Lip adhesion is the first closure of the lip
In the complete bilateral cleft lip and palate, the first operation takes place when the infant is 6 to 8 weeks old. At the time the lip adhesion is performed, the patients must weigh over 4 kilogrammes. The aim of this procedure is to convert a complete cleft lip to an incomplete one and reduce the lip nose deformity by moulding the maxillary segments that facilitate the definitive lip repair. Correction of the nose will also be an outcome of this surgery to some degree. In severe bilateral clefts, the lip adhesion has to be performed in two stages; first on one side then the other. The second stage will be done together with the soft palate closure.
Soft palate closure
The next operation is the soft palate closure and it is performed at six months of age. In this procedure, only the posterior part of the palate is closed. Thus, after surgery, residual clefts will remain in the hard palate.
Final lip nose repair
In patients with a bilateral cleft lip and palate, corrections of the lip and nose are performed at 10 to 12 months of age to create symmetrical balance. The nostrils are often allowed to be a little wider than normal. If the nostrils are made too small, it is difficult to perform a secondary correction later.
To further support asymmetrical growth of the nose during a child’s postoperative healing, a nasal conformer is fixed for 8 to 12 weeks postoperatively. Immediately after the surgery, the lip scar is often red and swollen. There is often a contraction in the scar which pulls up the lip border. This is a result of scar tissue formation and will gradually improve and normalize. However, it may take one to two years before the scar is soft and one can see the final outcome.
Hard palate closure
When the patient is two to two-and-a-half years old, the residual clefts in the hard palate will have reduced in size and become adequate for surgical closure. Studies have shown that early closure of the cleft in the hard palate may restrict growth of the upper jaw. This can cause undesirable facial appearance and bad occlusion of the teeth. Therefore, closure of the clefts in the hard palate should not be performed until two to two-and-a-half years of age. By this age, the hard palate clefts are smaller due to growth of the palatal edges. This delay in surgery allows closure of the hard palate to be a less extensive surgical procedure.
Bone transplant to the alveolus
This procedure is the last planned surgery in patients with UCLP which is performed around 7 to 9 years. During this operation, bone is taken from the lower leg (Tibia) and transplanted to the cleft in the alveolar ridge. The lateral incisor or the canine is at that time, on its way to erupt into its position in the cleft area. If the bone is missing, the tooth cannot erupt properly in to the position in the alveolar ridge. After bone grafting, it is possible for the tooth to erupt through the grafted bone and can be brought into position by orthodontic means.
More corrections might be necessary in the late teens
After bone grafting, the planned surgical treatment is finished. However, patients will be followed regularly at 10, 13, 16, and 19 years of age. On these occasions, the results from earlier operations are discussed and the patient is informed about possible future secondary corrections.