Cleft Lips and Palates

The birth of a baby is a joyous occasion for parents.  Every parent imagines their newborn baby to be perfect with a life full of possibilities ahead of them.  Sometimes babies are born with health issues that need to be addressed.  One of the most mysterious conditions that children are born with is cleft lips and palates.  While not much is known about what causes cleft lips and palates to happen, doctors have made strides in developing solutions to effectively treat the condition.

CAUSES

At this time, nobody knows what causes cleft lips and palates. It’s been linked somewhat to prenatal care and some inheritance genetically, but not directly. It’s also been linked to vitamin deficiency and malnutrition.  People who are in a more indigent group tend to have a little higher incidence.  Drugs and excessive use of chemicals during pregnancy has also been linked to this condition but not directly so it doesn't happen every time.    

It varies in population, which also adds to the complexity. It can be passed on through a family.  For example, if two parents with no prior family history of any clefts have a cleft child, the chance of the next child from the same parents is only about 4%.  So 96 times out of 100, the next kid will be normal. On the other hand, if one parent has got a cleft and one child has got a cleft, the chances of the next one having cleft goes up to 25%.

There are some mechanical theories because the lip closes and diffuses from different parts of the developing cleft.  It comes together by the joining of three processes in the fetal phase and this occurs around the seventh week of intrauterine life. If a child has a cleft lip, it will show up on an ultrasound. It’s even more complicated if the palate closes as late as the 12^th week.

Finally, there is a syndrome called Pierre Robin Syndrome in which there's about a 90% association of cleft of the secondary palate, which is the posterior part of the palate. These are kids with very small jaws so their tongue relatively occupies more space.  The large tongue gets in the way of the palates from fusing vertically. Normally, there are two vertical shelves that swing from a vertical to a horizontal position, which allows the palate to fuse in the middle.  The theory is that if the tongue doesn't get out of the way in time for the two sides to fuse, it can cause cleft lip.

WHAT IS THE PALATES?

The palate is what a person touches when they reach up with the tip of their tongue. It's behind the upper teeth and between the arches of the upper teeth. It’s that tissue between the teeth-bearing parts of the upper jaw. It goes way back to this little thing that hangs down in the back called the uvula. When it’s a cleft, the palate goes all the way in the back so there's a split. It could split the whole way or part of the way. It could split one side or it could split both sides.

SEVERITY LEVELS

The cleft lip could be incomplete where there's only a slight groove. As an example, look at the actor Russell Crowe. He has a cleft lip that’s never been repaired. He has a slight separation of the muscle underneath his skin and it's a very minor cleft. A cleft can go anywhere between the edge of the red part of the lip all the way through the base of the nostrils. If it does not go right through the nostrils, and the nostril hole is still intact, that is called incomplete. When it goes through so a person can see through the whole thing, it's called complete. 

The cleft palate is the same way. The cleft always occurs in the four front teeth called incisors. The ones in the middle are medial and the ones on the sides are lateral for a total of four teeth. The tooth next to that is called a canine. The cleft always occurs between the lateral incisor and the canine.  The reason for this is because the middle teeth come down and the two side teeth come together and they fuse. When they don't fuse is when the cleft occurs. The severity comes from just how much it separated or how much it didn't fuse. There could be a low cleft, just like a lip, or it could go all the way back into the uvula.

It can also come from the other way, where it can start from the uvula and partly split so instead of one hanging down the back there will be two little bumps. It could be all the way up to the front making the uvula look like it's two instead of a single one. A lot of times that is a sign that the muscle in the palate, the soft palate, has the muscle in it. The lip and the palate are not always together so there could be a lip cleft without the palate or it can be together. A person can get almost any combination.  It can just be on either the left or right side or it can happen on both sides.

TREATMENT

To treat cleft lip and palates, a parent should wait until the infant is big enough so that anesthesia is okay to give because it's risky to put a newborn to sleep. The general rule is “a rule of 10” which says 10 weeks, 10 pounds or 10 grams of hemoglobin. The reason for 10 grams of hemoglobin is the baby's fetal hemoglobin will change into the normal hemoglobin. It's a drop in the hemoglobin level immediately after the birth. So doctors wait until the point when the hemoglobin comes up and reaches about 10 grams.  All three “10s” usually come together about the same time and that's when it is normally done.

When a child is at the age to start saying words, a palate that is not repaired will cause problems.  The longer a parent waits, the more the child will have speech problems. It's important to make sure the palate is repaired by 18 months of age.

PARENTAL GUILT

Most parents think a cleft lip or palate is their fault. It takes some psychological settling of their minds and some genetic counseling to put them at ease. It's about the genes and what you inherit and don't inherit. They have to be prepared ahead of time that this is going to be a long-term treatment.

COST

A cleft lip procedure is around $1,600-$15,000. Since the palate is fixed in multiple stages, it can be three, four or five different operations. This does not include orthodontics because a visit to the dentist might be necessary to take out some teeth due to crowding.

LIMITATIONS

One palate procedure limitation happens if it's so wide that the sides are less than the gap. If the two pieces of mucosa added together are less than the gap then it involves some creative maneuvering. Other tissues are brought in from adjacent areas to add into the mouth. If extra tissue is needed in the back, some tissues from the back of the throat are brought up to attach to the soft palate. If it is just behind the teeth, some tissue from inside the upper lip and the adjacent cheek can be placed and sutured over the holes. There is a chance that it can be split again. For various reasons along the suture lines, little areas may not heal well and end up creating fistula.  Fistula means a hole between two spaces. In this case, it's the space between the nose cavities. The space doesn't have to be very big before liquid starts to go from the mouth into the nose and out through the nostril.  This usually happens because of too much tension on the sutures trying to pull the two sides together. The suture has to be tied under some tension.  In this case, the part of the tissue that's inside that suture loop doesn't heal and ends up with a hole.

RECOVERY

The recovery for cleft lip and palate surgery offers a fast time frame. Kids can bounce back within a week to ten days.

FINAL THOUGHTS

To successfully treat a cleft lip or palate, it’s important to have the surgical procedure performed within the first 18 months of life.  There are multiple cleft lip and palate treatment options and an experienced doctor can give parents a complete rundown of their choices.  While the reason some babies are born with a cleft lip or palate is still unknown, a skilled doctor can correct the condition and help the young patient lead a normal life free of speech issues as well as any visible signs of surgery. 

Written by Cosmetic Town Editorial Team - MA

Based on an exclusive interview by Dr. Wallace Chang in Renton, WA