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This one is about: Timing is Everything
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Timing is Everything
by Bruce M Aucher, MD
When an infant is born with a cleft deformity the family is faced with the prospect of numerous surgeries. All parents have questions about the timing of various cleft lip and palate operations. There are many reasons for selecting a particular age for doing each surgery. Many decisions are individualized for a particular child. However, an attempt will be made to give an overall discussion and mention some of the deciding factors which determine the timing of operations.
One should keep in mind, however, that there are many variations based on different practices and communities. It is important to remember that repairs of cleft lip and palate are not urgent procedures. It is wise to do these at the proper time as far as the child's growth and development is concerned. The child will need to have the palate repaired before developing speech, so there are some important developmental milestones to keep in mind.
Traditionally, the cleft lip is done when the child is 10 weeks old, weighs 10 pounds, and has a 10-gram hemoglobin. Like most cliches, this does not hold true for everyone. There are always exceptions. Waiting until each of these parameters is met assures that the infant's immune system and blood levels are strong enough to tolerate the surgery. Anemia is reason enough to not do this elective procedure. The lip repair is done when the child is in general good health. Three to six months of age is an excellent time to perform this surgery. Occasionally, in very wide clefts, the lip will be repaired in two stages. If the repair is done in two stages, the first is a temporary closure called an "adhesion".
The surgeon may want to do this procedure in the first ten days of life. The second stage would be done at 3 to 6 months of age and is the final repair. Typically these procedures have been done in he hospital with general anesthesia and have included an overnight stay at the hospital. Special feeding techniques are used afterward to protect the surgical area.
The major change that has come about in the past few years is that this procedure, in many cases, is done on an outpatient basis and the infant goes home the same day. Also, many surgeons are allowing the infant to use a nipple or breast feed immediately after surgery when appropriate, rather than requiring alternate feeding methods (ALWAYS follow the instructions of your own surgeon.)
The cleft palate procedure is more extensive than the lip repair. The major reason for doing the palate repair is for speech. It is important that the child will have the speech mechanism available as speech develops, even though a child may not begin speaking until age 2. The speech mechanism will begin developing long before this age. Traditionally, the palate has been repaired at 18 months of age. This has been and continues to decrease with 12 months being the average for many centers and some even doing the repair at 6 to 9 months of age.
The major concern about doing early repair is that it might result in greater interference of growth of the middle face. Other factors that must be considered when choosing the time to repair the palate would be the child's general health and development.
Many cleft patients also have a cleft in the gum line. If this is the case there is an actual defect in the bone. There are usually tooth buds on each side of this cleft. As the permanent teeth come in the orthodontist can move these teeth into the cleft space if it has been filled with bone graft. Permanent teeth begin appearing around age 8. Usually the bone grafting is done at this time, in cooperation with the orthodontist.
Extensive surgery on the nose, particularly involving the septum, is delayed until the child has achieved full growth, which would be age 16 for girls and 18 for boys. However, the deformity in the cartilage in the tip of the nose can be corrected at an earlier age. There is wide variation of timing of this procedure based upon surgeon preferences. Some doctors prefer to work on the nose at the time of the initial lip repair. Many prefer to wait until the child is of school age. If the deformity is mild, it might be advisable to wait until the entire nasal correction can be performed.
At times, cleft patients will have underdevelopment of the middle part of the face. Actually, a variety of irregularities are seen. These can be corrected by adjusting the teeth and facial bones with the use of surgical techniques. There has been a lot of discussion about timing of this type of surgery. It is helpful if one can wait until facial growth has been completed. However, depending upon the severity of the deformity, early surgery may be needed. These procedures are typically done in the later teenage years. They usually follow orthodontic correction and thorough
evaluation of facial growth with x-rays.
-----------------------------Bruce Achauer MD. is a plastic surgeon on the Cleft Palate/Craniofacial team at the Children's Hospital of Orange County in California and an Assistant Profession of Plastic Surgery at the University of California at Irvine.