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 weeks 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 (the first months after birth) in babies born with this anomaly is that the development of these children is slow due to difficulty in feeding. and frequent upper and lower respiratory tract infections. This very common anomaly can be completely corrected with a good and organized multidisciplinary team approach, and children born with this anomaly live 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 a cleft lip and palate anomaly in the family, the risk of the baby also increases. If there is no such history in the family, the cleft may occur with mutant genes and chromosomal deletions or with an isolated genetic anomaly along with syndromal anomalies such as trisomy D and trisomy E. Environmental factors play a more active role in cleft formation, and most of the time a specific cause cannot be found. Experimentally, high doses of cortisone can cause cleft lip and palate in the offspring of pregnant animals. Again, a rubella infection experienced by the mother in the first 3 months of pregnancy causes cleft formation. It has been shown that smoking and some vitamin deficiencies also affect the formation of clefts. In addition, the risk of cleft lip and palate is higher in cases where the socioeconomic level is low.

The following point should be underlined carefully; In many cases, the parents, especially the mother, are not responsible for the formation of cleft lip and palate. After birth, parents often blame each other and themselves for giving birth to such a child, but such an approach is not correct and has no positive effect on the child's treatment.

Epidemiology

Cleft lip and palate roughly:

• Pure cleft lip: 25%
• Pure cleft palate: 25%
• Combined cleft lip and palate: 50%.

Cleft lip and palate occurs approximately 1/1000. While it is seen at birth, isolated cleft palate is seen at a rate of 1/2500, and while cleft lip and palate is 2 times more common in boys, isolated cleft palate is 2 times more common in girls. The reason for this is that the mesodermal protrusions in the mouth fuse 1 week later in the embryonic period in female babies, and if these mesodermal protrusions do not fuse, cleft palate occurs. Again, while cleft palate and lip are more common in Far Easterners and rarer in African Americans, there is no such distinction in isolated cleft palate.< br />
Anatomy of cleft lip and palate anomaly:

• Cleft lip anomaly is seen on the upper lip.
• One-sided incomplete lip cleft lip
• One-sided complete cleft lip
• Bilateral incomplete cleft lip
• One-sided complete and one-sided incomplete cleft lip
• Both bilateral complete cleft lip
• Midline cleft lip (rarely seen)

Cleft Palate:

• Cleft soft palate
• Cleft hard palate
• Submucous clefts
• Occurs as a bifid uvula. (separation of the uvula into two)
• These are the cleft lip and palate classifications that families should generally know, and Plastic Surgeons use a more anatomical classification.

Cleft Lip Treatment

Surgical repair of cleft lip aims to normalize the anatomy of the facial features. Since the lip is both a cosmetic and a functional organ, the result should be both cosmetic and functional. Since nasal deformity will always be seen in cleft lip cases, the aim is to create the lip mucosa and skin symmetrically with the working lip muscles, while creating the Cupid's bow in an aesthetic way with the phytrum columns and vermillion tubercle. The symmetry of the nostrils, a sufficient nasal lining and columella length, a symmetrical and sufficient nasal tip projection, and symmetrical nasal wings are the goals of nose treatment.

Operation Age

Op It would be more accurate to say the time to start treatment rather than the age of initiation. Treatment of babies with cleft lip and palate begins in the first 48 hours after birth. While some surgeons perform cleft lip surgery in the first week after birth, some surgeons perform this operation 2-6 weeks after birth, taking into account the development of the child. They do it for months. Some surgeons perform a temporary lip operation before the actual lip operation to prepare the baby's anatomical structures for the actual operation (lip adhesion). These methods generally do not differ greatly from each other. Plastic Surgeon prefers whatever teaching he received during his training. Families do not need to worry about this. On the other hand, regardless of the level of deformity, the baby should be evaluated by an orthodontist immediately after birth, and regular development of anatomical structures should be ensured with various intraoral or extraoral devices depending on the type of deformity. While preoperative orthodontic treatment is applied very well in the Far East, where this deformity is common, unfortunately, in our country, this is only available in certain centers. In addition, these babies should be examined by a pediatrician immediately after birth and it should be investigated whether there is an additional anomaly. Meanwhile, psychological support should be provided to parents (especially if cleft lip and palate was not diagnosed before birth). Since the sucking function is not sufficient in these babies, the mother is explained about the baby's feeding method (on her lap and with a spoon or a special bottle, and using an intraoral obturator in babies with cleft palate).

The surgery must be performed within the first week. It is a more difficult method. Because in this period, the baby is not yet stable and carries risks in terms of anesthesia. In addition, since the lip structures have not yet reached a sufficient size, it is very difficult to perform an operation on them. Babies with cleft lip are usually operated on in the 2-3 months after birth. It is important that the baby's weight increases and develops before the operation. It is best not to perform surgery on babies whose development is not good until the problem is resolved. Preoperative analysis of the baby must be done to show that blood values ​​such as hemoglobin, hematocrit, bleeding clotting time are at normal levels. this case Since surgeries are always operated under general anesthesia, it is essential that the baby be prepared very well before the surgery.

Cleft Lip Post-Operation Care

Patients are usually treated on the day of surgery. and are kept in the hospital overnight and sent home the next morning. Babies are fed with a spoon in a sitting position, starting from the day of surgery. Contamination of incision lines with nasal discharge and food should be prevented. For this purpose, the incision is dressed with antibiotic ointment every day. It is important to keep the wound lines dry. 5-7 days after surgery. All sutures are removed on the following days.

Cleft Palate Treatment

The anomaly present in cleft palate varies from complete clefts where the oral and nasal cavities open to each other, to clefts only in the dental arch and It varies from clefts only in the soft palate or uvula to clefts. Another condition of cleft palate is submucous clefts. These clefts can only be diagnosed by plastic surgeons and are clefts that form a mucosal curtain between the nasal and oral cavities. However, since the muscles are separate from each other under this mucosa, the baby will have rhinolalia aperta or cleft palate speech, which is called "hm hmm" speech, in which sounds come from the nose. Although there is no visible cleft in these babies, repair of the submucous cleft is necessary for the baby to have proper speech in the future.

Aims of cleft palate treatment:

• Creation of an air and watertight velopharyngeal valve
• Preservation of hearing
• Preservation of midface growth
• Creation of a functional and aesthetically adequate upper dental arch
• It is to ensure proper speech in the future.

Operation Age

Treatment is also possible only in babies with cleft palate, in the first period after birth. It starts with orthodontic treatments in 48 hours. Various intraoral appliances reduce the size of the cleft, making future surgery easier. As with lip surgery, the age of surgery for palate surgery varies according to different teachings. While one group considers 6 months as the appropriate treatment age, another group finds 12-18 months appropriate. As various studies have shown, these are just These are academic discussions and each group claims that their own surgery is better. If the operation is done well, it is not really a big deal. However, most plastic surgeons suggest that it is necessary to wait at least 9 months for surgery.

Cleft Palate Post-Operation Care

Surgery in babies with cleft palate Aftercare is more important and difficult than cleft lip. There may be bleeding in the form of leakage from the mouth starting from the early postoperative period and this bleeding should be closely monitored as it may cause asphyxia. Likewise, a swollen tongue may fall back and cause choking. In the early period and at least for the first 48-72 hours, the baby's food should not contain particles and he should receive clear food. Although care is difficult at first, the incisions inside the mouth heal quickly within 3-4 days.

Cleft lip and palate surgeries are operations performed by plastic surgeons. In cleft lip and palate surgeries, the family's expectations are to have a completely flawless and scar-free face, a normal nose, and speech as a child without cleft lip and palate can speak, but the results are often far from perfect. . It is inevitable that scars will remain in the cleft area, especially after lip surgeries.

Patients will definitely have nasal deformities, and after the development of these deformities is completed, they need aesthetic nose surgery (17-18 years of age). The closure of the palate may not be complete and patients may experience symptoms such as speech defects, swallowing food through the nose, and patients may have to use a palate prosthesis. Since many patients do not have the opportunity to receive orthodontic treatment immediately after birth, the likelihood of such complications increases. However, families should know that these children are completely normal (except for their deformities) and not abnormal children.

Alternative Treatment

There is no alternative to cleft lip and palate surgery. These surgeries provide functional and aesthetic improvement of the child. Surgeries should be performed at the ages recommended by your doctor. Various functions for delaying or early execution

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