ENT surgeon tion, and a cleft palate. Although originally labelled as a
and audiologist. The participation of several other disci- syndrome, it is now recognised that this combination of
plines is also crucial in the management of the child with features may be associated with a variety of conditions.
a cleft deformity, including paediatricians, geneticists, Feeding difficulties associated with the respiratory
paediatric dentists, hygienists, prosthodontists, psy- obstruction are also very common.
chologists and specialist nurses and dieticians. Various manoeuvres have been utilised to prevent the
The initial management of the child born with a cleft glossoptosis, which is the fundamental cause of the
deformity is essentially supportive. The birth of a baby intermittent airway obstruction. These include nursing in
with a facial deformity is often a traumatic experience for the prone position in special harnesses, suturing the tongue
the parents and other members of the family. The staff to prevent retraction, nasopharyngeal or oropharyngeal
involved in immediate perinatal care (the obstetricians, airways, endotracheal intubation and tracheostomies.
midwives and paediatric perinatologists) must be able to The problems of airway obstruction tend to be more
recognise and deal with the shock and distress of the pronounced when the baby is more relaxed or asleep and
parents, as well as with any medical problems that may are unusual when awake, crying or in the upright
arise. It is vital that the parents are visited as soon as position. Fortunately, severe problems of airway obstruc-
possible by a member of the cleft team to discuss the tion warranting a tracheostomy or other surgical pro-
long-term management of the condition. A considerable cedures are relatively rare. However, it is essential to
effort must be made to allay the fears and anxieties of the recognise the condition and institute early appropriate
parents and relatives with detailed discussions to explain treatment. Failure to recognise the problem is potentially
the nature of the problem and the long-term prognosis of fatal because of the possibility of acute obstruction,
treatment. progressive exhaustion or brain damage associated with
Parents of babies born with clefts are often overcome chronic hypoxia. Pulmonary hypertension and cardiac
by feelings of guilt and self-accusations of punishment failure may result from the chronic hypercapnia and
for past sins, as well as with a significant loss of self- hypoxia.
esteem generated by feelings that the appearance of In mild cases, simple postural measures are often
facial deformity in the baby is a manifestation of their adequate and careful supervision with the judicious use
own imperfection. The absence of perceptible emotional of devices such as pulse oximeters and sleep apnoea
distress should not be considered as evidence of coping. monitors to detect episodes of airway obstruction are
It is essential to explore the parents' feelings, ideally sufficient. The immense emotional and physical stress
with the support of a clinical psychologist, as rejection of imposed on the parents or carers of the child must not be
the baby will have significant long-term consequences underestimated. It is essential to ensure that the child is
for both the parents and the child. Non-syndromic clefts kept in a suitable high-dependency or intensive care
of the lip and palate are unlikely to present any serious facility until it has been established that the risk of
medical problems and the only immediate concerns apnoea or cyanotic spells is minimal and the parents feel
are mainly related to potential airway problems and comfortable about the prospect of managing the problem
134 feeding. at home.
 It may be necessary to arrange readmission to hospital pulmonary aspiration and gastro-oesophageal reflux. In
to 'wean' the infant from the apnoea monitor and demon- extreme cases, percutaneous gastrostomy might have
strate to the parents that the airway problems are unlikely to be considered. Careful and regular monitoring of
to constitute a serious risk. A combination of establishing weight gain and development is essential to ensure that
breathing patterns and the progressive growth of the nutritional requirements are being met.
mandible often results in fairly rapid improvement in the
situation. In severe cases requiring surgical intervention
such as tracheostomies, it may take a long time to Surgical treatment
decannulate the child.
The fundamental objectives of surgical treatment for
clefts of the lip and palate are listed in Table 16.5. A wide
Feeding
range of procedures and protocols for surgical manage-
Feeding problems associated with clefts of the lip alone ment of this deformity has been described and contro-
are unusual. Mothers should be encouraged to attempt versies exist regarding the optimum modalities of
breast-feeding as an adequate lip seal over the nipple can treatment. Rather than becoming immersed in this
be achieved. Clefts of the palate, and especially the sec- debate, it is advisable to grasp the underlying rationale of
ondary palate, result in an inability to generate sufficient treatment (Table 16.6).
oropharyngeal negative pressure and tongue compression
against the palate. Milk reflux into the nasal cavity and
associated problems such as respiratory difficulties and Surgical procedures
fatigue, as well as frustration on the part of the mother,
The evolution of surgical procedures for the treatment
compound the problems. Historically, feeding with spoons
of cleft deformities has only been possible because of
and cups have been advocated to allow gravity-assisted
advances in the field of anaesthesia, and especially
presentation of the feed into the oropharynx, as the ability
paediatric anaesthesia. The earliest repairs of clefts of the
to swallow is not affected by palatal clefts.
lip consisted of hastily paring the edges of the cleft
A wide variety of proprietary teats with compressible
deformity without the benefit of anaesthesia and
reservoirs and feeding devices have also been designed to
attempting to suture or appose the edges in an effort to
facilitate feeding by minimising the need to suck or by
seal the gap. Palatal clefts were treated with simple
attempting to obturate the palatal cleft. Feeding plates
obturators or crude surgical attempts to repair the cleft
comprising an acrylic palatal coverage constructed on a
dental cast and secured with ribbon attached to extraoral
flanges improve sucking ability, but there is less need for
Table 16.5 Objectives of surgical treatment of
these nowadays with improvements in other feeding tech- clefts
niques, and they are now not generally recommended. In
many instances, a normal teat with an enlarged hole The restoration of normal facial appearance and facial
symmetry
to permit a steady, gravity-assisted delivery of milk into
Normal speech
the oropharynx is adequate and the mother should be Normal occlusion
encouraged to identify, by a process of trial and error, the Normal hearing
best method suited to mother and baby. However, it is
crucial that this process is undertaken under the super-
vision of a cleft nurse specialist or other member of the Table 16.6 Treatment of the cleft deformity
cleft team with a specific interest and knowledge of components
feeding problems in babies with clefts.
Correction of the surface geometry of the affected
Feeding may be seriously compromised by associated
tissues
respiratory or other problems and it may be necessary to Restitution of the underlying structural and functional
resort to nasogastric tube feeding if adequate nutrition anatomy
cannot be delivered by oral feeds. However, resident Modulation of growth and development of the jaws and
nasogastric tubes are associated with significant mor- dentition
Development of normal speech and hearing
bidity, such as increased risk of respiratory infections, 135
 addressing the geometric deformity and restore the
Table 16.7 Rule of 10s
underlying structural and functional anatomy of the
Age: 10 weeks affected tissues.
Weight: 10 lb
Haemoglobin: 10 g/dL
The lip
The timing of cleft lip repair ranges from neonatal repair
Table 16.8 Stages of cleft repair to delaying surgery to between 6 and 9 months of age.
Primary surgery
The advantages and disadvantages of neonatal repair are
Secondary surgery listed in Table 16.9.
Revision surgery

Lip adhesion
Lip adhesion involves merely approximating the skin
defect. As repair of palatal clefts under such conditions without muscle repair. Although it is routine practice in
was associated with risks of considerable blood loss or some leading centres to employ lip adhesion as a primary
other complications, they were often undertaken in adults procedure at varying times, there is no evidence to
and, until the 1970s, repair of palatal clefts was not suggest that the procedure confers any long-term benefit
recommended before the age of 18 months. Repair of lip and it has the disadvantage of increasing the total number
clefts was advocated by the rule of 10s (Table 16.7). of operative procedures if palatal repair is not undertaken
These classic recommendations for the timing of surgery at the time of the definitive lip repair.
are still widely applied today in several leading cleft Proponents of primary lip adhesion argue that it
centres in the world. serves the same function as preoperative orthopaedics to
Repair of the cleft deformity can be divided into three mould the component tissues into a more favourable
categories (Table 16.8). position without the considerable inconvenience and
cumbersome nature of the process. Lip adhesion may
have a role in wide bilateral clefts or in wide unilateral
Primary surgery
clefts if preoperative orthopaedics have failed to narrow
The objective of primary repair is to close the cleft gap, the cleft gap or the risks of breakdown of a definitive
restore the symmetry or dimensions of the lip by repair are likely to be high.

Table 16.9 Advantages and disadvantages of neonatal repair of cleft lip

Advantages Disadvantages

Theoretical advantage of scarless fetal wound healing Tissues are more friable and delicate
Reduction of psychological trauma period for parents Need for postoperative intensive care, which may adversely
and possibly better maternal bonding because of affect maternal bonding and compound psychological
restoration of facial aesthetics stress factors
Higher levels of circulating maternal immunoglobulins Underlying cardiac or other abnormalities may not be
conferring improved resistance to infection manifest at this age. Risk of producing a patent ductus
Higher haemoglobin level with possibly better wound Neonatal jaundice and risks associated with neonatal
healing anaesthesia
Dimensions of lip and nose are only slightly smaller than Primary rhinoplasty with alar cartilage dissection is difficult.
at 3 months. Surgical planning is not compromised Functional restoration of muscle anatomy is difficult.
Anatomical landmarks are not clearly defined
Parents take home a baby with a repaired lip cleft The period of psychological adaptation to an unrepaired
cleft may reduce long-term unrealistic expectations
Underlying alveolus is more malleable and moulded after Repair is more difficult in wide or bilateral clefts with no
136 repair opportunity to utilise preoperative orthopaedics
Lip repair at 3 months ration of the symmetry of the nose. Several techniques
have been described. Those utilising extensive incisions
This is the traditional recommended timing for lip repair.
of the nasal lining should be avoided as the risk of
The anatomical landmarks are well developed at this
stenosis of the nasal airways is high.
stage permitting accurate planning and restoration of the
The restoration of the nasal architecture, form and
geometric anatomy of the soft tissues. The nasal tissues
symmetry can be properly achieved only by utilising the
and alar cartilages are also sufficiently developed to
tissues of the nose. The alar cartilage on the cleft side, or
permit dissection for a primary rhinoplasty.
both alar cartilages in a bilateral cleft, may be mobilised
quite radically through the cleft lip incisions, avoiding
Lip repair at 6 months or later
the need for any incisions in the nasal lining. The growth
It is easier to repair the palate and undertake a more and development of the nose is very dependent on the
comprehensive palatal repair, especially of the primary normal flow dynamics of the nasal airways and the temp-
palate and the nasal floor, using the 'working forward tation to use the lining of the inferior turbinates or similar
from the back' approach. Some proponents advocate a structures, which result in gross distortion of the airway
one-stage repair of the entire deformity at this age. architecture, should be avoided.
'Functional' repair of the muscles of the lip, nose and
palate are believed by advocates of the Delaire functional
The alveolus
repair philosophy to be possible at this stage, when the
component muscles of the orbicularis oris and perinasal Primary repair of the alveolus has been attempted by
muscle ring can be more readily recognised. many authorities in an attempt to stimulate normal dev-
The correction of the vertical dimensions of the elopment of the alveolar arch form. Primary bone
vermilion itself is equally important and the value of grafting, with cancellous bone at the time of lip repair,
identifying the 'dry' vermilion and restoring the vertical has been largely abandoned because of long-term facial
height of the dry vermilion - and avoiding any use of growth problems that result. There is at present some
'wet' vermilion as a substitute - is being increasingly renewed interest in gingivoperiosteoplasty, which con-
recognised. sists of initial orthodontic manipulation to produce
The importance of the restoration of the muscular abutment of the gingival cleft edges prior to the lip repair
anatomy of the orbicularis oris in maintaining the and a simple restoration of the gingival continuity with
proportions of the lip, and especially the symmetry of the minimal dissection at the time of the lip repair.
face during dynamic movements, is crucial. Meticulous Alveolar closure undertaken in the mixed dentition,
attention needs to be directed to the careful detachment just prior to the descent of the canine, is often referred to
of the abnormal insertions of the muscles into the soft as a secondary alveolar bone grafting procedure to dis-
tissues and bony structures adjacent to the cleft as well as tinguish it from alveolar closure undertaken at the time of
reconstruction of the superficial and deep components of lip repair. This is a planned procedure in terms of the
the muscle. Some authorities propose that the accurate timing of surgery and is undertaken at the age when
reconstruction of the superficial part of the orbicularis sufficient permanent teeth have erupted to allow
oris, which arises from the muscles of facial expression, preoperative orthodontics with expansion of any collapse
requires radical subperiosteal mobilisation of the facial at the site of the cleft and alignment of the alveolar
soft tissue mask to adequately reposition the muscles of segments.
facial expression and reconstitute the anatomy of the lip. Resorption of the alveolar bone graft is likely to occur
Reconstruction of the anterior nasal floor and any if canine descent does not follow soon after the
associated cleft of the primary palate is desirable at the procedure, and the bone grafting is therefore timed to
time of the primary lip repair as the access to these areas coincide as closely as possible with the time of expected
is considerably facilitated at this time. canine eruption at the site of the cleft. At the time of
alveolar bone grafting, it is common practice to augment
the bony foundation of the alar base on the cleft side with
The nose
cancellous bone chips or corticocancellous bone block to
Primary correction of the cleft nasal deformity is now improve the projection and symmetry of the nose.
137
widely accepted as an essential procedure for the resto- Revision surgery might be indicated also for the lip and
 the nose to minimise the total number of surgical
Table 16.10 Secondary surgical procedures
interventions.
Fistula closure
Surgery for speech - pharyngoplasty
The primary palate
Rhinoplasty
Closure of the primary palate at the time of the lip repair Orthognathic surgery
is recommended as access to this area is extremely
difficult after lip closure. The repair may be a single layer fistula does not warrant closure if there is no demon-
repair using the mucoperiosteal lining of the vomer. Two- strable or predicted functional problems likely to be
layer closures have been described if the gap is narrow or associated with the fistula.
using buccal mucosal flaps for the oral lining.
Surgery for speech
The secondary hard palate
As speech develops, the regular and expert assessment of
The cleft of the bony secondary palate is often quite wide a cleft speech therapist is essential to detect and rectify
and attempts to achieve closure may require extensive problems of articulation or other speech problems. Velo-
lateral releasing incisions. Studies evaluating facial pharyngeal incompetence resulting from ineffective
growth in patients with unrepaired clefts of the palate or closure of the velopharyngeal aperture is often not
delayed repairs clearly suggest that surgery of the palate correctable by conservative treatment and early surgical
may be directly implicated in the subsequent restriction intervention may be warranted.
of facial growth. Pharyngoplasties are designed to reduce the dimen-
Some authorities undertake repair of the palate in two sions of the velopharyngeal aperture to facilitate closure
stages by initially repairing the soft palate, which or simply increase the resistance of the airway to
encourages descent of the hard palatal shelves and minimise nasal air escape. They are broadly classified as
narrowing of the cleft gap, allowing closure at a second dynamic - procedures (e.g. orticochea pharyngoplasty),
stage with minimal dissection. which are designed to mobilise the palatopharyngeus
muscle bundles in the posterior tonsillar pillars and
attach them to the posterior pharyngeal wall - or passive
The soft palate
- procedures that simply narrow the velopharyngeal
Early observations that the anteroposterior length of the aperture or augment the posterior pharyngeal wall using
palate was deficient led to the design of passive push implanted materials.
back techniques aimed at lengthening the palate to allow
velopharyngeal contact. Detachment of the abnormal Rhinoplasty
insertions of the muscle elements into the soft tissues and
The preschool age is also a common time for parents to
posterior edge of the bony hard palate and restoration of
request secondary corrective procedures for the
the muscular anatomy of the soft palate is essential to
asymmetry of the nose by a rhinoplasty procedure. If an
achieve effective velopharyngeal closure.
adequate primary rhinoplasty was undertaken and the
degree of asymmetry is within expected limits, every
Secondary surgery additional procedure undoubtedly confers additional
Secondary procedures in the management of cleft lip and scars within the nasal tissues, which may compromise
palate may be grouped chronologically, as listed in Table the final result. Secondary rhinoplasty at this age, or in
16.10. the preteen age group, should be undertaken only for
gross or obvious deformities causing problems of sig-
nificant psychological or functional distress.
Fistula closure
Secondary rhinoplasty at or nearing the end of the
Fistula closure following palatal cleft repairs is often growth phase is common. If orthognathic surgery is
undertaken early if it is felt that the fistula may cause planned, it is often preferable to undertake the surgery
functional problems with speech, swallowing or nasal following the orthognathic procedures to restore the sym-
138
regurgitation of ingested foodstuffs. The presence of a metry and aesthetic balance of the face, and especially
the bony foundations of the nose. The procedure can be Philosophy
combined with the orthognathic operation, if preferred,
to minimise the number of operative interventions. The management of the patient with a facial cleft
deformity is a lifelong project. The long-term con-
sequences of each procedure undertaken must be
Orthognathic surgery analysed carefully to weigh-up the potential advantages
With improvements in primary surgical techniques and and disadvantages with the full involvement of, initially,
the recognition of the potentially harmful effects of the parents or carers and subsequently the patient. All
surgery on facial growth and symmetry, it is anticipated members of the cleft team should share equal responsi-
that a smaller proportion of patients will eventually bility in the decision-making process. It is essential that
require orthognathic procedures. the care of cleft patients is undertaken by dedicated cleft
In those patients with gross occlusal problems caused teams with adequate centralisation of resources and
by restriction of midfacial growth or other facial skeletal patient referrals. Continuous and intercentre audit of the
problems, Le Fort osteotomies, bimaxillary surgery, dis- outcome of established protocols of care, which are
traction osteogenesis, on-lay bone grafts or other pro- strictly enforced, is essential to monitor outcome and
cedures may be indicated. Fixed orthodontic appliances refine techniques. It will also help to identify factors for
are required to achieve the optimal occlusal outcome in poor outcome. The search for the optimum protocol of
conjunction with surgery. The use of osseointegrated care is currently a subject of considerable interest and
implants and facial reconstruction is becoming more speculation.
common in the management of patients with clefts.

139