The precise details of the timing of surgery will vary depending on the individual case. All we can give here are approximations and advise to speak to the surgeon or nurse specialist involved. Some general advice is available for the UK via the website of the Cleft Lip & Palate Association.
Cleft lip and / or alveolus and / or soft palate repair at three to six months old
- Short term: difficulties feeding following repair whilst sutures are in. Sutures are removed 5 to 6 days afterwards, often with a short general anaesthetic although this varies by team. Encourage your baby to suckle and feed as much as you can as the latching can be altered to the bottle or nipple. There are special bottles that will help the baby feed. The scar will remain red and raised for several weeks, massage and emulsification help. Brief standard analgesia for children.
- Medium term: the aim of surgery is to enable the child’s lip to function normally to latch on to a bottle or nipple and in the medium term the baby may benefit from speech and language therapy input. A noticeable scar will have settled largely within 3 to 4 months although all scars mature over an 18 month period. No analgesia required in the medium term.
- Long term: as with all surgery in children there are growth considerations and nasal and top jaw growth can be the main long-term impact as surgery can inhibit growth. There are a variety of staged orthodontic and surgical interventions to minimise the impact.
Repair of residual palatal defect at nine to twelve months old
- Short term: feeding assistance required, usually accomplished by bottle feeds either formula or expressed breast milk. The sutures are dissolvable and do not need removing, they are usually dissolved within weeks. Scarring is not noticeable; a nasal connection can occur called a fistula. If it develops it may need to be surgically closed.
- Medium term: no remarkable changes in feeding, there may be some regurgitation through the nose. Scarring not a major issue, there may be some shortening of the palate but children adapt to this and no intervention is usually required other than speech and language therapy support. Pain relief would not normally be required.
- Long term: nasal speech can be a long-term problem in a few people.
Hard palate repair only
- Short term: feeding oral/nasal regurgitation can be an issue which can spontaneously resolve or occasionally a fistula may form. The fistula between the mouth and the nose may require treatment. Scarring is not usually of any concerns in the short term. However extensive surgery in areas of the palate which influence growth can restrict the development of the top jaw. Routine children’s analgesia if required.
- Medium term: no particular issues.
- Long term: growth issues related to the top jaw and the nose may require orthodontic or orthognathic interventions.
Audiology +/- myringotomy (ventilation incision in the ear drum) either at this time or as indicated by audiological assessment
If this is required the child is usually fully recovered within the week.
Pharyngeal surgery if indicated by speech and language therapy assessment at four to five years old
Pharyngeal surgery, if necessary, is very individualised in its progress. If necessary, children seem to recover more quickly than adults but it is uncomfortable and creates issues with swallowing for 10 to 14 days after surgery. The aim of modern cleft surgery is to avoid these operations.
Alveolar bone grafting assessment at age eight years, followed by actual alveolar bone grafting between the ages of nine and eleven
This is a slightly awkward age for children’s surgery as they are reaching one of the tipping points between being a child and an adult in physical growth and psychology. They are also otherwise healthy children who have experienced several operations and many clinical visits (often to busy hospitals).
- Short term: usually no more than an overnight stay in hospital is necessary. The oral part of the operation is usually not overly painful. The sutures dissolve, the area is tender and must be kept as clean as possible (and, in particular, not played with) and even if wound breakdown occurs, conventional 3-layer closure techniques tend to eliminate oral to nasal communication. Stitches will take 3 weeks to dissolve and would require normal child analgesia. The bone donor site (hip, leg or chin – usually hip) is uncomfortable for several days. A variety of local analgesia techniques are used to reduce this.
- Medium term: the aim of this operation is to enable the canine tooth to grow into the correct place in the top jaw and eliminate any residual oral to nasal communication. The area that may be the most discomfort is the donor site but with modern techniques this is very unlikely. There may be persisting oral/nasal regurgitation, this will usually settle spontaneously. Re-operation for a persisting fistula, which usually indicates a failed bone graft, is rare. Orthodontics before and after surgery help align the dental arches.
Definitive orthodontics with or without orthognathic surgery between the ages of 15 and 18 years old
One of the many reasons not to exhaust the cleft patient with multiple interventions throughout childhood is to help them maintain psychological motivation. Another reason is to avoid inhibition of growth, particularly to the top jaw. Despite this a substantial number of cleft patients will have jaw disproportion and/or malalignment. Orthognathic surgery, particularly bimaxillary (2 jaw) surgery is a significant operation.
- Short term: usually patients are admitted on the day of surgery but stay at least one night in hospital. The surgery takes several hours with considerable postoperative swelling and the teeth are connected together by elastic bands or sometimes wires. This feels quite unpleasant and uncomfortable. Steroids are often used to try and reduce the swelling but they are used around the time of the operation and coming off steroids (which produce euphoria) at a time when you first look in a mirror after an appearance altering operation when you have your teeth clamped together and are puffed up is a strong reason to feel very down. The good news is that as the effect of the steroid lifts, the mood improves and this then goes hand in hand with recovery.
- Medium term: the swelling improves rapidly and teeth move in orthodontic braces faster after surgery for several not quite understood reasons. This period is spent under orthodontic care getting the alignment of teeth and the bite correct.
- Long term: unless you have had the unfortunate but recognised unwanted effect of a numb lip or tongue after surgery, the effects of this have now gone and your facial appearance from the perspective of jaw disproportion has been dealt with. Orthodontics takes a variable length of time but is usually complete by 18 months although life-long ‘retention’ (hidden fixed wires to keep the teeth in the right place) is common.
Definitive rhinoplasty plus definitive restorative dentistry at age 18 years plus
The post osteotomy sequence is very variable and entirely dependent on the individual. So other than to say it may be needed and refer you to the relevant pages (rhinoplasty, restorative dentistry) nothing more can be added by way of timelines.