Cleft lip and cleft palate are congenital deformities that occur when the tissues of the upper lip or roof of the mouth do not fuse properly during early fetal development. These conditions can lead to significant challenges with feeding, speaking, hearing, and social development if left untreated. Thankfully, advancements in surgical care have made it possible to correct these issues effectively.
Cleft lip and palate surgeries are tailored based on the severity of the cleft, the patient’s age, and associated anatomical considerations. The approach may involve one or multiple staged surgeries over the course of a child’s development. The various types of cleft lip and palate repair surgery, detailing when they are performed, how they are done, and their roles in long-term functional and cosmetic outcomes.
Understanding Cleft Lip and Palate
Before we dive into surgical types, it’s important to understand the two conditions:
- A cleft lip is a physical split or gap in the upper lip, which can range from a small notch to a complete separation extending into the nose.
- A cleft palate involves an opening in the roof of the mouth (palate) that may affect the hard palate, soft palate, or both.
Some children are born with only a cleft lip, some with only a cleft palate, and others with both. The types of repair surgery vary depending on which structures are involved and how extensive the cleft is.
Types of Cleft Lip and Palate Repair Surgery
Primary Cleft Lip Repair (Cheiloplasty)
This is the initial surgery done to repair a cleft lip. It is typically performed when the baby is between 3 to 6 months of age, once they are healthy enough for anesthesia and the tissues are large enough for reconstruction.
Surgical Objectives:
- Close the cleft in the lip
- Restore normal shape and function
- Create a more symmetrical appearance
- Reconstruct the muscles of the lip for natural movement
Types of Techniques:
- Millard Rotation-Advancement Technique :- This is the most widely used method. It rotates tissue from the cleft side and advances the non-cleft side to reconstruct the lip and philtrum.
- Tennison-Randall Technique :- This method involves creating Z-shaped incisions to lengthen and align the lip structures. It may be preferred in wide clefts.
The choice of technique depends on the surgeon’s training, cleft severity, and cosmetic goals. The repaired lip will continue to mature and improve as the child grows, though revisions may be needed later.
Primary Cleft Palate Repair (Palatoplasty)
Cleft palate repair is usually performed between 9 to 18 months of age. This surgery aims to close the cleft in the roof of the mouth and reconstruct the soft palate muscles to enable proper speech and swallowing.
Surgical Objectives:
- Separate the oral and nasal cavities
- Reconstruct muscles responsible for speech (levator veli palatini)
- Prevent nasal regurgitation during feeding
- Enable the development of normal speech
Types of Techniques:
- Von Langenbeck Technique :- Involves making incisions on both sides of the cleft and mobilizing the tissue flaps toward the midline to close the defect.
- Two-Flap Palatoplasty :- Similar to Von Langenbeck but with a more comprehensive muscle reconstruction.
- Furlow Double Opposing Z-Plasty :- This technique repositions and lengthens the palate using Z-shaped incisions. It provides excellent speech outcomes and muscle function.
- Veau- Wardill- Kilner Technique :- Used for wider clefts. It includes tissue flaps rotated from the back of the palate to achieve closure.
The choice of method depends on the cleft’s size, location, and tissue availability.
Secondary Speech Surgery
While primary palate repair usually allows for normal speech development, some children may have persistent speech issues, such as velopharyngeal insufficiency (VPI). This means the soft palate doesn’t close properly against the throat during speech, allowing air to escape through the nose.
Types of Secondary Speech Surgery:
- Pharyngeal Flap Surgery :- A flap of tissue is taken from the back of the throat and attached to the soft palate, creating a bridge that helps close the gap during speech.
- Sphincter Pharyngoplasty :- Muscle flaps are rearranged in the throat to form a circular sphincter behind the soft palate, helping with closure.
- Furlow Palatoplasty (as secondary procedure) :- A second Furlow repair may be used to lengthen or reinforce the soft palate.
Speech therapy usually accompanies these surgeries to optimize outcomes.
Alveolar Bone Grafting
The alveolar ridge is the bony part of the upper jaw that holds the teeth. In many cleft cases, this ridge is also affected. Alveolar bone grafting is typically done between 7 and 11 years of age, before the eruption of the permanent canine teeth.
Surgical Objectives:
- Fill the bone gap in the gum line
- Provide support for the teeth to erupt normally
- Stabilize the upper jaw
- Close any residual gaps between the mouth and nose
Procedure:
Bone is usually harvested from the child’s own hip bone (iliac crest) and transplanted into the cleft in the gum. This procedure improves dental function and prepares the child for orthodontic treatment.
Revision Lip or Nose Surgery (Lip/Nasal Revisions)
As children grow, subtle differences in lip shape or nasal symmetry may become more noticeable. Revision surgeries are often performed during late childhood or adolescence for cosmetic or functional enhancement.
Goals:
- Improve lip symmetry and contour
- Adjust nasal tip and nostril shape
- Address scarring or asymmetry from previous surgeries
These procedures are not always medically necessary but can greatly improve confidence and facial harmony.
Orthognathic Surgery (Jaw Surgery)
Children with cleft palate may develop midfacial hypoplasia, where the upper jaw doesn’t grow as much as the lower jaw, leading to an underbite. Orthognathic (jaw) surgery is performed after the child has finished growing—usually around 15 to 18 years of age.
Objectives:
- Realign the jaws for proper bite and function
- Improve facial appearance and symmetry
- Enhance speech and breathing in some cases
Orthognathic surgery is usually coordinated with orthodontic treatment before and after the procedure.
Ear Tube Placement (Tympanostomy)
While not a direct cleft repair, many children with cleft palate experience chronic ear infections due to poor eustachian tube function. Ear tube surgery is often done alongside palate repair to prevent fluid buildup and hearing loss.
Multidisciplinary Approach to Cleft Surgery
Cleft treatment is not limited to one operation. It often requires a staged, team-based approach that includes:
- Plastic and maxillofacial surgeons
- Pediatricians
- Speech-language pathologists
- Audiologists
- Orthodontists
- Psychologists and social workers
Together, they support the child through the physical, emotional, and social aspects of treatment.
Conclusion
Cleft lip and palate repair surgeries are among the most transformative procedures in pediatric surgery. They address essential functional needs—like eating, breathing, and speaking—while also improving appearance and self-esteem. From primary repairs in infancy to corrective jaw surgery in adolescence, each procedure plays a key role in a child’s development and long-term health.
Understanding the types of cleft repair surgeries helps parents make informed decisions and prepares them for the care journey ahead. With the right team and timely interventions, children born with clefts can enjoy healthy, confident, and fulfilling lives.
