We watch over growth of children, from infanthood to adulthood, growth of lips, teeth, and jaws, and the development of speech ability, along with parents. We watch over growth of children, from infanthood to adulthood, growth of lips, teeth, and jaws, and the development of speech ability, along with parents.

As explained before, every patient have different patterns of cleft: cleft lip that is one-sided (unilateral), cleft from the red lip (red lips) to nostrils (complete cleft), double-sided cleft (bilateral), cleft lip only without cleft palate, etc. In all cases, the aims of surgery are to reestablish the deviation of the muscle (orbicularis oris muscle) due to the cleft and to make the lips and nose normal in terms of the function and shape. Therefore, the incision must be carefully performed, considering the direction of the muscles and the direction of tissue displacement, rather than simply attaching the left and right lips together. Therefore, the surgical incision line is complicated. At present, technology and materials have advanced significantly, and scars are less likely to remain. Now, it is possible to maintain the natural shape of the lips and nose.

Before operation

After suturing

After operation

Regarding the timing of surgery, some believe that it should be performed soon after birth, but it is safer and better to be performed after the body has grown to some extent and the muscles of the lips have been strengthened. Therefore, in our department, surgery is performed 2-3 months after birth in the case of patients with unilateral cleft. Furthermore, in the case of bilateral patients, there are cases where each side is operated on separately (two surgical interventions), and cases where both sides are operated on at the same time. The most suitable surgical method is selected for each child. Regarding the timing of surgery, in the case of one side at a time, the first operation is performed 2-3 months after birth and the second operation is performed 5-6 months after birth, and when both sides are performed simultaneously, the surgery is performed 2–4 months after birth. Meanwhile, the Hotz-type plate is adjusted to make the shape of the upper jaw as easy as possible to operate on. Since the optimal treatment method may change a little for each patient, we are careful to perform surgery at the most appropriate time and in the most appropriate method based on the preoperative examination. The surgery is performed under general anesthesia, and the period required for hospitalization is about 10 days to 2 weeks.

After leaving the hospital, it is requested to exchange the tape attached to the wound on the lips and wear a silicone nose plug called a retina. This should be done for 3-4 months after surgery to prevent deformation due to relapse immediately after surgery and scar formation after surgery. However, the healing process of the wound differs depending on the patient, so please listen carefully to the guidance given by the attending physician at hospital admission, and to the outpatient department physician.

It was mentioned in detail earlier that cleft palate causes various problems. Palatoplasty is performed to solve these problems, but the purpose of this operation is not only to close the cleft but also to suture the splitted soft palate muscle (levator veli palatini muscle), return it to a normal position, and reduce the dilated rhinopharynx.

If cleft palate surgery is performed too early, it will impair the growth of the upper jaw. However, if the surgery is delayed too much, the habit of abnormal pronunciation (abnormal articulation) will develop. Therefore, in our department, surgery is performed at the age of around one year, when both of these conditions are satisfied fully, that is, before the baby starts active pronunciation exercise, and at the time when there is as little growth of the upper jaw as possible. However, in reality, the timing may change a little depending on the condition of the baby at that time.

Moreover, there are cases where the palate surgery is completed in one stage and cases where the surgery is performed in two stages. The reason for dividing the surgery into two stages is to improve the growth of the upper jaw as much as possible, but the optimal method changes depending on the condition of the mouth, so preoperative examination is performed to determine which method is better. Even in the case of the two-stage method, the first palatoplasty is performed around the age of 1 year, and the second surgical hard palate closure is performed around the age of 1 year and 6 months to 2 years. The surgery is performed under general anesthesia, and the length of the hospital stay is about 2 weeks.

Regarding the surgical method, we select the optimal surgical method for each patient from the following two surgical methods based on the width of the cleft, the length of the soft palate, and the state of muscle development.

In both surgical procedures, the surgery causes partial bone exposure of the upper jaw, so the entire upper jaw is covered with a celluloid cover until a new mucous membrane is formed to protect the wound. The period of wearing it is about one week. Please eat soft meals for a while after discharge. After about 4 weeks after surgery, it is possible to return to the same diet as before surgery.

Additionally, since infants at this time put anything in their mouths, please be careful not to put any sharp objects (ball pens, chopsticks, etc.) into the mouth (please be especially careful until around 3 months after surgery).

Regarding speech training, you will visit our division of Oral-Facial Disorders during the hospitalization to receive detailed explanations about future treatment (details will be described later).

If the scars on the white lip area (the area between the red lip and the nose) are noticeable after cheiloplasty, or the shape of the red lips is irregular, or the nose is deformed, the patient will undergo corrective surgery before attending school. Since this is the time when the nose and upper jaw are growing, large-scale surgery may affect the growth of the face, so only relatively small surgery is performed.

Major surgery (e.g., nose formation due to transplantation of ear cartilage) is performed after the patient's growth and development are almost complete (14–18 years).

The bones of the alveolar ridge of the upper jaw (where the teeth are lined up, i.e., the gums) are lined up with not only teeth but also the base of the nose. Therefore, in patients with an alveolar cleft, the base and ala of the nose appear to be depressed. Additionally, because there is no bone that forms the base of the teeth, the eruption of the anterior teeth cannot be expected, and the teeth cannot be moved by orthodontic treatment. To solve such problems, our department perform surgery to transplant bone marrow collected from the ilium to this area around the age of eight.

In the case of patients with a cleft palate that extends to the alveolar region, the alveolar region is closed only by the mucosa during palatoplasty. However, if the width of the fissure is very large, it may be difficult to close the alveolar region completely, and after surgery, a small hole (residual hole) that connects to the nasal cavity may remain in the alveolar region. Even if there is no hole after surgery, a hole may be formed around the alveolar area by performing orthodontic treatment, lateral enlargement of the upper jaw. If this hole is large, the water in the mouth will leak to the nose, causing various problems such as difficulty using a straw. When producing sounds, the pronunciation may be obscured because there is not enough air in the mouth. Therefore, we are trying to solve such problems by performing surgery to close this hole (residual hole closing surgery) together with bone grafting to the alveolar region mentioned previously.

Surgery for bone grafting to the alveolar region is performed at an appropriate time from the age of 5 in consultation with the orthodontic department. Bone is collected from the ilium or mandible according to the required amount. This cancellous bone is a sherbet-like bone that exists inside the bone, and a part of the outer hard bone (cortical bone) is removed for collection, but the hard bone is replaced after collection, so there is almost no deformation of the ilium. Even if the collection from the ilium is performed, it is possible to walk within 3 days from the day after the operation. The collection from the chin cannot be performed unless the mandibular anterior teeth have been replaced with permanent teeth.

If the hole in the palate is large, the mucous membrane of the tongue may be transplanted to close the hole (tongue flap transplantation), and these operations completely eliminate the alveolar fissure (jaw cleft).

In patients with a unilateral cleft, the growth of the cartilage that forms the nose differs between the right and left sides, and the difference may be noticeable as the body grows. In patients with a bilateral cleft, the central part of the nose, especially the tip of the nose, may be stunted and the nose may be low. We perform such external nasal morphological surgery from the age of 14 when the growth of external nasal cartilage is almost complete (this period varies between men and women).

The surgery focuses on restoring displaced nasal cartilage with the aim of making the shape of the nose symmetrical, but if significant cartilage growth impairment is noted, we will transplant the auricular cartilage and the mandibular chin bone. The cartilage of the auricle is collected from the back of the ear, so the scar is unnoticeable. Additionally, since the cartilage is collected in a window shape, the shape of the ear does not change after surgery.
Additionally, although some facilities perform silicon transplantation for the formation of the nose, we do not use silicon as the adverse effects of transplanting artificial materials cannot be ruled out.

After surgery, it is necessary to wear a silicone nasal plug (Retina) for 3 to 4 months to prevent relapse of the morphology.

When a child is 14–16 years old and has passed the growth period, the lips and nose may change from a child’s shape to an adult’s shape, resulting in a marked distortion. If there is concern about this kind of distortion, the final surgery to shape the lips is performed at this time, similar to the above-mentioned revision surgery for the external nose.

The surgery method is completely different for each patient and may include repairing only the red lip, repairing scars on the white lip, or using external rhinoplasty to correct the entire lips. Small corrections may be performed outpatiently, but if relatively large surgery is required, surgery is performed under general anesthesia after hospitalization. After the surgery, it may be required to apply tape to make the scars less noticeable, just like after the lip plastic surgery when the patient was a baby.

There is also a surgical procedure to transplant the tissue of the lower lips to the upper lips (inversion flap transplantation [Abbe’s flap transplantation]). This surgery is performed for patients with bilateral cleft lip whose upper lip is extremely poor growth and whose lower lip is relatively prominent or for patients with severe scarring.