Sunday, December 4, 2011

How do they repair a cleft palate?


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When the roof of the mouth doesn't grow together properly, the condition is called a cleft palate. To repair it, the surgeon will make an incision along both sides of the cleft.

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Tissue is drawn together from both sides of the cleft to rebuild the roof of the mouth.
Many people have been asking what is involved in fixing a cleft palate.    I found these diagrams to be the most helpful when trying to understand what happens during the surgeries. They are from this site: WFU Cleft Lip and Palate Repair  

To see what Paige's Cleft is like, why they occur and her personal treatment timeline click here: Paige's Cleft Journey

Cleft Palate Surgery
In some children, a cleft palate may involve only a tiny portion at the back of the roof of the mouth; for others, it can mean a complete separation that extends from front to back. Just as in cleft lip, cleft palate may appear on one or both sides of the upper mouth. However, repairing a cleft palate involves more extensive surgery and is usually done when the child is nine to 18 months old, so the baby is bigger and better able to tolerate surgery. 

Paige's cleft lip was considered incomplete because it did not extend into her nostril all the way and was only on the right side; but her palate is considered to be somewhat wide and affects both sides of her mouth, involving the soft and hard palate. You can also see that there is another submucous layer of her palate closer to her sinuses that is also clefted, more on the right side than the left. That is why food come out of her right nostril. 

Currently her skin is so clefted down the middle she does not have a visible Uvula. The doctor said he will try to make one but often, as the tissue heals, it just pulls up again and it won't be as visible as a natural one would be. Speech therapy will be a part of her life 6 weeks after surgery. Her roof will get tough and the bones may even grow a little closer together but it will never be as hard as someone's palate that is not clefted. It should be completely functional though. Holes called fissures can open back up, but are very rare. These usually close on their own but may require future surgery to re-close. Our doc says his fissure rate is VERY low. And that's another reason why we chose him.      

 


To repair a cleft palate, the surgeon will make an incision on both sides of the separation, moving tissue from each side of the cleft to the center or midline of the roof of the mouth. (See diagrams above right)This rebuilds the palate, joining muscle together and providing enough length in the palate so the child can eat and learn to speak properly.

The doctor will close both layers. He said that the incisions left behind will remain raw and open and the open raw areas will fill in on their own like wisdom teeth holes. I remember this when I had mine out.

Recovering From Cleft Palate Surgery
For a day or two, your child will probably feel some soreness and pain, which is easily controlled by medication. During this period, your child will not eat or drink as much as usual -- so an intravenous line will be used to maintain fluid levels. Elbow restraints may be used to prevent your baby from rubbing the repaired area. Your doctor will advise you on how to feed your child during the first few weeks after surgery. It's crucial that you follow your doctor's advice on feeding to allow the palate to heal properly.

Paige's Surgery will be in the Morning on Dec. 12th and we will be at the hospital for 2-3 days depending on how well she is eating. The doctor said it is important for her to be on the IV fluids so that she does not get dehydrated while not eating much; as soon as she is eating ok he wants to send us home because he thinks kids thrive better in their own home than in a hospital. His post op instructions seem a little stricter than some. She is supposed to wear her arm restraints for 3 weeks and eat only pureed baby food for 6 weeks. That means no rice puffs, cheerios, bits of apple, banana, cooked brown rice etc....she hasn't been a fan of regular baby food lately so this will be interesting. Maybe I will puree some avocado and add some whole yogurt.  Most likely birthday cake (Jan. 2) will not make the list of ok food for palate surgery recovery....so we are thinking a big pile of whip cream to get those classic first birthday pics.

Children with a cleft palate are particularly prone to ear infections because the cleft can interfere with the function of the middle ear. To permit proper drainage and air circulation, the ear-nose-and-throat surgeon on the Cleft Palate Team may recommend that a small plastic ventilation tube be inserted in the eardrum. This relatively minor operation may be done later or at the time of the cleft repair. In addition, surgery may be recommended by your plastic surgeon when your child is older to refine the shape and function of the lip, nose, gums, and palate.



This site has some info about cleft occurrence statistics and a great anatomy of the inner ear and how a cleft palate affects hearing and speech. 
Paige had her first set of eartubes at two months. She is getting over a month long ear infection and the ENT is watching her tube on the right because it is about to fall out and isn't working properly. This is why her palate surgery was postponed another month and pushed into December near Christmas. We may have another ear tube surgery in the near future.  See the blog posts about her previous ear tube surgery: Ear Tube Posts

Perhaps most important, keep in mind that surgery to repair a cleft lip or palate is only the beginning of the process. Family support is critical for your child. Love and understanding will help him or her grow up with a sense of self-esteem that extends beyond the physical defect.

And this is why we are so appreciative of all the support, love and prayers our loved-ones continuously send our way!

Here are a few more diagrams of palate surgeries if you are having trouble visualizing.

Our doctor said the diagram below is closest to what he does and it show that there are several layers that need to be sewn.  He looked at the diagrams above and said sewing the flaps to that small point in the middle is a week point and could lead to fissure.  He also said that there will be a small hole behind Paige's gums where the notch in the bone is and for some kiddos who have a complete cleft in their gumline up to their nose, until they get a bone graft about 8 or 9 years old.  So some liquid may come out her nose a little for years to come.

Another technique that they do where they sew the tissue flaps together in a zig-zag but our doctor doesn't do this technique for the palate but uses it for submucous clefts only.    



Here are the diagrams of a lip repair surgery as well. Paige's scar follows this pattern almost exactly but on the right side.
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A cleft lip is a separation of the upper lip that can extend into the nose.

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To repair a cleft lip, the surgeon will first make an incision on each side of the cleft from the lip to the nostril.
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The cleft lip is then drawn together and stitched to create a normal "cupid's bow" shape to the upper lip.
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The scar left after surgery will gradually fade with time.




2 comments:

  1. Wow, you did an awesome job describing and including diagraming everything - I wish I'd have had that to read prior to my little one's palate surgery 4 months ago! :) That being said, I know that I was really worried about recovery from palate surgery, remembering what lip surgery was like. However, we were happily surprised that after that first day things seemed almost back to normal once we got home on that second day. She bounced back so quickly we were amazed. Hope all goes well with little Paige on her surgery this month! We'll be thinking of you!

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  2. Thank you for all that info, wish that would have been available 47 years ago when my son was born just with the lip.
    At this very moment my beautiful 23 year old grandaughter is recovering from the 5th attempt to repair her palate in Brisbane. Hope all goes well.

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