Cleft Lip and Cleft Palate and Associated Anomalies
Facial clefting is a congenital phenomenon whose explanations have remained elusive since its earliest documented descriptions. With advances in the fields of genetics and embryology, a multifactorial and case specific explanation for clefting has developed. The most important thing that Drs. Rousso, Bernstein and the entire cleft team at New York Eye and Ear Infirmary of Mount Sinai (NYEE) emphasize is that it is never a parent’s fault that their child was born with a cleft and that we are always here to help through the entire process.
Cleft Lip and Palate Diagnosis
Cleft lip and palate literally comes in many shapes and sizes. There are over 17,000 known genes that contribute to craniofacial development and over 300 known syndromes with associated clefting.
Different widths and lengths of the cleft lip exist. Some cleft lips consist of only a partial cleft that does not go all the way through to the nose while others are significantly bigger and include significant nasal deformity. The cleft team at NYEE tailors every surgical procedure to produce the most aesthetic results for each individual patient. Our center handles everything from the most basic deformities to the most complex reconstructions, and using the most cutting edge evidence based surgical techniques and technology we produce the highest-level cosmetic and functional results of both the lip and nose at the same time.
Below are a handful of images showing before and after repairs of just a few of the many cleft lip patients we have had the privilege of treating. Note that all before pictures are on the left of each image and after pictures on the right of each image. Some of the after images are immediately after the repair, to depict what to expect on the day of surgery and some are a year after the repair when full aesthetic healing has occurred.
Cleft palate can accompany the cleft lip or can form as an isolated event. The repair of the cleft palate at an appropriate age is important for the child to be able to develop understandable speech, and to prevent difficulty with eating and swallowing. The cleft team at NYEE is composed of a multidisciplinary group of specialists that includes speech & swallow therapists who specialize in the care of the cleft palate patient. Comprehensive and ongoing speech therapy is a part of our routine treatment plan with cleft palate patients. Below is an image depicting a before and after cleft palate. Our speech team monitors developmental progress with many cutting edge tools that determine the amount of air escaping through the nose and uses 3 dimensional video imaging to assess the motion of the palate both before and after repair.
Other procedures associated with cleft repair include speech surgery for velopharyngeal insufficiency, alveolar bone grafting and gingivoperiosteoplasty, cleft rhinoplasty, orthodontics, and complex dental care. Below are some images depicting before and immediately after cleft rhinoplasty: Notice that the nostril of the clefted side (patients left nostril in both images below)is collapsed and this is repaired immediately after surgery to give symmetry to both sides of the nose and open up the nasal airway for improved breathing.
Orofacial clefting can be divided into one of two categories:
- Cleft Lip +/- Palate: occurring at a frequency of about 2 cases per 1,000 births, occurs most typically in the setting of genetic association, although non-mendelian form of inheritance. This means that there seems to be genetic factors, as demonstrated by the higher prevalence in certain races like Asians, Native Americans, and Caucasians as compared to others like African Americans. However, the more stringent rules of genetic predictability do not apply to this malformation.These are 2 distinct entities with different patterns of development.
- Isolated Cleft Palate: occurring at a frequency of about 1 case per 1,000 births, does not seem to have a predilection for any race and is found with equivelant frequency in infants of all backgrounds. There is, however, a higher prevalence of this form in females than in males.
Cleft Lip and Palate Treatment
A high quality interdisciplinary approach is required for treatment of the child with cleft lip and palate. This means that a reputable center with a team of different specialists, each of whom can take care of specific needs, is the best option. A comprehensive diagnosis and treatment plan should begin early after birth and the child consistently followed thereafter.
NYEE’s team consists of a broad variety of specialists that treat everything from the surgical correction of the cleft to the therapy necessary for improved speech and feeding. The schematic below represents a basic timeline of the typical ages for treatment. NYEE offers a cleft deformity clinic and a team of professionals with a goal-oriented, patient specific agenda for every baby with a cleft deformity. Not every treatment plan will be identical, because every child gets the individual attention necessary for the highest standards of functional and aesthetic reconstruction. Each child receives an individualized functional and cosmetic assessment as they are evaluated. From a functional standpoint the following questions need to be answered to determine the appropriate courses of actions:
- Is this affecting the child's feeding and growth?
- Is this affecting the child's speech and intelligible language development?
- Is this affecting the child's hearing?
As far as aesthetic considerations in the child with the cleft lip, the following questions need to be answered to determine the appropriate courses of action:
- Is this a unilateral (one sided) or bilateral (two sided) cleft lip
- Is this a complete cleft of the entire lip going through the floor of the nose?
- Is this a partial cleft lip affecting only some parts of the visible lip
- Regardless of the size of the cleft how much of the nasal shape and form is affected, and from how far away is the external nasal asymmetry noticed?
Intervention: Diagnosing clefting and associated anomlies and creating tentative plan of care, including immediate feeding interventions. Identifing whether the child may be a candidate for Naso-Alveolar Molding device (NAM)
Intervention: Cleft lip repair and cleft nose repair. Insertion of ear tubes. This may be delayed to 4-5 months of age in certain situations including the use of NAM.
Intervention: Cleft palate repair
Intervention: Speech therapy and adjunctive surgical procedures
Intervention: Bone grafting for Alveolar clefting
Intervention: Cleft Rhinoplasty for definitive nasal repair when necessary
To find out more about cleft lip and palate treatment, please call (212) 979-4200.