Pediatric Plastic and Craniofacial Surgery
The Center for Cleft Lip, Palate, and Velopharyngeal Insufficiency (VPI) at Cohen Children’s provides specialized care for children with cleft lips, palates and speech deficits. Through innovative surgical procedures and therapies, our physicians improve the facial differences and speech capabilities of these patients.
Cleft lip and cleft palate are commonly occurring conditions, with one in 1,000 newborns in the United States, if not more, with these deformities. Clefts are most often diagnosed on prenatal ultrasound at around 20 weeks of gestation, but sometimes are not detected until the birth of a child.
Our relationship often begins prenatally after the initial diagnosis. During this time, we counsel expectant parents on the treatment plan of action and what to expect before and after the treatment. After birth, a physical exam is performed, including a feeding evaluation. Staff educates parents on the proper feeding techniques and feeding supplies are provided.
No matter the age of the child, we provide services to treat the whole patient, as well as their family. Our multidisciplinary team includes:
- Plastic surgeons
- Speech and language therapists
- Social workers
- Developmental pediatric specialists
- Ear, nose and throat doctors
What we treat
At the Center for Cleft Lip, Palate and VPI, we treat:
Unilateral cleft lip - A cleft that occurs on one side of the mouth is known as a unilateral cleft lip. This deformity also involves the gum tissue and nose. Children with this condition may need several surgical procedures from infancy to adulthood for functionality and aesthetic quality.
Children born with a cleft lip require an interdisciplinary team of doctors and specialists for ongoing care. Following lip repair surgery, therapy for hearing and speech may also be necessary, as well as oral treatments and psychological counseling.
Though the age of the initial reconstruction surgery varies depending on the patient, most children begin treatment at 3-4 months of age. They will require periodic treatment throughout their childhood.
Final reshaping of the nose is typically done in the teen years after puberty. If the child has a deviated septum, it can also be corrected at this time, opening the air passage and improving the ability to breathe through the nose. The nose is straightened, nostrils made more symmetric, and the tip given more projection and definition through sculpting and cartilage grafts.
Bilateral cleft lip - A bilateral cleft lip affects two sides of the lip, dividing the lip into three sections. Similar to a unilateral cleft, children born with a bilateral cleft may require several surgeries from early childhood into adulthood and multidisciplinary care throughout their life. Hearing and speech therapy may be required, as well as psychological counseling and orthodontic care.
Though the age of the initial reconstruction surgery varies depending on the patient, most children begin treatment at 5 months. They will require periodic treatment throughout their childhood.
Final reshaping of the nose is delayed until the teen years, after the child has stopped growing. The deviated septum can also be corrected at this time opening the air passage and improving the ability to breathe through the nose. The nose is straightened, nostrils made more symmetric, and the tip given more projection and definition through sculpting and cartilage grafts.
Cleft palate - cleft palate occurs when the tissue at the roof of the mouth does not completely join during pregnancy. For some infants the front (hard) and back (soft) of the palate are open, in others only part of the palate is open. A cleft palate can cause issues with feeding, breathing and problems with the ear.
Though babies with a cleft palate can make sucking movements with the mouth, the cleft prevents them from developing normal suction. Breastfeeding is generally unsuccessful, though bottle feeding of breast milk or formula with specially designed bottles and nipples makes feeding easier. Some children with cleft palates are prone to upper airway obstructions and middle ear infections.
Treatment of cleft palate depends on the severity of the cleft, the age of the child and any associated conditions.
Typically, surgical repair cannot be done until the child is at least 1 year old. This gives the child time to grow, which makes for greater surgical success. Specialty bottles and nipples are available to help your child feed normally prior to surgery.
During the surgery, the muscle in the roof of the mouth is repaired, allowing for normal speech by sealing off the nose from the mouth during muscle contraction. In some cases, a follow-up surgery is required to improve speech.
All children with cleft palate are referred to our experts in pediatric otolaryngology for consultation for possible ear tubes, called myringotomy tubes. These tubes are placed at the time of surgery for cleft palate repair.
Some cleft palates are not obvious at birth. A submucous cleft of the soft palate is a muscular tissue deficiency. In these cases, lining of the palate appears to be fully intact but close inspection may reveal a split uvula, the ball in the back of your throat, and more importantly an abnormally attached muscle.
Surgical repair involves reconstruction of the muscle to allow for proper closure of the nose during feeding and speech and is often performed around 11 months of age. Children are kept in the hospital for observation overnight.
Eyelid deformity - A coloboma is a hole in one of the structures of the eye, like the iris, retina or optic disc. Patients with coloboma must take care to avoid the eye from drying out by using lubricating drops or temporary sutures to protect the eye. Reconstruction of the eyelid involves a lid switch technique or skin grafting as well as reconstruction of the corner of the eye.
Mandible deformity - An underdeveloped lower jaw may cause airway obstruction, which can require emergency intubation, where a flexible plastic tube is placed into the windpipe to help with breathing. Traditionally, tracheostomy is used to establish an unobstructed airway until the jawbone grows and the tube can be removed.
Northwell Health offers neonatal jaw distraction, a technique where the lower jaw can be lengthened, which resolves the breathing problems by pulling the tongue forward and off the airway.
This can be performed within the first two weeks after birth and will allow for the breathing tube to be effectively removed. The tracheostomy may be removed after the surgery.
Pierre-Robin sequence - Babies born with a small lower jaw, called a mandible, can lead to abnormal tongue positioning causing a cleft palate, which may obstruct the airway in some newborns. The small jaw prevents the tongue from moving forward, making it hard for the child to breathe. Immediate treatment involves placing the baby on his or her stomach to allow the tongue to fall forward. In addition, a nasal trumpet may be necessary to help your baby to breathe
The pediatric craniofacial team at Cohen Children’s can offer life-saving surgical treatment and correct the deformity by permanently bringing the lower jaw forward by a process known as mandibular distraction. Distraction is a process that will lengthen the jaw and allow new bone to grow. Lengthening the jaw may alleviate the obstructive sleep apnea, improving your child’s ability to breathe and feed. Tracheotomy tubes are removed after treatment.
Tessier clefts - Facial clefts are defects in the bone and tissue of the face as a result of failure of these structures to properly form. They are called Tessier clefts and can extend into the skull, leading to encephaloceles, a sac-like bulge on the skull. The treatment of these complex abnormalities is site specific and often requires several operations to restore the normal architecture of the facial structure.
The most common tessier cleft is the tessier no. 7 cleft, which produces an enlarged mouth. The corners of the mouth are blunted because the muscles do not meet. Treatment involves restoring oral competence by repairing the muscle of the lip and narrowing the mouth.
Treacher-Collins syndrome - Treacher-Collins syndrome is a condition that affects the development of bones and tissue of the face. It can be genetically inherited or occur as new mutations and cause a pattern of facial clefting as well as a small lower jaw. The exact number of patients with this condition is unknown because many individuals with this mutation do not have obvious symptoms or are underdiagnosed, but is estimated to be one in 10,000 to one in 50,000 live births.
VPI - Velopharyngeal insufficiency (VPI) occurs when the soft palate cannot properly close during speech, allowing air to escape through the nose instead of the mouth. This may lead to very nasal speech and make it hard for people to understand your child when he or she is speaking.
The motion of the soft palate can be evaluated using endoscopy through the nose. If indicated, surgery can be performed to help close off the connection and improve speech.