Which of the following is the ideal time for the repair of cleft palate?
Ans. a. 9-12 months (Ref: Sabiston 19/e p1923-1924; Schwartz 9/e p1658-1663: Bailey 26/e 634-648, 25/e p657-668; Nelson 19/e p1252- 1253)Ideal time for the repair of cleft palate is 6-18 months of age. Best choice among the given options is 9-12 months.'Cleft lip repair is commonly performed between 3 and 6 months of age whereas cleft palate repair is frequently performed between 6 and 18 months. - Bailey 26/e 638Surgical closure of a cleft lip is usually performed by 3 months of age. when the infant has shown satisfactory weight gain and is free of any oral, respiratory: or systemic infection. Z-plasty is the most commonly used technique; a staggered suture line minimizes notching of the lip from retraction of scar tissue. The initial repair may be revised at 4 or 5 year of age. In an otherwise healthy child, closure of the palate is usually done before 1 year of age to enhance normal speech development.' - Nelson 19/e p1252-1253Cleft Lip and PalateClefts of the lip, alveolus and hard and soft palate are the MC congenital abnormalities of the orofacial structuresQ.Frequently occur as isolated deformities but can be associated with other medical conditions, particularly congenital heart diseaseQ.Incomplete clefts affect only a portion of the lip and contain a bridge of tissue connecting the central and lateral lip elements, referred to as Simonart's bandQ.Cleft lip is due to non-fusion of maxillary process with medial nasal processQ.Unilateral cleft lip is associated with posterior displacement of alar cartilageQIncidence:Highest incidence reported for cleft lip and palate occurs in the Indian tribes of Montana, USA (1:276).Cleft lip/palate predominates in malesQCleft palate alone appears to be more common in femalesQ.Incidence of cleft lip and palate is 1:600 live birthsQIncidence of isolated cleft palate is 1:1000 live birthsQDistribution:In unilateral cleft lip the deformity affects the left sideQ in 60% of cases.Typical distribution of cleft typesCleft lip alone: 15%Cleft lip and palate: 45% (MC)QIsolated cleft palate: 40%Etiology of cleft lip and palateEtiology of cleft lip and palate: Genetic predisposition and a contributory environmental componentQ. Environmental factors: Maternal epilepsyQ and drugs (steroids, diazepam and phenytoinQ).Associated syndromes:Although most clefts of the lip and palate occur as an isolated deformity, Pierre Robin sequence remains the most common syndromeQ.Other associated syndromes: Stickler's (ophthalmic and musculoskeletal abnormalities), Shprintzen's (cardiac anomalies), Down's, Apert's and Treacher-Collins'syndromes.Types of Cleft lipTypes of Cleft palate* Unilateral deft lip* Bilateral deft lip* Incomplete: Cleft of the hard palate remains attached to the nasal septum and vomerQ* Complete: Nasal septum and vomer are completely separated from the palatine processesQAntenatal diagnosis:All but isolated cleft palate can be diagnosed by ultrasound after 18 weeksQ gestationProblems immediately after birth:Some babies are able to feed normally but some will need assistanceBreathing problems in Pierre Robin sequence may be life threateningManagement:Surgical techniques are aimed at restoring normal anatomy.Cleft lip* Repaired between 3-6 months of ageQCleft palate* Repaired between 6-18 months of ageQPrinciples of surgery:Cleft lip surgery attaches and reconnects the muscles around the oral sphincterQCleft palate surgery aims to bring together mucosa and muscles with minimal scarringQTwo-stage procedures attempt to minimize dissectionQSecondary Management:Following primary surgery, regular review by a multidisciplinary team is essentialQ.Many aspects of cleft care require long-term review: Hearing, speech, dental development, facial growthQ.Timing of Primary Cleft Lip and Palate Procedures (after Delaire)Cleft lip aloneCleft palate aloneCleft lip and palate* Unilateral (one side): One operation at 5-6 months* Bilateral (both sides): One operation at 4-5 months* Soft palate only: One operation at 6 monthsQ* Soft and hard palate: Two operations- Soft palate at 6 monthsQ - Hard palate at 15-18 months* Unilateral: Two operations- Cleft lip and soft palate at 5-6 months- Hard palate and gum pad with or without lip revision at 15-18 months* Bilateral: Two operations- Cleft lip and soft palate at 4-5 months- Hard palate and gum pad with or without lip revision at 15-18 months
9-12 months
18-24 months
2-3 years
5-6 years
Cleft Lip & Palate