Timing of Surgical Repair
The.timklg of the Surgical repair has been and remains one Of the most debated issues among surgeons, speech pathologists, audiologists, and orthodontists. It is tempting to correct all of the defcct-, as ~OOJ1 as the baby is able to withstand the surgical procedure. The parents of a child born with a facial cleft would certainlv desire this mode of treatment, eliminating all of the baby’s clefts as early in life as possible. Indeed the cleft lip is usually corrected as early as possible. xrost surgeons adhere to the proven “rule of 10” as determining when an otherwise healthy baby is fit for surgery (i.e., 10 weeks of age, 10 lb in body weight,’ and at least 10 g of hemoglobin per deciliter of blood). However, because surgical correctionof the cleft is an elective procedure, if any other medical condition jeopardizes the health of the baby, the cleft surgery s postponed until medical risks are minimal.
Unfortunately each possible advantage for closing a palatal cleft early in life has several possible disadvantages for the individual later in life. The six advantages for early closure of palatal defects are (1) better palatal and pharyn- . geal muscle development once repaired, (2) ease of feeding,
(3) bette r development of phonation skills, (4) betterauditory tube function, (5) better hygiene when the oral and nasal partition is competent, and (6) improved psychologic state for parents and baby. The disadvantages of closing palatal clefts early in life are also several: The twomost important are (1) surgical correction is more difficult in younger children with small structures, and (2) scar formation res ulting from the surgery causes maxillary growthrestriction. Althougp different cleft teams time the surgical repair differently, a widely accepted principle is compromise. The lip iscorrected as early as is medically possible. The
soft palatal cleft is closed between 8 and 18 months of age, depending upon a host of factors. Closure of the lip as early as possible is advantageous, because it performs a favorable “molding” action on the distorted alveolus. It also assists the -child in feeding and is of psychologic benefit.The palatal cleft is closed next, to produce a functional velopharyngeal mechanism when or before speech skills are developing. The hard palatal cleft is occasionally not repaired at the time of soft palate repair, especially
if the cleft is wide. In such cases, the hard palate cleft is left open as long as possible so that maxillary growth will proceed as unimp ded as possible. Closure of the hard palatal cleft can be postponed at least until all of the
deciduous dentition’ has erupted. This postponement facilitates the use of orthodontic appliances and allows more maxillary growth to’ occur before scarring from the surgery is induced. Because a significant portion of maxillary growth has already occurred by ages 4 to 5, closure of the hard palate at this time is usually performed before the child’s enrollment in school. Removable palatal obturators can be fitted and worn in the meantime to partition the oral and nasal cavities.The largest problem in evaluation of treatment regimens is the fact that the final results of surgical repair of clefts can only be judged conclusively when the individual’s
growth is complete. A surgical method used today cannot be put to careful scrutiny for 10 to 20 years. which, unfortunately, may allow many individuals with cleft deformities to be treated with procedures that later be discarded, when follow-up examinations studies show unsatisfactory or poor effects