Plastic Surgery · Supplementary · from Plastic Surgery
Case 1: Cleft Lip and Palate Repair
Patient Presentation
Demographics: 3-month-old male infant
Chief Complaint: "Born with a gap in his upper lip and roof of the mouth"
History of Present Illness: This 3-month-old male infant was born at 38 weeks gestational age via spontaneous vaginal delivery to a 28-year-old G2P2 mother. Prenatal ultrasound at 20 weeks had identified a left-sided facial cleft. At birth, examination confirmed a left unilateral complete cleft lip and palate extending through the alveolar ridge, hard palate, and soft palate. Birth weight was 3.2 kg.
The infant initially had significant difficulty with breastfeeding due to inability to generate adequate negative pressure for suction. He was transitioned to a specialized cleft palate bottle (Haberman feeder) and has been gaining weight appropriately, currently at the 35th percentile for age. He has been followed by the multidisciplinary cleft team since birth, including plastic surgery, speech-language pathology, audiology, orthodontics, and genetics.
A nasoalveolar molding (NAM) device was placed at 2 weeks of age to approximate the cleft lip segments and reshape the nasal cartilage prior to surgical repair. Genetic workup including chromosomal microarray was normal, and no syndromic features were identified. The family is now presenting for planned surgical repair of the cleft lip.
Past Medical History:
- Left unilateral complete cleft lip and palate
- Two episodes of acute otitis media
- No other congenital anomalies identified on echocardiogram and renal ultrasound
Medications:
- Multivitamin drops with iron 1 mL daily
- Amoxicillin recently completed for otitis media
Social History:
- Lives with both parents and a 3-year-old sibling
- No family history of cleft lip or palate
- Non-smoking household
- Mother took prenatal vitamins with folic acid throughout pregnancy
Family History:
- No family history of craniofacial anomalies
- Father has history of mild childhood speech delay
Physical Examination
- Vital Signs: HR 140 bpm, RR 32/min, Temp 36.8°C, Weight 5.4 kg (35th percentile), Length 59 cm (40th percentile)
- General: Alert, active, well-nourished infant in no distress
- Head: Normocephalic, anterior fontanelle open and flat
- Face: Left unilateral complete cleft lip extending from the left nostril through the vermilion border. Left nasal ala is flattened and displaced laterally. NAM device in place with improved alignment of lip segments
- Oral Cavity: Complete cleft of the primary and secondary palate on the left side. Cleft extends through the alveolar ridge, hard palate, and soft palate to the uvula. Vomer visible in the cleft
- Ears: Bilateral middle ear effusions noted on otoscopic examination
- Cardiac: Regular rate and rhythm, no murmurs
- Lungs: Clear to auscultation bilaterally
- Abdomen: Soft, non-tender, no organomegaly
Workup and Results
Laboratory Studies:
| Test | Result | Reference Range |
|---|---|---|
| Hemoglobin | 10.8 g/dL | 9.5-13.5 g/dL |
| Hematocrit | 32% | 28-42% |
| WBC | 9,200/μL | 6,000-17,500/μL |
| Platelets | 310,000/μL | 150,000-400,000/μL |
| PT | 12.1 seconds | 11-14 seconds |
| PTT | 28 seconds | 25-35 seconds |
| Basic Metabolic Panel | Within normal limits | -- |
Imaging/Additional Studies:
- Echocardiogram: Structurally normal heart
- Renal ultrasound: Normal bilateral kidneys
- Chromosomal microarray: No pathogenic copy number variants
- Audiology: Bilateral conductive hearing loss consistent with middle ear effusions (ABR thresholds 35-40 dB bilaterally)
Clinical Image
Anatomical diagram of unilateral complete cleft lip and palate showing affected structures and the rotation-advancement repair technique. Source: Educational illustration.
Diagnosis
Left Unilateral Complete Cleft Lip and Palate (ICD-10: Q37.1)
Key Diagnostic Criteria:
- Complete cleft of the lip extending through the nostril floor
- Cleft of the primary palate (alveolar ridge)
- Cleft of the secondary palate (hard and soft palate)
- Non-syndromic presentation confirmed by genetic testing
Treatment Plan
- Cleft lip repair (cheiloplasty) at 3 months of age using the Millard rotation-advancement technique with primary nasal correction
- Myringotomy with bilateral pressure equalization tube placement at the time of lip repair to address conductive hearing loss
- Palate repair (palatoplasty) planned at 10-12 months of age using the Furlow double-opposing Z-plasty technique
- Continued nasoalveolar molding until lip repair
- Speech-language pathology monitoring beginning at 12 months with formal assessment at 18-24 months post-palatoplasty
- Orthodontic management for alveolar bone grafting planned at age 7-9 years during mixed dentition
- Long-term follow-up through skeletal maturity for possible secondary rhinoplasty, orthognathic surgery, or lip revision
Key Learning Points
- The "Rule of 10s" guides timing of cleft lip repair: 10 weeks of age, 10 pounds body weight, and hemoglobin of 10 g/dL
- Cleft palate repair is typically performed at 10-12 months to optimize speech development before the onset of meaningful language
- Nasoalveolar molding (NAM) prior to surgery reduces cleft width and improves nasal symmetry, potentially reducing the number of future surgical revisions
- Eustachian tube dysfunction is nearly universal in cleft palate patients, making otologic monitoring and early PE tube placement essential
- A multidisciplinary cleft team approach is the standard of care, involving plastic surgery, ENT, audiology, speech pathology, orthodontics, pediatric dentistry, genetics, and psychology