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Auckland Regional Plastic Reconstructive and Hand Surgery

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Cleft Lip & Palate

In Auckland, children with cleft lip/palate are cared for by the Plastic Surgery Department at Middlemore Hospital. This regional service cares for children from Mercer to Northland. We see between 35-40 new born babies every year. We also accept referrals for older cleft children and children with speech problems related to palatal dysfunction. 

This information has been developed by the Cleft Lip and Palate Team, Plastic Surgery Department based at Middlemore Hospital.


What is a cleft?
A cleft lip is a separation in the upper lip. It involves the muscles and tissue of the lip and can affect the shape of the nose and the alveolus (gum line). A cleft lip can be unilateral (one side) or bilateral (both sides) and can be complete (involving the nostril) or incomplete (up to but not involving the nostril).

A cleft of the palate is an opening in the roof of the mouth. The roof of the mouth is made up of the hard palate (the bony part at the front) and the soft palate (soft tissue part) and either or both portions can be affected.

A child can be born with a cleft lip, a cleft palate or both.

Clefts occur in approximately 1 in 700 live births, so it is a relatively common birth defect.

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When does a cleft occur?
The lip and palate are formed early in embryological development. During pregnancy, development of the lip and alveolus (gum) occurs at approximately 6-8 weeks of gestation. A cleft lip can occur at this time.

The development of the palate occurs during weeks 8 -12 and a cleft palate can occur during this period.

Because the lip and palate develop at different times, it is possible for a child to be born with only a cleft lip, only a cleft palate, or with both a cleft of the lip and the palate. The type of cleft and severity can vary. 

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Why does a cleft occur?
There is a lot of research occurring around the world but no one knows for certain what causes clefts. It is not due to what you did or didn’t do during pregnancy. It is not your fault.

It is believed that environmental and genetic conditions or a combination of both may contribute to the cleft condition. In some families there is a history of clefting and this can increase the chance of a cleft occurring.

Clefts can occur with a combination of other problems. A cleft may be part of a syndrome. If you have concerns it is important to speak to your midwife and be referred to a paediatrician or the ‘Foetal Medicine’ team at Auckland Hospital and to the cleft service at Middlemore to get all the correct relevant information. 

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Why is the palate important?
A palate separates the nasal cavity from the mouth. It prevents food and fluids from entering the nose when we eat and drink. It is very important in the formation of sounds for speech and it stops air escaping out of the nose when we speak. The muscles of the palate also aid in opening the Eustachian tube (the duct that connects the back of the throat with the middle ear).
So even though a cleft of the palate may be difficult to see, it does need to be repaired.

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Our Team
At Middlemore, we believe the multidisciplinary approach is necessary for the treatment of cleft lip and palate. This means that several specialties will be involved in the care of the cleft child from birth to adulthood.

At a cleft clinic there may be the following specialists.

Plastic Surgeon: for consultation and management of the cleft condition.

Speech / Language Therapist:  for advice on feeding methods and regular assessment/review of speech and language development.

Orthodontist:  specialises in the correction of teeth positioning and occlusion (bite) and dental care.

Ear, Nose and Throat Surgeon:  will monitor ear health and function, will also assist with the diagnosis and treatment of related airway and hearing issues.

Cleft Service Coordinator:  who coordinates the Cleft Service and will be the contact person should you have any queries.

At cleft clinic you may also meet with the:

Photographer:  will take photographs pre and post surgery for our records.

Registrars and students:  as Middlemore is a teaching hospital there may be times when other training doctors are present in clinic. This is an opportunity for them to learn about cleft lip and palate. 

For more information, view the Cleft Team Member Profiles

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Antenatal diagnosis
With the high quality technology available and careful scanning it is possible to detect cleft lips at the 18-20 week anatomy scan. Occasionally a cleft is not picked up on the scan because they have not been able to see the baby’s face. Cleft palate without cleft lip is difficult to detect antenatally.

An antenatal diagnosis from ultrasound of a cleft condition can be upsetting and stressful. The news that your baby has something wrong, that it is not perfect, is a shock. You will be trying to come to terms with the news and cope with all the information that health professionals are giving you.

If you are reading this, you are looking in the right place. It is important to read up on information that is relevant to your baby and the centre that will be looking after your baby. It is important to speak to your lead maternity carer or the health professional looking after you. Have them arrange a referral to the Cleft Service at the Plastic Surgery Department, so you can talk to the specialists, who care for children with a cleft condition and can provide the correct information, support, advice and reassurance.

With all that is going on, you also have to tell family and friends. This can be a very difficult thing to discuss but it is important to remember that your baby will grow up to be a beautiful child who happens to have a cleft and that it can be fixed. He or she is a baby first – the cleft is secondary. Once people are told and understand the condition they will love your baby unconditionally, just like you will.

The Cleft Support Group can help with support and advice and we recommend that you contact them. The group is made up of families who have been there before. Meeting other parents of children with clefts can help put things into perspective and can be helpful for coping with the early days and the times ahead. 

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When your baby is born
When your baby is born a referral is sent to the Cleft Service so the coordinator can visit you as soon as possible. The coordinator’s role is to provide information, support and to coordinate the ongoing care of your baby. The coordinator is your contact person within the team.

If your child has a cleft that involves the lip, gum and hard palate they will require an early appointment with the orthodontist for pre-surgery orthodontic care such as a plate and taping.

The speech language therapist will also visit you in hospital and you will be visited at home regularly by a speech language therapist from the community who will assist with feeding, speech and language development and will monitor your baby’s progress.

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Cleft clinic appointments
Your first appointment with the cleft team will be within 6 weeks of birth. This is an opportunity to meet the surgeon and other members of the multidisciplinary team who will be assessing and providing a coordinated plan of care for your child. There will be some paperwork to fill out, so your baby is on the surgeon’s wait list for surgery. We will also arrange for photos to be taken to record all stages of your baby’s care.

This is an opportunity to ask questions so remember to write them down in your Blue Book. You are welcome to bring a support person or relative with you.

Your surgeon will be able to discuss the surgical technique to be used to repair your child’s cleft as there are several different methods available.

The next appointment will be after surgery and then every 1-2 years, depending on the needs of each child. See plan of care.

Once your child reaches 9 years of age they may need to attend dental appointments to prepare for orthodontic treatment. At this time, to save having to attend different clinics, we may suspend your cleft lip and palate team appointment until all dental treatment is complete. A cleft team appointment can be made after orthodontics, if your child has any concerns or requires further plastic surgery.

It is important to continue attending cleft clinic appointments. These appointments are an opportunity for your child to be reviewed by a team of specialists specifically caring for the cleft condition and any ongoing issues your child may have. If you change address please ring the hospital or cleft coordinator so we may update our records. 

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Aim of cleft treatment
As well as being fundamental to ‘normal’ facial appearance, the structures involved in cleft lip and/or palate repair are vitally important to the development of normal speech, feeding and dentition.

A cleft lip and/or palate has tremendous aesthetic and functional implications for the patients in their social interactions therefore the multidisciplinary team need to take into account, not only the anatomical impairment of the cleft, but the potential impact of the cleft on the patient's ability to communicate effectively, and their facial appearance.

The overall aims in treating cleft lip and palate are: 

1.  To give the best possible appearance of the lip, nose and face
2.  To repair the palate to enable production of normal speech and no difficulty eating/drinking.
3.  The correct alignment of the teeth and the jaws.
4.  To ensure adequate hearing. 

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Surgery
We realise that coming into hospital can be a stressful time and a major upheaval to family routines, so you will be notified of the date and time to come to hospital a week or two before the surgery date. Sometimes there are changes to the theatre schedule and you may be asked to come in at short notice. Sometimes surgeries can be cancelled for reasons such as hospital occupancy pressures, baby’s health or staffing shortages, but there is a window of opportunity for surgery and we strive to rebook cleft surgery as soon as possible. A short delay will not affect the long term outcome for your child (see When a Child is Admitted to Hospital for Cleft Lip and/or Palate Surgery).

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Cleft lip surgery (see Care of the Cleft Lip Child)
The aim of cleft lip surgery is to achieve the most normal appearance possible.
There will always be a scar but over time the appearance of the scar will greatly improve. 

Surgery for cleft lip will be approximately 3-5 months of age. The timing of this procedure may vary due to the health of the baby or the success of the taping and orthodontic plate.
If the shape of the nose is affected by the cleft, the nose is usually operated on at the time of the lip repair, resulting in significant improvement. However, further nasal surgery may be required – sometimes during the primary years but often after facial growth is completed in adolescence.

If the alveolus (gum line) is affected, this will be repaired at the time of lip surgery. This will only be a soft tissue repair and the bony aspect will be repaired at about 9 years of age. See alveolar bone graft

Most babies with an isolated cleft lip will be able to breastfeed before and after surgery or return to the previously used method of feeding. If you have concerns you can contact your speech language therapist or call the cleft coordinator.

After surgery, the scar will look red and there may be some bruising. This will settle down over time. To help reduce scarring, the surgeon repairs the top layer of tissue with sterile surgical glue so there are no sutures to be removed.

Arm splints are required to be worn for 3 weeks post surgery to prevent your child from bumping their lip with toys etc.

You can expect to stay in hospital for 1-2 days after surgery. 

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Cleft palate surgery
The aim of cleft palate surgery is to achieve normal speech. The surgeon’s aim is to reconstruct the muscles and tissue of the palate that are present but have attached in the wrong position. These muscles need to meet in the centre of the mouth to form a sling of muscle that allows the palate to move to the back wall of the throat during speech.

Surgery to repair a cleft palate will be at approximately 9 – 12 months of age. You can expect to stay in hospital for 2-4 days after cleft palate surgery.

Most babies with a cleft of the palate will have specialised cleft feeding equipment supplied to them by their speech language therapist. After surgery, most babies will be able to resume feeding with a Pigeon teat (soft side up) or sipper cup.  It is important that babies do not have any harder teats in their mouths at this time so dummies and normal teats should not be used.

A soft sloppy diet is recommended for 3 weeks after surgery and arm splints should be worn during this time so fingers and other objects are prevented from being placed in the mouth, which could damage the delicate stitches of the repair.  See Care of the Cleft Palate Child

For more information about Kidz First Children’s Hospital and what to bring in to hospital see the A-Z guide for Kidz First Children's Hospital Information Booklet and Patient Information for Admission into Hospital for Cleft Care.

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Support Group
Cleft Lip & Palate Support Group
Website: www.cleft.org.nz
Email:

This page was last updated at 12:46PM on June 6, 2019.