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CLEFT LIP AND PALATE
It is a sad experience for any parent to find its
newborn child to have a birth defect of Cleft Lip and
Palate. It is not only the parents, but also close
relatives and friends, who get alarmed about the nature
and the cause of the defect and worry about future
development of the child. In general, birth defects could
either involve internal organs, the external parts
separately or both in varying combinations. Usually
defects involving internal organs of the body are
detected late in childhood either due to their effects on
the child's growth or due to incompatibility with life
and thus do not have an immediate significant
psychological stress. But birth defects like Cleft Lip
and Palate are obvious immediately after the birth and
these can cause more psychological problems to parents.
Fortunately, with the modern surgical techniques
available today, most of the deformities of Cleft Lip
& Palate could be reconstituted to a near normal
appearance and function.
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Cleft
Lip before repair
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Cleft
Lip after repair
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Which other types
of defects can be corrected with plastic surgery ?
The congenital defect coming under the scope of Plastic
and Reconstructive surgery range from deformities
of the External Ear, Facial Bones, Eyelids, Nose, Lips,
Palate, Trunk, Extremities and Genitalia.
Is it true that exposure
to a Solar Eclipse during pregnancy can cause congenital
deformities in the fetus?
It is a widely accepted and a popular
myth, that watching of a solar eclipse by an expectant
mother may lead to d evelopment of cleft lip in children,
but fortunately, it does not have any scientific
rationale. It is a fact, that parents often blame
themselves for development of such birth defects in their
children, which is totally wrong. In trying to find out
the causes for such a calamity, they start believing in a
number of unscientific theories like exposure to eclipse
or God's punishment etc. Often, under the belief that the
God for some misdeed has punished them, they do not
subject their children for surgical correction at proper
age. Scientifically, it is extremely difficult to
attribute any single factor responsible for any type of
birth defect. Familial tendencies (hereditary), severe
anemia during pregnancy, viral diseases like measles,
typhoid etc. during early weeks of pregnancy, can be
contributing factors. Drug addiction as well as excessive
smoking of pregnant women may influence the development
of the organs during the formative period i.e. 6 - 9
weeks of gestation. Also excessive use of antibiotics,
painkillers, Vitamin A or sedatives, do have an effect on
the fetus. However, it is difficult to pinpoint any
single factor in a given case but these factors alone or
in combination may lead to congenital defects.
What about the
hereditary factor you had mentioned earlier?
Hereditary does play a significant role
in development of certain congenital defects e.g. cleft
lip and palate. If either of the parents or both, have
this deformity, chances of their child developing a
similar deformity is definitely more than otherwise.
However, it is also not certain that a child will
definitely inherit all birth defects of either of his /
her parents.
Why is it that
often-congenital defects not only affect the physical,
but also the mental capacity of the child?
Congenital defects do have a great impact on a child's
physical, mental, psychological and personality
development. By and large, most of these defects barring
a few like hearing, vision or articulation of the speech,
do not affect normal mental development or intelligence
of the child. The feeling of not having something or
looking different from others may sometimes make these
children either more hostile or introverted in their
personal life.
What is the Image
building role of parents in such cases?
Parents should be well advised by their family doctor or
attending physician to understand the exact nature of the
birth defect and its implications, which would end up in
influencing the development of personality complexes. For
some times even after successful physical and functional
correction of the defects, it is difficult for a child to
revert back to normal behavior.
In order to avoid
prolonged mental agony, is it advocated to resort to an
Immediate Surgery for correction of this congenital
defect?
It is not necessary that all defects are corrected
immediately after birth, but a regular examination by the
specialist doctor and monitoring the growth of the child,
would be very helpful in over all rehabilitation of these
children. Proper medical guidance and reassurance that
the child would look as normal as otherwise and be able
to perform most of the physical necessities effectively
would defin itely restore the confidence of parents, thus
influencing the child's psychology in formative years of
his life.
Is it possible that all
these defects can be rectified with surgery?
Not all congenital defects need surgical procedures for
their reconstitution. Quite a few of these defects are
self-limiting and would cease to grow after a certain
age. You will be surprised to know that many children
with severe congenital deformities adapt to their
deformities so well by natural development, that any
surgical or external interference would hamper rather
than help functioning of these children.
At what age is it
advisable to undergo surgical correction?
Common and an ideal age for surgical correction of most
of these congenital defects is preschool age, so as when
the child leaves the protected atmosphere of his home and
has to mix with unfamiliar faces, he is apparently normal
both in appearance as well as in functioning. Some
defects can be corrected in one stage; however, others
may require a series of stages, depending upon the nature
of the defect.
Which congenital defects
in your opinion would require an early surgery?
Deformities like cleft lip, cleft palate, club foot,
extrophy of the urinary bladder, ano-rectal malformation,
arterio-venous malformations etc., which either influence
proper development of the child or hamper vital
functions, are subjected to an early surgical procedure.
On the other hand, defects like port wine stains,
cavernous Hemangioma, polydactily, facial asymmetry,
distal hypospadias etc. can be left untreated for years
or to be operated upon after complete body growth.
Which is the most common
congenital defect?
Cleft lip and palate is one of the commonest congenital
defects. On average about 1 in 800 normal childbirth, has
one of these deformities. It has been observed that cleft
of the palate is found more in females than in
males.
Is a cleft lip normally
accompanied by a cleft palate?
The structural identification and formation of lip,
palate and other organs begin sometimes between seven
to nine weeks of gestation. Lip and palate
develop independently embryologicaly, hence either of
these defects could occur separately or in varying
combinations. In case of cleft of lip, invariably upper
lip is involved and may range from a small notch at the
lower border to a complete cleft of the lip upto the base
of the nose, either on one side or both. This may also
extend up to teeth, jaw or even junction of eye and nose.
Similarly the defect in the palate may be a small
invisible hole in the mobile portion of the palate or
split uvula to complete cleft of both the mobile (soft)
and bony palate. This may also extend up to the jaws in
continuity with the cleft of the lip or may occur alone.
A mother would find it difficult to breast-feed her
newborn infant, who has a cleft lip and palate.
How does she go about
it?
Due to muscular deficiency associated with cleft lip and
palate, the child cannot develop sufficient intra-oral
pressure to suck the milk from the mother's br east. A
mother should understand this and either assist the child
by manual pressure on the breast or feed the child with a
spoon or even from a feeding bottle with a large nipple
hole. It must be further understood that children born
with a cleft lip and palate, have a tendency to swallow
excessive air along with milk and burping them often is
important.
At what age is it
important for cleft lip and palate to be surgically
operated?
The aim of surgery in these cases is to restore
anatomical continuity of the affect part before their
normal functioning utility. Surgical correction of the
cleft lip deformity is done between the age of 3
months to 6 months. At few centers of the world
including one in India, the cleft lip is corrected within
24 - 48 hours after the birth, so as to minimize the
psychological impact on the parents and to take advantage
of extra strong healing power at this age transferred to
the neonate from his / her mother. In case of cleft of
the palate, the ideal time for surgical correction is
between 12-18 months before the child
starts articulation of speech, as also the oral cavity
becomes large enough to allow the surgeon to work inside.
In some cases additional surgical correction may be
required to improve the speech at around the age of 4 - 5
years.
In this modern high
technology age, do all parents of children with such a
congenital deformity of cleft lip and / or palate want to
have this operation performed immediately?
You will be surprised to know that most of such children
do not get proper medical attention or advise for
surgical correction. Due to some unfounded myths, parents
do not come forward requesting an immediate surgery and
some do not bother at all. Recently, there was a case of Young
lady of 62 years, who had this operation
performed. Often unacceptable results are due to
operation performed by an incompetent or unqualified
surgeon and may require secondary corrections, when the
child has reached adolescence.
Is there anything wrong
in having this operation done at a later age?
When children with a cleft palate come for surgery at a
later age, they pose one more problem of faulty speech
and articulation habits. It would require postoperative
treatment of a speech therapist to retrain the child for
correct speech. If for some medical reasons, the child
cannot be subjected to an early surgery, then a
prosthetic obturator is recommended. For proper growth of
the jaw and dental arches in these patients, orthodontic
assistance is required and this treatment may continue
till the age of 15-16 years.
What are other common
congenital defects?
Deformities of extremities are one of the common
congenital deformities. Congenital defects in Upper limbs
vary from minor bending of fingers to a total absence of
the limb. Commonly seen problems include joining of two
or more fingers (Syndactily), presence of extra fingers
or digit (Polydactily) or short fingers (Bradydactily),
absence of thumb, index or more fingers etc. These may be
associated with deformities of muscles and / or bones.
Can you explain the
corrective surgery for such defects?
Supernumerary digit can be surgically removed. The joined
fingers are usually separated at the age of 4 - 5 years,
unless they hamper the normal growth of the adjoining
finger. The absence of thumb can also be corrected either
by transferring the great / second toe from the foot by
Microvascular surgery or by repositioning the index
finger in place of thumb. Most commonly seen congenital
deformities of the external genital organs are
hypospadias i.e. the urinary opening on the undersurface
of the penis, epispadias - urinary opening on the dorsal
surface of the penis or extrophy of the bladder. Genital
organs may be poorly developed or totally rudimentary.
Minor and rare deformities include torsion of penis,
anterior location of scrotum, bifid penis or absence of
vagina. Preschool age is usually best time to undertake
and complete most of the Reconstructive Surgical steps.
For extreme case e.g. Extrophy of the Urinary bladder,
which r equires a multi-stage correction, Reconstructive
surgery is started at the age of 1-1.1/2 years.
Dr.
Sanjeev Uppal
Plastic Surgeon
DMCH Ludhiana
133
D, Kichlu Nagar,
LUDHIANA
141001
suppal@satyam.net.in
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