Cleft lip and cleft palate
Cleft lip and palate occur in about 1 to 2 per 1000 births in the developed world. Cleft lip is about twice as common in males as females, while cleft palate without cleft lip is more common in females.A cleft lip contains an opening in the upper lip that may extend into the nose. The opening may be on one side, both sides, or in the middle.A cleft palate occurs when the roof of the mouth contains an opening into the nose.Cleft lip and palate are the result of tissues of the face not joining properly during development. As such, they are a type of birth defect. The cause is unknown in most cases These disorders can result in feeding problems, speech problems, hearing problems, and frequent ear infections. Less than half the time the condition is associated with other disorders.Risk factors include smoking during pregnancy, diabetes, obesity, an older mother, and certain medications (such as some used to treat seizures). Cleft lip and cleft palate can often be diagnosed during pregnancy with an ultrasound exam.A cleft lip or palate can be successfully treated with surgery. This is often done in the first few months of life for cleft lip and before 9 to 12 months for cleft palate.Speech therapy and dental care may also be needed.
With appropriate treatment, outcomes are good.
Treatment
Services and treatment for children with orofacial clefts can vary depending on the severity of the cleft; the child’s age and needs; and the presence of associated syndromes or other birth defects, or both.
Cleft lip and palate are very treatable; however, the kind of treatment depends on the type and severity of the cleft.
It is a multidisciplinary approach. Team consists of Plastic surgeons, orthodontists, speech and language therapists, restorative dentists, psychologists, ENT surgeons and audio-logical physicians.
Treatment of these cleft patients are staged involving multiple surgeries each at different age of development.
At Craftsman we individualize each person’s treatment schedule.
CLEFT LIP
Within the first 2–3 months after birth, surgery is performed to close the cleft lip. Preferred age is at approximately 10 weeks of age, following the “rule of 10s” (the child is at least 10 weeks of age; weighs at least 10 pounds, and has at least 10g hemoglobin).
Most common procedure to repair a cleft lip is the Millard procedure. Your baby will be given a general anesthetic (where they’re unconscious) and the cleft lip will be repaired and closed with stitches.
The operation usually takes 1 to 2 hours.
Most babies are in hospital for 1 to 2 days.
The stitches will be removed after a few days.
Your child will have a slight scar, but the surgeon will try to line up the scar with the natural lines of the lip, to make it less noticeable. It should fade and become less obvious over time.
CLEFT PALATE
Cleft palate can be corrected by surgery, usually performed between 9 – 12 months. Often a cleft palate is temporarily covered by a palatal obturator (a prosthetic device made to fit the roof of the mouth covering the gap). The obturator will improve feeding and breathing as the gap in the hard and soft palate is closed over so cannot affect it. However, combinations of surgical methods and repeated surgeries are often necessary as the child grows.
Your baby will be given a general anaesthetic (where they’re unconscious) The gap in the roof of the mouth is closed and the muscles and the lining of the palate are rearranged. The wound is closed with dissolvable stitches.
The operation usually takes about 2 hours and is done using a general anaesthetic. Most children are in hospital for 1 to 3 days, and again arrangements may be made for you to stay with them.
The scar from palate repair will be inside the mouth.
Your child’s care plan
Children with clefts will have a care plan tailored to meet their individual needs. A typical care plan timetable for cleft lip and palate is:
birth to 6 weeks – feeding assistance, support for parents, hearing tests and pediatric assessment
3 to 6 months – surgery to repair a cleft lip
6 to 12 months – surgery to repair a cleft palate
18 months – speech assessment
3 years – speech assessment
5 years – speech assessment
7 to 12 years – bone graft to repair a cleft in the gum area (Alveolar cleft)
For the children born with alveolar clefts, they may need to have a secondary alveolar bone graft. This is where autogenous cancellous bone from a donor site (often the pelvic bone) is transplanted into the alveolar cleft region. This transplant of bone will close the osseous cleft of the alveolus, close any oro-nasal fistulae and will become integrated with the maxillary bone. It provides bone for teeth to erupt into and to allow implants to be placed as a possible future treatment option. The procedure should be carried out before the upper canine has erupted. Ideally the root of the canine should be one to two thirds formed and that there is a space available to place the bone graft. Radio-graphs are taken to determine the quantity of missing bone in the cleft area.
12 to 15 years – orthodontic treatment and monitoring jaw growth
16 to 18 years – cleft rhinoplasty (nose reshaping)
Additional surgery
In some cases, additional surgery to improve the appearance and function of the lips and palate – this may be necessary if the original surgery did not heal well or there are ongoing speech problems, improve the shape of the nose (rhinoplasty) improve the appearance of the jaw – some children born with a cleft lip or palate may have a small or “set-back” lower jaw.
Children born with orofacial clefts might need other types of treatments and services, such as special dental or orthodontic care or speech therapy.
Your child will also need to attend regular outpatient appointments at our craftsman centre so their condition can be monitored closely and any problems can be dealt with. These will usually be recommended until they’re around 21 years of age, when they’re likely to have stopped growing.
With treatment, most children with orofacial clefts do well and lead a healthy life. Some children with orofacial clefts may have issues with self-esteem if they are concerned with visible differences between themselves and other children. At Craftsman, our Craftsmind Mental health care center (an Craftsman initiative) would take care of your child psychological issues and address them with compassion and care.
Congenital hand deformity
Congenital anomalies are deformities that are present at birth. Any type of deformity in a newborn can become a challenge for the child as he or she grows.
Hand deformities can be particularly disabling as the child learns to interact with the environment through the use of his or her hands. The degree of deformity varies from a minor deformity, such as unequal fingers, to joined fingers to severe deformity, such as total absence of a bone.
Congenital hand deformity can range from simple rudimentary accessory digits and (polydactyly) to finger fusion (syndactyly), shortening (brachydactyly) or duplications and a host of other complex developmental abnormities that affect both form and function. Early assessment and intervention is important if the optimal outcome is to be achieved
Early consultation is an important part of the treatment process for the child born with a hand deformity. Even if reconstructive surgery is not possible, there are many different types of prosthetic devices that can be used to increase function.
Treatment for congenital hand deformities
Specific treatment for congenital hand deformities will be determined by your child’s doctor based on:
Your child’s age, overall health, and medical history
Extent of the condition
Cause of the condition
Your child’s tolerance for specific medications, procedures, or therapies Expectations for the course of the condition
Your opinion or preference
Appropriate Timing of Surgical Intervention
Operations for congenital hand differences are rarely a medical emergency.
Important considerations regarding surgical timing include the following:
Anatomy of the Growing Hand
A defined period of rapid hand growth occurs from birth through the first few years of life. Therefore, delaying surgery, if possible, until the patient is 2 to 3 years old makes the procedure technically easier and yields a result that may be at decreased risk to deteriorate over time (i.e., at skeletal maturity).
Development of Functional Skills
The developmental stage of the child is also an important factor in achieving a good result after surgery. This is particularly true when a certain level of cognitive development is imperative to successful treatment of a condition.
A prime example of this “developmental requirement” is in patients with a hypoplastic thumb. Throughout the first 3 months of life, the thumb is primarily in a palmar position. At this stage, the thumb is merely an accessory appendage and functions more as a pacifier than anything else. However, by 9 months, as the child begins the exploration of the environment in earnest, the thumb gains its independence. Mobility from the palm begins commensurate with new functional demands. At 12 months, the thumb has become a critical portion of the hand and serves a multitude of functions.
Therefore, a clear assessment about strength and mobility cannot accurately be achieved before reaching this level of cognitive and motor development. This can be very important, because determination of prehensile grasp patterns is mandatory in determining proper surgical treatment for these patients.
Treatment may include:
Limb manipulation and stretching
Splinting of the affected limbs
Tendon transfers
External appliances (to help realign misshapen fingers or hands)
Physical therapy (to help increase the strength and function of the hand)
Correction of contractures
Skin grafts. These involve replacing or attaching skin to a part of the hand that is missing skin or has been removed during a procedure.
Prosthetics. These may be used when surgery is not an option, or in addition to surgical correction.
Simple accessory digits attached to the little finger by a rudimentary stalk are excised under local anesthetic in infants below the age of 3-4 months.
Syndactyly reconstruction, which is one of the most common congenital hand differences encountered. The success of any syndactyly reconstruction is largely dependent upon the design of the skin incision and flaps. In the majority of cases a dorsal flap is used to reconstruct the web space. There are many designs for the dorsal flap, but the primary objectives are for a tension-free closure and appropriately placed scars.
Hypospadias
Hypospadias (hi-poe-SPAY-dee-us) is a birth defect (congenital condition) in which the opening of the urethra is on the underside of the penis instead of at the tip. The urethra is the tube through which urine drains from your bladder and exits your body. Hypospadias is common and doesn’t cause difficulty in caring for your infant. Surgery usually restores the normal appearance of your child’s penis. With successful treatment of hypospadias, most males can have normal urination and reproduction.
Symptoms
In hypospadias, the opening of the urethra is located on the underside of the penis instead of at the tip. In most cases, the opening of the urethra is within the head of the penis. Less often, the opening is at the middle or the base of the penis. Rarely, the opening is in or beneath the scrotum.
Signs and symptoms of hypospadias may include:
Opening of the urethra at a location other than the tip of the penis
Downward curve of the penis (chordee)
Hooded appearance of the penis because only the top half of the penis is covered by foreskin
Abnormal spraying during urination
Complications
If hypospadias is not treated, it can result in:
Abnormal appearance of the penis
Problems learning to use a toilet
Abnormal curvature of the penis with erection
Problems with impaired ejaculation
Treatment
Some forms of hypospadias are very minor and do not require surgery. However, treatment usually involves surgery to reposition the urethral opening and, if necessary, straighten the shaft of the penis. Surgery is usually done between the ages of 6 and 12 months.
If the penis looks abnormal, circumcision should not be done. If hypospadias is found during circumcision, the procedure should be completed.
Surgery
Most forms of hypospadias can be corrected in a single surgery.
Some forms of hypospadias will require more than one surgery to correct the defect. When the urethral opening is near the base of the penis, tissue grafts from the foreskin or from the inside of the mouth to reconstruct the urinary channel in the proper position, correcting the hypospadias.
Results of surgery
In most cases, surgery is highly successful. Most of the time the penis looks normal after surgery, and boys have normal urination and reproduction.
Occasionally, a hole (fistula) develops along the underside of the penis where the new urinary channel was created and results in urine leakage. Rarely, there is a problem with wound healing or scarring. These complications may require an additional surgery for repair.
Follow-up care Your child will need a regular follow up at Craftsman center after surgery to check for healing and possible complications.
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