STATE OF THE ART CLEFT LIP AND PALATE TECHNIQUES

Presurgical preparation with NAM (nasoalveolar molding) is often recommended to reduce tension on the repair.

Millard-type, cutting modified rotation advancement cleft lip repair is performed with special attention to correcting nasal deformity.

Techniques for cleft palate repair use the patient’s own tissue to close the cleft and give muscle function for palate movement.

WHAT SHOULD WE EXPECT DURING CLEFT LIP AND PALATE REPAIR?

Your child will look “normal” and have a more balanced and natural appearance after cleft lip repair. After palate closure, your child will be able to eat and talk without escape of fluid, food or air through the nose.

HOW MANY SURGERIES WILL MY CHILD NEED?

The number of surgeries depends in part by the type and severity of cleft lip and palate. Dr. Gargano attempts, with his techniques, to minimize the number of procedures while maximizing the outcome. He will discuss specifics during your consultation. The routine scheduled surgeries are:

1. Cleft Lip Repair at 3 months
2. Cleft Palate Repair at 10 months and placement of ear tubes
3. Secondary Cleft Rhinoplasty at 6 years
4. Alveolar Bone Graft at 8 years
5. Cleft Jaw Surgery at 16 years
6. Cleft Septorhinoplasty at age 17 as the final procedure
7. Some patients require “touch up” procedures to correct imperfections or complications that occur during the treatment.

ALVEOLAR BONE GRAFT (ABG)

ABG is performed at 8 years of age to correct a cleft in the alveolus or upper jaw and to allow the permanent teeth to erupt. Orthodontic preparation is required to expand the alveolus and is begun when the first molar teeth have erupted (around age 6).

ALVEOLAR BONE GRAFT OBJECTIVES

• Close the hole or fistula defect in the upper jaw so speech is improved.
• Provide solid bone for the teeth to erupt through or for the teeth to be repositioned orthodontically.
• Unify the upper jaw in a nice arch form that will match the lower jaw.

STATE OF THE ART TECHNIQUES

Dr. Gargano has pioneered techniques that reduce pain from the alveolar grafting techniques. At times, he used a GPP at initial cleft lip repair to reduce the need for an alveolar bone graft. If required, he prefers more minimally invasive techniques that minimize hospital stays and reduces lip pain.

WHEN IS AN ALVEOLAR BONE GRAFT PERFORMED?

After orthodontic alveolar widening, the bone graft is performed around age 6-8 years with the use of nearby flaps of mucosa (gums).

HOW LONG IS THE SURGERY AND RECOVERY?

The surgery is performed under general anesthesia, takes 2 hours, and requires a 23-hour hospital stay.

CLEFT RHINOPLASTY

Cleft rhinoplasty is used to correct nasal tip asymmetries and septal deviations. There are 3 ages when a cleft rhinoplasty may be performed: 1) During cleft lip repair-age 3 months; 2) At school age-age 5-8 years; 3) At skeletal maturity-age 15-18 years. The technique is different depending on each age.

CLEFT RHINOPLASTY OBJECTIVES

• To improve breathing with improvement of underlying sleep apnea.
• To improve nasal shape and give a more harmonious and natural look.

STATE OF THE ART TECHNIQUES

• Initial Cleft Nose Repair: Repositioning the ‘slumped’ cartilage with a closed technique at the time of lip repair.
• Secondary Cleft Rhinoplasty (at 5-8 years of age): Improvement in nose tip projection and nasal symmetry.
• Final Cleft Septorhinoplasty (at 15-18 years of age): Definitive correction of nose anomalies.

DO SECONDARY AND FINAL CLEFT RHINOPLASTIES HAVE TO BE PERFORMED?

No, because rhinoplasty performed at the time of cleft lip repair can be satisfactory.

WHY DOES THE SEPTAL SURGERY HAVE TO WAIT UNTIL TEENAGE YEARS?

The septum is a center for face growth and often septal deviation is not that apparent until teenage years.

Cleft Jaw Surgery 

Maxillary growth can be impaired in cleft patients and this can result in an ‘underbite’ or malocclusion that requires a surgical procedure called Le Fort I (upper jaw advancement). Orthodontic preparation of the teeth is often required to optimize the alignment.

Cleft Jaw Surgery Objectives

• To correct the malocclusion of the teeth and achieve improved facial appearance. 
• To improve breathing by creating space for the airway in the back of the throat.

State of the Art Techniques

Dr. Gargano uses 3D imaging and model surgery to prepare the patient for the procedure working with the cleft orthodontist.

IS THE LE FORT I SURGERY NECESSARY?

The maxillary advancement surgery will correct your malocclusion, relieve tension on your TMJ (joint), and give a better comesis to the face.

WHAT DOES THE SURGERY INVOLVE?

The procedure involves orthodontic preparation for 9 months; followed by the surgery; followed by final orthodontics which may take several months. If necessary, extraction of the third molar is performed.