Cleft Lip and Cleft Palate: An Overview of Cause and Surgical Treatment
Guest: Dr. Krishna Patel – Facial Plastic Surgeon, MUSC
Host: Dr. Linda Austin – Psychiatrist, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Krishna Patel who is a surgeon specializing in facial plastic and reconstructive surgery. In a previous podcast, we talked about procedures like rhinoplasty, or nose jobs, but in this podcast, Dr. Patel, let’s talk about surgery for kids who have cleft lip and cleft palate. How common is that problem?
Dr. Krishna Patel: It is relatively uncommon. For children who are born with just a cleft palate, not involving the lip, that tends to be as common as 1 in 2000 children born. For children who are born with a cleft lip and cleft palate, that tends to be 1 in 1000 births.
Dr. Linda Austin: Can you explain, it’s hard to do, I’m sure, with words, and without a chalkboard handy, what that abnormality consists of? What has not happened properly in the development of these kids?
Dr. Krishna Patel: With cleft lip, during development, and it’s usually a very early process in pregnancy when this occurs, the right and left side of the lip start to fuse in the midline; during the developmental period, they did not fuse, so they end up with a crease, or a cleft, that’s essentially open between the right and left side of their lips. Some children have it just on the left, and some have it just on the right side. And then some children have it on both left and right, and we call that a bilateral cleft lip.
Cleft palate is the same idea. When babies develop, the palate, which is the roof of the mouth, starts to fuse in the middle, or midline. With a cleft palate, that doesn’t happen. If you look in the mouth of someone who has a cleft palate, and look at the roof of their mouth, they have an opening, like a big V, and you can actually see straight into their nose. And not having a roof of mouth the mouth plays a huge role in people’s ability to speak and swallow.
Dr. Linda Austin: Now, I understand that there are many different approaches to doing the surgery, and I’m sure that the way you approach this must depend on the severity, and whether it’s just cleft lip, just cleft palate, or both, is that right?
Dr. Krishna Patel: That’s definitely right. Also, the timing of when you do those repairs is important. For children who have just a cleft lip, we tend to close the lip at three months of age. And they usually have to be a certain body weight, because many children who are premature, three months isn’t quite enough time; they’re still too small. So, usually, when they weigh about 10 pounds, and they’re about three months, we close the lip. For the cleft palate, we wait until they’re older, usually around a year, or 9 to 18 months, to close the palate. And, again, the reason is that you have to let the child grow enough to be able to tolerate the surgery.
Dr. Linda Austin: So then, if the child has both, would there be multiple operations?
Dr. Krishna Patel: Two surgeries, yes.
Dr. Linda Austin: In infancy? Is that right?
Dr. Krishna Patel: Yes. At three month’s, they would have their lip closed, and then at 9 to 12 months have their palate closed.
Dr. Linda Austin: And, how successful are those procedures, generally?
Dr. Krishna Patel: Very successful. With respect to the lip, cleft lip surgeries have really transformed over the years. It used to be that, literally, people would just sew the two sides of the lip together, and it left a very unsightly scar, and it didn’t function correctly. Now, people have really studied it, and we understand that you have to get the muscle together in just the right way. You also try to design the incision so that they fall in a place on the lip that’s more natural looking. Sometimes with cleft lips, at a later stage; when the child is a teenager, you can do some small revisions if there’s some slight asymmetry to the lip.
For the palate, this is also very successful, although the wider the cleft, the higher the risk that you might end up with something called a fistula; a small area that didn’t get closed completely. But even with wide palates, it tends to be a very low risk. An important part of that is we’re very careful after the surgery to do all the right things to prevent that, such as not letting the child suck his/her thumb, or put any kind of pressure on the repair.
Dr. Linda Austin: So, in other words, for most kids, is it just the surgeries in infancy, or are there additional surgeries after that?
Dr. Krishna Patel: Usually there are more surgeries. Children who have cleft palates, especially, they usually have to undergo further surgeries later on in their life. The reason is that the palate plays a very important role in both speech development and swallowing. What we’ve found is that even though we’ve closed the palate, it still doesn’t always function like a normal palate, because there’s a lot of scar tissue involved.
It’s very important that these children are followed, usually, in a craniofacial center, where speech therapists can be involved, and they can be very carefully watched to make sure they develop their speech well. Sometimes these kids, if they do not, require another surgery that will actually help with their speech. A lot of children with cleft palates can have very nasal speech; like they have air escaping through their nose, and will require another surgery to help prevent this.
Another thing: oftentimes what we don’t think about is that children who have cleft lips, it’s not just the lip that’s affected. Their nose is also affected. So, even if you close the lip, oftentimes there’s asymmetry; their nose is not quite in the middle. We almost always, for children with cleft lip, need to do some type of nose surgery. Now, the timing for that is very different. If you operate too early on the nose, you can stunt its growth. So oftentimes we’ll do what is called a cleft rhinoplasty on children when they’re teenagers.
Dr. Linda Austin: I would imagine that it must be incredibly rewarding to help these children and see, what I gather, are very beautiful results, with time.
Dr. Krishna Patel: Absolutely. It is probably one of my favorite things that I do in my job. These children are wonderful and very complex. They have to endure many surgeries, and they’re extremely strong children for that. It is extremely rewarding. Another thing: because this is actually a malformation that’s fairly common worldwide, and there aren’t a lot of people around the world that have the ability to provide such complex care, oftentimes we take trips to other countries where we offer to do cleft lip and cleft palate repairs on underprivileged children.
Dr. Linda Austin: Have you been able to do that?
Dr. Krishna Patel: I have. Last year I went to Ecuador. It’s very intense. You’re essentially operating all day for about two weeks. But the people are just incredible. They essentially come from many miles away with whatever resources they have to take advantage of this opportunity.
Dr. Linda Austin: And I would imagine the experience for you is invaluable too, to do the same procedure, or variations of it, day after day. It must really hone your skills as a surgeon.
Dr. Krishna Patel: Absolutely.
Dr. Linda Austin: Tell me about your training. I know that you’re highly trained in several different areas. How does that come into play in your surgical approach to this problem?
Dr. Krishna Austin: I think my training has really helped to provide the patient with an excellent cosmetic outcome, as well as functional. I did my residency in Ear, Nose, Throat and Head and Neck surgery, also called Otolaryngology. There, I spent five years, essentially, operating on the face, and understanding the function and importance of preserving the function of the lips, nose, and ears. In addition to that, I completed a fellowship in facial plastics and reconstructive surgery. There, I reinforced that and, in addition, have placed a lot of emphasis on cosmetics. So, for me, this has really enabled me to provide excellent outcomes, functionally and cosmetically.
Dr. Linda Austin: Dr. Patel, thanks so much for talking with us.
Dr. Krishna Patel: Thank you.
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