A cleft lip and/or palate is a congenital condition that occurs when the lip or the two halves of the palate (roof of the mouth) do not join properly during early pregnancy. This may affect one side of the face (unilateral) or both sides (bilateral). Clefts occur in around 1 in every 600 to 800 babies. Surgery is needed in infancy to close the cleft and support feeding, speech development, and normal growth of the face and jaws. Many children with a cleft lip and/or palate will also need ongoing care throughout childhood, adolescence, and sometimes adulthood. This may include help with speech, dental and orthodontic support, and monitoring of hearing. Care is best provided by a multidisciplinary cleft team, usually including paediatricians, plastic surgeons, speech pathologists, dentists, orthodontists, otorhinolaryngologists (ENT specialists), and psychologists. As a child grows, additional surgeries may be required, such as alveolar bone grafting, speech surgery, orthognathic surgery (corrective jaw surgery), or refinement of the lip and nose.
At Terrace Plastic Surgery, we provide the full range of surgical care for children and young adults with cleft lip and palate. Some procedures can be performed in the private sector, but we strongly recommend that all children remain linked with the Cleft Lip and Palate Multidisciplinary Team Clinic at Queensland Children's Hospital. We are happy to help coordinate referrals to ensure your child receives safe, coordinated and comprehensive care.
Key Procedures in Cleft Care
Cleft Lip Repair and Primary Rhinoplasty
Age: around 3 months.
Cleft lip repair brings the separated parts of the lip together to create a natural lip shape and improve feeding, appearance, and lip function. At the same time, a primary rhinoplasty is often performed to improve the shape of the nose and create better nasal symmetry from an early age. After surgery, most babies stay in hospital for one to two days. A short anaesthetic is often required one week later to remove the tiny skin sutures. Babies need to change to a different teat for feeding for a period of two weeks after surgery, though breastfeeding can continue normally. Arm splints are used for two weeks to prevent the baby rubbing or injuring the repair. The scar will continue to soften and settle over several months.
Note that in the lead up to the cleft lip repair presurgical orthodontic treatment is used in selected babies. The most common presurgical orthodontic treatment in Brisbane is nasoalveolar moulding (NAM) which are generally used for babies with a bilateral cleft lip and palate or a wide unilateral cleft. NAM uses a small custom-made plate that fits against the palate, sometimes combined with nasal stents and soft lip taping. Its purpose is to guide the gum segments and nose into a better position before surgery, improving the final lip and nasal result. NAM is planned and fitted by an orthodontist through the Queensland Children’s Hospital, and parents are shown how to clean and maintain the device at home. Treatment usually continues until the time of lip repair.
Cleft Palate Repair Age:
Age: 9-12 months (can be 12-18 months in patients with a small lower jaw i.e. Pierre-Robin sequence).
The cleft palate repair closes the gap in the roof of the mouth and recreates the normal muscle sling of the soft palate (levator muscles), which are essential for speech and swallowing. At the same time, grommets (tiny ear ventilation tubes) are often placed by an otorhinolaryngologist to treat ‘glue ear’ (otitis media with effusion) which is common in children with cleft palate. After surgery, babies usually stay in hospital for a few days. A soft diet is required, and no hard objects (including cutlery or toys) should go into the mouth during healing. A Nuk teat or soft spoon is be recommended for a period of two to four weeks. Arm splints are commonly used for the two weeks week.
Speech Surgery
Age: 4-5 years onwads.
Around 10–20% of children require additional surgery to improve their speech if the palate does not close tightly enough during speech (velopharyngeal insufficiency). Speech surgery can involve:
- Posterior pharyngeal wall augmentation.
- Revision palate repair with additional tissue to lengthen the palate (sometimes taken from the cheeks).
- Pharyngoplasty: either a sphincter pharyngoplasty or pharyngeal flap procedure to reduce the size of the nasopharyngeal port.
Before any speech surgery, a detailed speech language therapist assessment and certain investigations are needed. These usually include a nasendoscopy (a small flexible camera to assess how the palate moves) and a videofluoroscopy (moving X-ray study of the palate during speech). Ongoing speech therapy remains essential both before and after surgery.
Alveolar Bone Graft Age:
Age: 8–12 years (period of mixed dentition).
An alveolar bone graft fills the gap in the gum line (alveolar cleft) to support the teeth and help stabilise the upper jaw. Before surgery, orthodontic expansion is usually needed to prepare the area. Bone is commonly taken from above the the hip (iliac crest). Children typically wear a palatal splint for around two weeks after surgery, and the hip donor site can feel tender for several days. This graft allows the adult canine tooth to erupt normally and provides structural support for dental alignment.
Orthognathic Surgery (Corrective Jaw Surgery):
Age: 16-20 years of age onwards.
Around 10-20% of patients with cleft lip and palate develop a significant underbite or jaw imbalance because of how the upper jaw grows. Orthognathic surgery, often involving both the upper and lower jaws (bimaxillary surgery), is performed when facial growth is complete, usually in the late teenage years. This surgery improves the bite or occlusion, facial balance, and long-term speech function.
Secondary Rhinoplasty and Lip Revision:
Age: 16-20 years onwards.
As the face grows, many patients benefit from refinement of the lip or nose during adolescence or adulthood. A secondary rhinoplasty often involves a full reconstruction of the nasal framework, including reshaping of the nasal bones and cartilage. In some cases, cartilage from the rib (autograft or allograft) is needed to provide support. Lip revision procedures vary depending on individual needs. They may include small refinements of the vermilion border, fat grafting or dermofat grafting for volume, or a complete re-repair to improve symmetry or function.
Summary
Cleft care is a long-term process that begins at birth and continues through to adulthood. With coordinated support from a multidisciplinary team, children with a cleft lip and/or palate can achieve excellent outcomes in feeding, speech, bite alignment, and appearance. Our team at Terrace Plastic Surgery is committed to guiding families through every step of this journey and ensuring close collaboration with the Queensland Children’s Hospital Cleft Team.
